Cigarette Smokers Twice as Likely to Die from Cardiovascular Causes


A new study from Northwestern breaks down the risk of cardiovascular mortality associated with smoking among younger patients. Dr. Gregory Weiss breaks down the study and offers further perspective.

Gregory Weiss, MD

Gregory Weiss, MD

It is well known that cigarette smoking is strongly associated with early death and both cardiovascular (CV) and respiratory disease. Over the years, increasing awareness and public health initiatives have led to some reductions in smoking at least in certain populations.

Still, it is estimated that as many as 34 million adults in the United States smoke, with tobacco use representing the leading cause of disability and the second leading risk factor for death in this country.1 While countless studies show a link between smoking and overall CV health including associations with stroke, heart failure, and heart attack, few investigations have looked at the long-term morbidity and mortality among the CV disease subtypes while taking into account competing risk for death posed by respiratory disease and lung cancer. The authors of this study sought to determine the long-term rates of incident CV disease related to smoking.

Sadiya Khan, MD, assistant professor of medicine at Northwestern University Feinberg School of Medicine, states,

“Most people are aware about the risks of lung cancer with smoking, but many people who smoke do not realize that dying from cardiovascular disease is more likely than dying from lung cancer.”2

The authors looked at nearly 2-million-person years of follow-up from over 100,000 individuals. In subjects 40 to 59 years of age there were over 7000 fatal or nonfatal coronary heart disease events, 3527 fatal or non-fatal strokes, and 4559 heart failure events.2 The cumulative risk for CVD and non-CVD deaths were higher in those who reported smoking.2 Across all groups smoking significantly lowered the number of years lived free from CVD.2

The most alarming result reported was that death as the first CV or non-CV event occurred in a larger proportion of middle-aged men and women who reported smoking than those who did not.2 Khan points out that,

“One of the most important findings of this analysis is that the first sign of cardiovascular disease is more likely to be a fatal event in those who smoke. Smoking is more likely to kill people from heart disease even before someone may know they have heart disease.”2

These data are alarming. At first glance it seems just a confirmation of what is already know. Smoking causes CVD. It appears, however, that the magnitude of the problem and its impact on middle-aged adults is far graver. The fact that, in this study, smoking was associated with a fatal event as the first manifestation of clinical cardiovascular disease is breathtaking. That means that smokers are dying from cardiovascular disease before they even know they have it.

It is easy to correlate smoking with CVD. These data put a magnifying glass on the known risk by zeroing in on specific subgroups of cardiovascular endpoints. Points added to the narrative by this investigation include:2

  • People who smoke are more likely to develop CVD at a younger age leading to up to a 5-year reduction in their lives.
  • Over half of middle-aged adults who smoked went on to develop CVD with nearly a 2-fold increase in their likelihood of dying from a heart attack, stroke, or heart failure.
  • Young people who smoked were twice as likely to die from a cardiovascular event as their first sign of CVD than those who did not smoke.

Fellow researcher Ranya Sweis, MD, also at Northwestern emphasizes that,

“Our findings show putting an emphasis on smoking cessation counseling is the most important preventable cause of death in the United States.”

While smoking cessation counseling has been a large part of clinical medicine for some time these data should add to the sense of urgency, we as clinicians feel. Many patients still believe that lung cancer is the greatest killer of smokers. We see now that this isn’t the case. While respiratory disease and cancer remain a significant consequence of smoking CVD and death as the first presenting sign of that disease should fuel a renewed effort on our part to convince our patients to quit smoking now.


  1. Wang TW, Asman K, Gentzke AS, Cullen KA, Holder‐Hayes E, Reyes‐Guzman C, Jamal A, Neff L, King BA. Tobacco product use among adults—United States, 2017. MMWR Morb Mortal Wkly Rep. 2018; 67:1225–1232. doi: 10.15585/mmwr.mm6744a2
  2. Khan, S. S., Ning, H., Sinha, A., et al. Cigarette smoking and competing risks for fatal and nonfatal cardiovascular disease subtypes across the life course. JAHA. 17 Nov 2021; 0:e021751
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