Since smoking is an important public health problem, The objective of this study was to explore smoking powerful association with carotid atherosclerosis. In observational cross-sectional study, 121 participants were investigated by B- mode and Doppler ultrasound at king Abdul Aziz specialty hospital –Taif, KSA (2011-2013). 92 of the participants were smokers and 29 were control group. The mean age was 40.9 ± 21.5 (range from 19 to 100 years old). Carotid arteries for all participants were examined using 7MHrz linear transducer according to the carotid ultrasound protocol. The frequency of carotid plaques was 22.8% (of 92). The high frequency registered in group that smoke > 20 cigarettes per day. All plaques were presented in population of age above 53 years old. There was association between duration of smoking and the presence & increases of plaque size, P = .002. The mean thickness of IMT in smokers was .8362 ± .37 mm. While it was .5 mm in control group. There was strong statistical association between the frequency of smoking and the increase in IMT, P = .000. The study suggested that there is a significant association between carotid atherosclerosis and smoking. Also carotid plaque may present at age of 54.