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What Is the Relationship Between Cigarettes and Heart Failure?

  • Authors: News Author: Stephanie Edwards; CME Author: Charles P. Vega, MD
  • CME / ABIM MOC / CE Released: 7/29/2022
  • Valid for credit through: 7/29/2023, 11:59 PM EST
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Target Audience and Goal Statement

This activity is intended for primary care physicians, cardiologists, addiction medicine specialists, nurses, pharmacists, physician assistants, and other members of the healthcare team who treat and manage adults at risk for heart failure.

The goal of this activity is for learners to be better able to assess the effect of smoking on the risks for heart failure with preserved ejection fraction and heart failure with reduced ejection fraction among adults.

Upon completion of this activity, participants will:

  • Distinguish the forms of cardiovascular disease most closely linked to cigarette smoking
  • Assess the effect of smoking on the risks for heart failure with preserved ejection fraction and heart failure with reduced ejection fraction among adults
  • Outline implications for the healthcare team


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News Author

  • Stephanie Edwards

    Freelance writer, Medscape


    Stephanie Edwards has no relevant financial relationships.

CME Author

  • Charles P. Vega, MD

    Health Sciences Clinical Professor of Family Medicine
    University of California, Irvine School of Medicine


    Charles P. Vega, MD, has the following relevant financial relationships:
    Consultant or advisor for: GlaxoSmithKline; Johnson & Johnson Pharmaceutical Research & Development, L.L.C.

Editor/Compliance Reviewer

  • Amanda Jett, PharmD, BCACP

    Associate Director, Accreditation and Compliance, Medscape, LLC


    Amanda Jett, PharmD, BCACP, has no relevant financial relationships.

Nurse Planner

  • Lisa Simani, APRN, MS, ACNP

    Associate Director, Accreditation and Compliance, Medscape, LLC


    Lisa Simani, APRN, MS, ACNP, has no relevant financial relationships.

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What Is the Relationship Between Cigarettes and Heart Failure?

Authors: News Author: Stephanie Edwards; CME Author: Charles P. Vega, MDFaculty and Disclosures

CME / ABIM MOC / CE Released: 7/29/2022

Valid for credit through: 7/29/2023, 11:59 PM EST


Clinical Context

Smoking is known to promote negative cardiovascular outcomes, but what is the relative effect of smoking on different manifestations of cardiovascular disease? Banks and colleagues addressed this question using a large database of adults without a prior history of cardiovascular disease. Their research was published in the July 3, 2019, issue of BMC Medicine.[1]

The risk for heart failure in general was raised with current smoking in this study, but the effect of former smoking and cumulative lifetime dose of cigarettes on the risk for heart failure with preserved ejection fraction (HFpEF) and heart failure with reduced ejection fraction (HFrEF) are not well understood. The current study addresses these issues.

Study Synopsis and Perspective

A study that used observational data from the Atherosclerosis Risk in Communities (ARIC) shows a significant association between cigarette smoking and increased risk for HFpEF and HFrEF.

Researchers found that the risk for HFpEF and HFrEF increased in conjunction with pack-years, duration, and intensity of smoking, indicating that longer, more intense exposure results in elevated risk.

"There was a dose-response relationship between smoking and heart failure overall, as well as [HFpEF] and [HFrEF]," said Kunihiro Matsushito, MD, PhD, from John Hopkins Bloomberg School for Public Health and John Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Baltimore, Maryland.

Smoking cessation significantly reduced the incidence of HF, but an elevated risk associated with previous smoking still existed decades later.

The results of this study "demonstrate that the excess risk created by smoking may last up to 30 years, and I think that clearly tells the importance of preventing smoking in the first place, but also encouraging current smokers to quit as soon as possible because the excess risk may last long," added Dr Matsushito.

The article was published in the June 14 issue of the Journal of the American College of Cardiology.[2]

A Modifiable Risk Factor

Prevention is "crucial" for HF, and specifically HFpEF, they note. "Since there are not many treatment options for that condition, it's critical that we try to prevent the occurrence of heart failure with preserved ejection fraction," said Dr Matsushita.

Using data from the ARIC study, the authors looked at outcomes in 9345 participants to determine whether there is an association between cigarette smoking and smoking cessation with incident acute decompensated HF overall, HFrEF, or HFpEF.

Baseline was January 1, 2005; adjudication for potential HF cases started at the beginning of 2005. Data from clinic exams and annual/semiannual phone interviews were used. Patients with previous HF or those with missing variables of interest were excluded from the study.

Mean age of the study cohort was 70.4±5.7 years, 57.3% of participants were women, and 20.8% were Black. Of the 9345 participants, 823 (8.8%) were current smokers, 4547 (48.7%) were former smokers, and 3975 (42.5%) were never smokers.

Pack-years of smoking showed an association with HF after adjustment for potential confounders. Participants with less than 10 pack-years of smoking did "not necessarily" have an increased risk for overall HF, they note. Participants with 10 to 25 pack-years had a borderline increased risk for overall HF (hazard ratio [HR], 1.19; 95% CI, 0.99-1.44), and those with 25 or more pack-years had an approximately 2-fold increased risk for overall HF.

Results for HFpEF and HFrEF were similar with continuous smoking. The HR per increment of 10 pack-years was 1.16 (95% CI, 1.12-1.20) for HFpEF and 1.09 (95% CI, 1.05-1.13) for HFrEF.

Smoking intensity and duration showed graded associations with overall HF, HFpEF, and HFrEF, the authors note.

Longer duration of smoking cessation was associated with less risk for HF, but compared with never smokers, there was still a significant elevated risk for HF from 20 to 30 years after cessation (HR, 1.34; 95% CI, 1.07-1.67).

However, participants with smoking cessation of more than 30 years had a risk for HF, HFpEF, and HFrEF similar to that of never smokers. There was a 50% lower risk for both types of HF among participants who remained abstinent for 30 years compared with current smokers.

Cigarette smoking is associated with increased risk for HFrEF because cigarette smoking is a significant risk factor for coronary heart disease, a major cause of HFrEF, the authors note. "However, the etiological link between cigarette smoking and the development of HFpEF remains unclear," they write.

The authors reported some limitations to their findings. First, using self-reported smoking status could result in measurement error. Second, baseline data were not available precisely at the beginning of 2005; however, the authors found consistent results using visit 1 as a baseline. Third, 15% of HF events could not be categorized into HF subtypes because of missing information. Fourth, there could have been residual confounding, as with any observational study.

Last, the data used in this study were for cigarette smoking only, so it is "unknown" whether the results would apply to cigars, pipes, secondhand smoke, or e-cigarettes.

Smoking Cessation an Important Tool

In an accompanying editorial, the authors acknowledge that despite the advances in treatment for HF, prevention remains at the forefront.[3]

"Smoking is a major cause of all types of heart failure, with detrimental effects that may persist several years after cessation. The focus on both heart failure with systolic dysfunction and heart failure without systolic dysfunction is particularly timely and confirms the multidimensional detrimental effects of smoking on cardiac pathophysiology," Dr Biondi-Zoccai,from Sapienza University of Rome, told | Medscape Cardiology.

The editorial also notes that although the study did not examine exposure to other substances, such as cannabis, cigars, pipes, heat-not-burn devices, vaping, and smokeless tobacco, it reinforces the efforts to minimize those exposures.

Dr Biondi-Zoccai added that decreasing exposure to such things as passive smoking and household or environmental pollution would also be beneficial.

The ARIC study is funded by federal funds from the National Heart, Lung, and Blood Institute, National Institutes of Health, Department of Health and Human Services. The authors have disclosed no relevant financial relationships. Dr Biondi-Zoccai has consulted for Cardionovum, Crannmedical, Innovheart, Meditrial, Opsens Medical, Replycare, and Terumo. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.

J Am Coll Cardiol. 2022;79:2298-2305, 2306.2309.

Study Highlights

  • Study data were derived from the ARIC cohort, which enrolled adults between the ages of 45 and 64 years from 4 US communities. The first clinical examination was completed in 1987, and participants were followed through 2019.
  • The current study focused on participants without a previous history of heart failure. The main variable was cigarette smoking, which was quantified by when the study subject quit smoking (if at all) and the number of pack-years smoked.
  • The main study outcome was hospitalization for heart failure, which was adjudicated with the health record of individual participants. The study analysis focused on the relationship between smoking and the risks for both HFpEF and HFrEF. The study analysis was adjusted to account for demographic and disease factors, as well as body mass index and medication use.
  • 9345 participants provided data in the current study. The mean age of participants was 70.4 years, and 57.3% were women; 20.8% of participants were Black.
  • 8.8% of participants were current smokers, 48.7% were former smokers, and 42.5% of participants were never smokers.
  • Variables associated with being a current smoker included younger age, being a man, lower educational attainment, and higher alcohol consumption. Current smokers also had lower body mass index and blood pressure, but higher rates of prevalent coronary heart disease.
  • There were a total of 1215 cases of incident heart failure documented, with 555 cases of HFpEF and 492 cases of HFrEF. The remainder of heart failure cases lacked an ejection fraction reading.
  • The adjusted incidence rates of heart failure per 1000 person-years among never, former, and current smokers were 9.7, 13.5, and 20.1, respectively.
  • Compared with never smokers, the HRs for heart failure among former and current smokers were 1.36 (95% CI, 1.19-1.55) and 2.36 (95% CI, 1.92-2.90).
  • The HR for HFpEF and HFrEF associated with smoking were similar (2.28 and 2.16, respectively, for current vs never smokers).
  • Although a smoking history of more than 25 pack-years was associated with a 2-fold increase in the risk for heart failure, a smoking history of from 10 to less than 25 pack-years was associated with a HR of just 1.19 (95% CI, 0.99-1.44) for heart failure. A smoking history of less than 10 pack-years was not associated with a higher risk for heart failure.
  • Each additional 10 pack-year increment in smoking history was associated with HRs of 1.16 (95% CI, 1.12-1.20) and 1.09 (95% CI, 1.05-1.13) for HFpEF and HFrEF, respectively.
  • Subgroup analyses based on sex, age, and a history of coronary heart disease failed to alter the main study findings.
  • There was a gradual decline in the risk for heart failure with longer durations of smoking cessation among former smokers. However, the elevated risk for heart failure associated with smoking remained significant for up to 30 years after smoking cessation.

Clinical Implications

  • In a previous study, smoking was less likely to be implicated in promoting cardiac valve disorders and arrhythmias. The highest risks for specific cardiovascular disease associated with smoking were for aortic aneurysm and dissection, arterial embolism and thrombosis, and occlusion of the precerebral arteries without ischemic event.
  • The current study demonstrates similar risks associated with smoking for HFpEF and HFrEF. A smoking history of less than 10 pack-years was not associated with a higher risk for heart failure. The elevated risk for heart failure associated with smoking remained significant for up to 30 years after smoking cessation.
  • Implications for the healthcare team: The healthcare team should use the risk for heart failure as another tool to help discourage cigarette smoking.


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