Tobacco use and risk of all-cause mortality in individuals with prior myocardial infarction or stroke: A prospective population-based study

BACKGROUND AND OBJECTIVES: Smoking cessation is a key secondary and tertiary prevention strategy in individuals with cardiovascular disease. We aimed to describe tobacco use among individuals with a history of myocardial infarction (MI) or stroke in Spain, identify factors associated with continued smoking, and assess its association with all-cause mortality. METHODS: Prospective cohort study including 65990 participants aged ≥15 years from the 2011 and 2017 National Health Surveys and the 2014 European Health Survey in Spain, linked to mortality registry data through December 2023. Smoking status was self-reported at baseline. Logistic regression was used to identify factors associated with continued smoking among individuals with prior cardiovascular events. Poisson regression models were used to estimate relative risks (RRs) for all-cause mortality. RESULTS: Overall, 13.3% of people with a history of MI or stroke consumed tobacco. Among these, younger individuals, women, and individuals reporting excessive alcohol consumption or sedentary leisure time were more likely to continue smoking. Compared to never smokers with no history of MI, former smokers with previous MI had a mortality RR of 1.36 (95% CI: 1.18-1.58), increasing to 2.26 (95% CI: 1.62-3.16) among current smokers. In participants with a history of stroke, corresponding RR were 1.40 (95% CI: 1.16-1.69) for former smokers and 2.48 (95% CI: 1.70-3.61) for current smokers. CONCLUSIONS: A substantial proportion of individuals with prior cardiovascular events continue smoking. Current smoking was associated with higher mortality compared to those who quit smoking, underscoring the importance of strengthening tobacco control interventions in secondary and tertiary cardiovascular prevention.