Heart failure and tobacco use disorder: mortality trends and disparities in the United States

Introduction: Tobacco use disorder is associated with increased morbidity and mortality from heart failure (HF) in the United States. Despite this burden, long-term trends in HF mortality among tobacco users and the extent of demographic and geographic disparities remain poorly understood, limiting targeted prevention and intervention strategies. This study examines these trends and disparities using the CDC WONDER database. Methods: Mortality data from 2003 to 2020 were analyzed for individuals aged ≥25 years with tobacco use disorder who died from HF. Age-adjusted mortality rates (AAMRs) per 100 000 general population were calculated. Joinpoint regression estimated annual percentage changes. Subgroup analyses were conducted by sex, race/ethnicity, region, and rural-urban classification. Results: From 2003 to 2020, 576 781 HF deaths occurred among tobacco users aged ≥25 years. The overall AAMR nearly quadrupled during this period. Men consistently exhibited higher AAMRs than women. Among racial/ethnic groups, American Indians or Alaska Natives had the highest rates, followed by Whites, Blacks, and Asian or Pacific Islanders. Regionally, the Midwest recorded the highest mortality, followed by the South, Northeast, and West. Rural populations had higher AAMRs than urban populations. At the state level, Oregon showed the highest AAMR, while California had the lowest. Conclusion: The sharp rise in HF mortality among tobacco users underscores critical public health gaps. Disparities were most pronounced among men, American Indians or Alaska Natives, Midwestern residents, and rural populations. By identifying high-risk populations and regions, this study provides actionable insights to guide targeted interventions, tobacco cessation programs, and equitable healthcare access, helping to address the growing burden of HF in tobacco users.