Ischemic heart disease mortality with documented tobacco use in the United States, 1999–2023: a nationwide population-based analysis

Q: What are the key findings of this study?

The age-adjusted mortality rate for ischemic heart disease with documented tobacco use in the US increased significantly from 3.90 in 1999 to 32.37 per 100,000 population in 2023 (AAPC 10.71).

Q: What is the clinical evidence from this study?

Study design: Observational. Population: Ischemic heart disease with documented tobacco use (n=1497919). Intervention: Tobacco use. Primary outcome: Age-adjusted mortality rate (AAMR) per 100,000 population (AAPC 10.71, 95% CI 8.35-13.12, p=<0.01).

Q: What question did this study set out to answer?

To analyze national trends and demographic disparities in ischemic heart disease mortality with documented tobacco use disorder among United States adults from 1999 to 2023.

Alyaa Ahmed Ibrahim; Zuha Tariq; Abdul Samad; Ahmed Khairy; Alaa Eldeeb; Malik Istikhar Ali Sajjad; Abdelrhman Hassan Mohamed; Walid Bechibchi; Mohamed Alatfawy; Karim Othman Abdelnaim; Amr M. Ibrahim; Ahmed Atef Mohamed; Rodina Sharaf; Irfan Ullah; Mohamed Fawzi Hemida

doi:10.1186/s13690-026-02013-y

July 18, 2026Archives of Public HealthOpen Access

Ischemic heart disease mortality with documented tobacco use in the United States, 1999–2023: a nationwide population-based analysis

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Key result

US tobacco-related ischemic heart disease mortality jumped over eightfold between 1999 and 2023.

AAPC 10.71
95% CI 8.35-13.12
P<0.01
n=1,497,919

Figures

Why the study?

Tobacco use is a major risk factor for ischemic heart disease, increasing premature mortality, prompting this analysis of U.S. trends in IHD mortality with documented tobacco use disorder from 1999 to 2023.

Key Points

To analyze national trends and demographic disparities in ischemic heart disease mortality with documented tobacco use disorder among United States adults from 1999 to 2023.
Analyzed CDC mortality records for 1,497,919 adults aged ≥ 25 years with ischemic heart disease (ICD-10: I20–I25) and documented tobacco use (ICD-10: F17) listed as contributing causes of death between 1999 and 2023.
Calculated age-adjusted mortality rates (AAMRs) per 100,000 population and crude mortality rates (CMRs).
Applied joinpoint regression models to estimate annual percent change (APC) and average annual percent change (AAPC) across demographic, geographic, and temporal strata.
The overall AAMR rose from 3.90 per 100,000 in 1999 to 32.37 per 100,000 in 2023, reflecting an AAPC of 10.71 (95% CI: 8.35 to 13.12; p < 0.01).
Males had a higher overall AAMR than females (39.68 vs. 14.05; AAPC: 10.72 vs. 10.77), and adults aged ≥ 65 years exhibited the highest CMR (92.16; AAPC: 11.68, 95% CI: 9.37 to 14.04; p < 0.01).
Non-Hispanic Whites experienced the highest AAMR (26.86), followed by American Indians (25.43), Non-Hispanic Blacks (19.77), and Hispanics (10.38); geographically, the Midwest (AAMR: 32.96) and non-metropolitan rural areas (AAMR: 35.73 vs. 22.95 urban) had the greatest burden.

Study Design

Type

Observational (n=1,497,919)

Structured PICO

P

Population

1,497,919 adults aged 25 years and older in the United States who died between 1999 and 2023 with ischemic heart disease and documented tobacco use.

O

Outcome

Age-adjusted mortality rates (AAMRs) per 100,000 population for ischemic heart disease with documented tobacco usehard clinical

Main Result

Effect estimate: AAPC 10.71 (95% CI 8.35-13.12)

Absolute Event Rate: 32.37% vs 3.9%

p-value: p=<0.01

Despite overall declines in smoking prevalence, documented tobacco-related ischemic heart disease mortality has risen sharply in the US over the past 25 years, disproportionately affecting older males, rural populations, and the Midwest.

Limitations

Potential misdiagnosis, underreporting, or omission of IHD or tobacco use on death certificates
Lack of detailed patient-level information such as frequency and duration of smoking, pack years, and comorbidities
Observed trends may be influenced by changes in death certification practices, coding behavior, and reporting completeness over time
Reliance on ICD-10 code F17 as a contributing cause rather than a direct measure of smoking-attributable mortality
COVID-19 pandemic serves as a major confounding factor for mortality data from 2020 onwards
Use of the 2000 standard U.S. population for age adjustment may not fully account for demographic changes over the past 25 years
Temporal variability in tobacco use disorder documentation on death certificates
Shift from ICD-9 to ICD-10 coding practices
Potential instability in states with small populations
Confounding effect of the COVID-19 pandemic from 2020 onwards
Increased use of high-sensitivity troponin altering IHD diagnosis rates

Implication

Rising tobacco-linked IHD mortality signals need for intensified cessation efforts; extends trend data but leaves causal drivers open for prospective study.

Abstract

Background Tobacco use is a major risk factor for ischemic heart disease (IHD), substantially increasing the likelihood of myocardial infarction, stroke, and premature mortality. This study examined U.S. trends in IHD mortality with documented tobacco use disorder from 1999 to 2023. Methods CDC mortality data for adults aged ≥ 25 years with IHD (ICD-10 codes: I20–I25) and documented tobacco use (ICD-10 code: F17) listed as contributing causes of death were analyzed. Age-adjusted mortality rates (AAMRs) per 100,000 population were calculated. Joinpoint regression was used to estimate annual percent change (APC) and average annual percent change (AAPC). Results From 1999 to 2023, 1,497,919 deaths were reported. The AAMR rose from 3.90 to 32.37 (AAPC: 10.71; p < 0.01). Males had a higher AAMR (39.68; AAPC: 10.72) than females (14.05; AAPC: 10.77). Non-Hispanic (NH) Whites had the highest AAMR (26.86), followed by American Indians (25.43), NH Blacks (19.77), and Hispanics (10.38). The Midwest had the highest regional AAMR (32.96). Most deaths occurred in inpatient facilities (27.9%). Adults aged ≥ 65 years had the highest mortality rate (CMR: 92.16). Rural areas exceeded urban (35.73 vs. 22.95). Conclusion IHD mortality with documented tobacco use has risen sharply, disproportionately affecting older adults, males, rural areas, the Midwest, and NH Whites.

Discussion

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Cite This Study

Ibrahim et al. (2026) conducted an observational in Ischemic heart disease with documented tobacco use (n=1,497,919). Tobacco use was evaluated on Age-adjusted mortality rate (AAMR) per 100,000 population (AAPC 10.71, 95% CI 8.35-13.12, p=<0.01). The age-adjusted mortality rate for ischemic heart disease with documented tobacco use in the US increased significantly from 3.90 in 1999 to 32.37 per 100,000 population in 2023 (AAPC 10.71).

synapsesocial.com/papers/6a5dba3f8bd453d3397ab827 https://doi.org/10.1186/s13690-026-02013-y

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Ischemic heart disease mortality with documented tobacco use in the United States, 1999–2023: a nationwide population-based analysis

Figures

Key Points

Study Design

Structured PICO

Main Result

Limitations

Implication

Abstract

Discussion

Cite This Study

Ischemic heart disease mortality with documented tobacco use in the United States, 1999–2023: a nationwide population-based analysis

Figures

Key Points

Study Design

Structured PICO

Main Result

Limitations

Implication

Abstract

Discussion

Cite This Study

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