Heart Disease and Stroke Statistics—2022 Update: A Report From the American Heart Association

Abbreviations Table e165

About These Statistics e170

Cardiovascular Health e173

Smoking/Tobacco Use e194

Physical Activity and Sedentary Behavior e210

Nutrition e223

Overweight and Obesity e246

High Blood Cholesterol and Other Lipids e260

High Blood Pressure e274

Diabetes e290

Metabolic Syndrome e311

Adverse Pregnancy Outcomes e333

Kidney Disease e354

Sleep e366

Total Cardiovascular Diseases e374

Stroke (Cerebrovascular Diseases) e391

Brain Health e427

Congenital Cardiovascular Defects and Kawasaki Disease e445

Disorders of Heart Rhythm e462

Sudden Cardiac Arrest, Ventricular Arrhythmias, and Inherited Channelopathies e489

Subclinical Atherosclerosis e517

Coronary Heart Disease, Acute Coronary Syndrome, and Angina Pectoris e528

Cardiomyopathy and Heart Failure e547

Valvular Diseases e562

Venous Thromboembolism (Deep Vein Thrombosis and Pulmonary Embolism), Chronic Venous Insufficiency, Pulmonary Hypertension e580

Peripheral Artery Disease and Aortic Diseases e591

Quality of Care e611

Medical Procedures e625

Economic Cost of Cardiovascular Disease e630

At-a-Glance Summary Tables e633

Glossary e637

A report pooled NHANES (National Health and Nutrition Examination Survey) 2011 to 2016 data and individual-level data from 7 US community-based cohort studies and estimated that 70.0% of major CVD events in the United States were attributable to low and moderate CVH; 2.0 million major CVD events could potentially be prevented each year if all US adults attain high CVH; and even a partial improvement in CVH scores to the moderate level among all US adults with low overall CVH could lead to a reduction of 1.2 million major CVD events annually.

The large number of individuals in the United States who contracted severe illness because of coronavirus disease 2019 (COVID-19) resulted in a huge mortality toll. As of March 2021, the cumulative number of COVID-19 deaths in the United States was ≈545 000, which equates to ≈166 cases per 100 000 people, with higher rates of deaths occurring among US counties with metropolitan areas (≈185 deaths per 100 000), with a high percentage (>45.5%) of the population that is non-Hispanic (NH) Black (≈200 deaths per 100 000), with a high proportion (>37%) of the population that is Hispanic (≈219 deaths per 100 000), or with a high percentage (>17.3%) of the population that are living in poverty (≈211 deaths per 100 000 people).

Because of the high COVID-19 mortality rates, life expectancy in the United States for the year 2020 has been estimated to decline with disproportionate impacts on populations with high COVID-19 mortality rates. Provisional US life expectancy estimates for January to June 2020 indicate that between 2019 and the first half of 2020, life expectancy decreased from 74.7 to 72.0 years for NH Black individuals, from 81.8 to 79.9 years for Hispanic individuals, and from 78.8 to 78.0 years for NH White individuals.

The prevalence of cigarette use in the past 30 days among middle and high school students in the United States was 1.6% and 4.6%, respectively, in 2020.

Although there has been a consistent decline in adult and youth cigarette use in the United States in the past 2 decades, significant disparities persist. Substantially higher tobacco use prevalence rates are observed in American Indian/Alaska Native adults and youth and lesbian, gay, and bisexual adults.

Over the past 9 years, there has been a sharp increase in electronic cigarette use among adolescents, increasing from 1.5% to 19.6% between 2011 and 2020; electronic cigarettes are now the most commonly used tobacco product in this demographic.

According to nationwide self-reported PA (YRBSS [Youth Risk Behavior Surveillance System], 2019), the prevalence of high school students who engaged in ≥60 minutes of PA on at least 5 days of the week was 44.1% and was lower with each successive grade (from 9th [49.1%]–12th [40.0%] grades).

From nationwide self-reported PA (NHIS, 2018), the age-adjusted proportion who reported meeting the 2018 aerobic PA guidelines for Americans was 54.2%.

An umbrella review of 24 systematic reviews of adults ≥60 years of age concluded that those who are physically active are at a reduced risk of CVD mortality (25%–40% risk reduction), all-cause mortality (22%–35%), breast cancer (12%–17%), prostate cancer (9%–10%), and depression (17%–31%) while experiencing better quality of life, healthier aging trajectories, and improved cognitive functioning.

Data from the Nurses’ Health Study (1984–2014) and Health Professionals Follow-up Study showed that daily intake of 5 servings of fruit and vegetables (versus 2 servings/d) was associated with 13% lower total mortality, 12% lower CVD mortality, 10% lower cancer mortality, and 35% lower respiratory disease mortality.

NHANES data and meta-analyses of prospective cohort studies show that higher intakes of total fat, polyunsaturated fatty acids, and monounsaturated fatty acids are associated with lower total mortality. However, the evidence for saturated fatty acid intake as a risk or protective factor for total and CVD mortality remains controversial.

Meta-analytic evidence from randomized clinical trials does not support vitamin D supplementation for improving cardiometabolic health in children and adolescents between 4 and 19 years of age.

From NHANES data, the overall prevalence of obesity and severe obesity in youth 2 to 19 years of age increased from 13.9% to 19.3% and 2.6% to 6.1% between 1999 to 2000 and 2017 to 2018. Over the same period, the prevalence of obesity and severe obesity increased from 14.0% to 20.5% and from 3.7% to 6.9% for males and from 13.8% to 18.0% and from 3.6% to 5.2% for females.

From NHANES data, among adults, from 1999 to 2000 through 2017 to 2018, the prevalence of obesity among males increased from 27.5% to 43.0% and severe obesity increased from 3.1% to 6.9%. The prevalence of obesity among females increased from 33.4% to 41.9% and severe obesity from 6.2% to 11.5%.

Significant increases in the prevalence of obesity were seen between 1999 to 2000 through 2017 to 2018 in all age-race and ethnicity groups except for NH Black males, in whom the prevalence increased from 1999 through 2006.

In 2015 to 2018, unfavorable lipid measures of low-density lipoprotein cholesterol ≥130 mg/dL were present in 6.1% of male adolescents and 3.0% of female adolescents 12 to 19 years of age, triglycerides ≥130 mg/dL were present in 9.7% of male adolescents and 6.6% of female adolescents, and high-density lipoprotein cholesterol measures <40 mg/dL were present in 18.4% of male adolescents and 7.4% of female adolescents.

In 2015 to 2018, total cholesterol ≥200 mg/dL was present in 38.1% of adults, low-density lipoprotein cholesterol ≥130 mg/dL was present in 27.8% of adults, triglycerides ≥150 mg/dL were present in 21.1% of adults, high-density lipoprotein cholesterol <40 mg/dL was present in 17.2% of adults.

From 2009 to 2019, the death rate attributable to high BP increased 34.2%, and the actual number of deaths attributable to high BP rose 65.3%.

The 2019 age-adjusted death rate attributable primarily to high BP was 25.1 per 100 000 people. Age-adjusted death rates attributable to high BP (per 100 000 people) in 2019 were 25.7 for NH White males, 56.7 for NH Black males, 23.1 for Hispanic males, 17.4 for NH Asian/Pacific Islander males, 31.9 for NH American Indian/Alaska Native males, 20.6 for NH White females, 38.7 for NH Black females, 17.4 for Hispanic females, 14.5 for NH Asian/Pacific Islander females, and 22.4 for NH American Indian/Alaska Native females.

In an analysis of 18 262 adults ≥18 years of age with hypertension (defined as 140/90 mm Hg) in NHANES, the estimated age-adjusted proportion with controlled BP increased from 31.8% in 1999 to 2000 to 48.5% in 2007 to 2008, remained relatively stable at 53.8% in 2013 to 2014, but declined to 43.7% in 2017 to 2018.

In NHANES 2015 to 2018, an estimated 28.2 million adults (10.4%) had diagnosed diabetes, 9.8 million adults (3.8%) had undiagnosed diabetes, and 113.6 million adults (45.8%) had prediabetes.

In NHANES 2003 through 2016, among adults with diagnosed and undiagnosed diabetes, the proportion taking any medication increased from 58% in 2003 through 2004 to 67% in 2015 through 2016, with an increase in the use of metformin and insulin analogs and decrease in sulfonylureas, thiazolidinediones, and human insulin.

In NHANES 1988 through 2018, among adults with newly diagnosed type 2 diabetes, there was a significant increase in the proportion of individuals with hemoglobin A1c <7% (59.8% for 1998–1994 and 73.7% for 2009–2018) and decreases in mean hemoglobin A1c (7.0% and 6.7%), mean BP (130.1/77.5 and 126.0/72.1 mm Hg), and mean total cholesterol (219.4 and 182.4 mg/dL). The proportion with hemoglobin A1c <7.0%, BP <140/90 mm Hg, and total cholesterol <240 mg/dL improved from 31.6% to 56.2%.

In the HELENA study (Healthy Lifestyle in Europe by Nutrition in Adolescence) among 1037 European adolescents 12.5 to 17.5 years of age, those with mothers with low education showed a higher metabolic syndrome (MetS) risk score (β estimate, 0.54) compared with those with highly educated mothers. Adolescents who accumulated >3 disadvantages (defined as parents with low education, low family affluence, migrant origin, unemployed parents, or nontraditional families) had a higher MetS risk score compared with those who did not experience disadvantage (β estimate, 0.69).

In HCHS/SOL (Hispanic Community Health Study/Study of Latinos), socioeconomic status was inversely associated with prevalent MetS among Hispanic/Latino adults of diverse ancestry groups. Higher income and education and full-time employment status versus unemployed status were associated with a 4%, 3%, and 24% decreased odds of having MetS, respectively. The association with income was significant only among females and those with current health insurance.

In combined analysis from ARIC (Atherosclerosis Risk in Communities) and JHS (Jackson Heart Study), among 13 141 White and Black individuals with a mean follow-up of 18.6 years, risk of ischemic stroke increased consistently with MetS severity z score (hazard ratio [HR], 1.75) for those above the 75th percentile compared with those below the 25th percentile. Risk was highest for White females (HR, 2.63), although without significant interaction by sex and race.

Adverse pregnancy outcomes (including hypertensive disorders of pregnancy, gestational diabetes, preterm birth, and small for gestational age at birth) occur in 10% to 20% of pregnancies.

Among 2304 female-newborn dyads in the multinational HAPO study (Hyperglycemia and Adverse Pregnancy Outcome), lower CVH (based on 5 metrics: body mass index, BP, cholesterol, glucose, and smoking) at 28 weeks’ gestation was associated with a higher risk of preeclampsia; adjusted relative risks were 3.13, 5.34, and 9.30 for females with ≥1 intermediate, 1 poor, or ≥2 poor (versus all ideal) CVH metrics during pregnancy, respectively.

In analyses of Swedish national birth register data (>2 million–>4 million individuals), gestational age at birth was inversely associated with the risks for type 1 diabetes, type 2 diabetes, hypertension, and lipid disorders among individuals born preterm versus term.

Overall prevalence of chronic kidney disease (estimated glomerular filtration rate <60 mL·min⁻¹·1.73 m⁻² or albumin-to-creatinine ratio ≥30 mg/g) was 14.9% (2015–2018).

Age-, race-, and sex-adjusted prevalence of end-stage renal disease in the United States was 2242 per million people (in 2018) with highest rates among Black adults followed by American Indian/Alaska Native adults, Asian adults, and White adults.

Medicare spent $81 billion caring for people with chronic kidney disease and $49.2 billion on those with end-stage renal disease in 2018.

In data from the 2014 BRFSS (Behavioral Risk Factor Surveillance System), 11.8% of people reported a sleep duration ≤5 hours, 23.0% reported 6 hours, 29.5% reported 7 hours, 27.7% reported 8 hours, 4.4% reported 9 hours, and 3.6% reported ≥10 hours. Overall, 65.2% met the recommended sleep duration of ≥7 hours.

Analysis of the UK Biobank study (N=468 941) found that participants who reported short sleep (<7 h/d) or long sleep (>9 h/d) had an increased risk of incident HF compared with normal sleepers (7–9 h/d). In males, the adjusted HR was 1.24 for short sleep and 2.48 for long sleep. In females, the adjusted HR was 1.39 for short sleep and 1.99 for long sleep.

A meta-analysis of 15 prospective studies observed a significant association between the presence of obstructive sleep apnea and the risk of cerebrovascular disease (HR, 1.94).

In the Cardiovascular Lifetime Risk Pooling Project among 30 447 participants from 7 US cohort studies, among individuals ≥60 years of age with low CVH, the 35-year risk of CVD was highest in White males (65.5%), followed by White females (57.1%), Black females (51.9%), and Black males (48.4%). These estimated risks accounted for competing risks of death caused by non-CVD causes.

In a meta-analysis of 14 studies that focused on CVD among individuals diagnosed with COVID-19, preexisting CVD had a relative risk of 2.25 for death resulting from COVID-19.

In 2020, ≈19 million deaths were attributed to CVD globally, which amounted to an increase of 18.7% from 2010.

In the Greater Cincinnati Northern Kentucky Stroke Study, sex-specific ischemic stroke incidence rates declined significantly between 1993 to 1994 and 2015 for both males and females. In males, there was a decline from 282 to 211 per 100 000. In females, the decline was from 229 to 174 per 100 000. This trend was not observed for intracerebral hemorrhage or subarachnoid hemorrhage.

In the Northern Manhattan Study, among 3298 stroke-free participants followed up through 2019, Black and Hispanic females ≥70 years of age had higher risk of stroke compared with White females after controlling for age, sex, education, and insurance status (Black females/White females: HR, 1.76; Hispanic females/White females: HR, 1.77). This increased risk was not present among elderly Black or Hispanic males compared with White males.

A systematic analysis of data from the GBD study (Global Burden of Disease) showed that, in 2017, Alzheimer disease/Alzheimer disease and related dementia was the fourth most prevalent neurological disorder in the United States (2.9 million people). Among neurological disorders, Alzheimer disease/Alzheimer disease and related dementia was the leading cause of mortality in the United States (38 deaths per 100 000 population per year) ahead of stroke.

In 2017, Alzheimer disease/Alzheimer disease and related dementia had the fifth leading incidence rate of neurological disorders in the United States according to the GBD study data. The US age-standardized incidence rate of Alzheimer disease/Alzheimer disease and related dementia was 85 cases per 100 000 people).

In a meta-analysis of 12 randomized controlled trials (>92 000 participants; mean age, 69 years; 42% females), BP lowering with antihypertensive agents, compared with control, was associated with a lower risk of incident dementia or cognitive impairment (7.0% versus 7.5% of patients over a mean trial follow-up of 4.1 years; odds ratio [OR], 0.93; absolute risk reduction, 0.39%).

The 2017 all-age prevalence of congenital cardiovascular defects in the United States was estimated at 466 566 individuals, with 279 320 (60%) of these under the age of <20 years of age. The 2017 global prevalence of congenital cardiovascular defects was estimated at 157 per 100 000 people. with the highest prevalence estimates in countries with a low sustainable development index (238 per 100 000 people) and the lowest in those with a high-middle or high sustainable development index (112 and 135 per 100 000 people, respectively).

Congenital cardiovascular defects appear to be more common among infants born to mothers with low socioeconomic status. In Ontario, mothers who lived in the lowest-income neighborhoods had higher risk of having an infant with a congenital cardiovascular defect compared with mothers living in the highest-income neighborhoods (OR, 1.29). Furthermore, this discrepancy between low and high was also found across measures of neighborhood education (OR, 1.34) and employment rate (OR, 1.18).

Since May 2020, the Centers for Disease Control and Prevention has been tracking reports of multisystem inflammatory syndrome in children. As of June 28, 2021, 4196 cases and 37 attributable deaths (0.89%) have been reported. Median age of cases was 9 years; 62% of cases have occurred in children who are Hispanic or Latino (1246 cases) or Black (1175 cases); 99% tested positive for severe acute respiratory syndrome coronavirus 2 (reverse transcription–polymerase chain reaction, serology, or antigen test); and 60% of reported patients were male.

A systematic review and meta-analysis of 18 published studies reported short-term and long-term associations of air pollution with atrial fibrillation (AF). For 10-mg/m³ increases in PM_2.5 and PM₁₀ concentrations, the OR of AF was 1.01 and 1.03, respectively. The corresponding ORs for long-term exposure were 1.07 for PM_2.5 and 1.03 for PM₁₀. SO₂ and NO₂ were also associated with AF in the short term: ORs for 10-ppb increments were 1.05 and 1.03, respectively.

A multicenter, open-label, randomized trial evaluated a 2-week continuous electrocardiographic patch and an automated home BP machine with oscillometric AF screening capability for the detection of AF compared with usual care over a 6-month period in participants ≥75 years of age with hypertension. AF detection was 5.3% in the screening group compared with 0.5% in the control group (risk difference, 4.8%; number needed to screen, 21). By 6 months, anticoagulation was more frequently prescribed in the intervention group (4.1% versus 0.9%; risk difference, 3.2%).

AF has been associated with increased mortality in patients with COVID-19. A meta-analysis of studies published in 2020, including 23 studies and 108 745 patients with COVID-19, showed that AF was associated with increased mortality (pooled effect size, 1.14).

There was a 119% increase in out-of-hospital cardiac arrest during the pandemic compared with earlier control periods in a meta-analysis in 10 countries. For the patients with known outcomes (n=10 992), mortality was 85% compared with 62% for the control periods.

Coinciding with timing of the pandemic in the United States, CARES Registry (Cardiac Arrest Registry to Enhance Survival) data indicate increased delays to initiation of cardiopulmonary resuscitation for out-of-hospital cardiac arrest and reduced survival after out-of-hospital cardiac arrest. Accompanying these effects were reductions in the frequency of shockable rhythms, out-of-hospital cardiac arrest in public locations, and bystander automated external defibrillator use, whereas field termination of resuscitation efforts increased. There was no significant alteration in frequency of bystander cardiopulmonary resuscitation.

Survival to hospital discharge was 22.4% of 33 874 adult pulseless in-hospital cardiac arrests at 328 hospitals in Get With The Guidelines 2020 data. Among survivors, 79.5% had good functional status (Cerebral Performance Category 1 or 2) at hospital discharge.

In 3116 MESA (Multi-Ethnic Study of Atherosclerosis) participants (58±9 years of age, 63% females) who had no detectable coronary artery calcification (CAC) at baseline and were followed up over 10 years, CAC score >0, CAC score >10, and CAC score >100 were seen in 53%, 36%, and 8% of individuals at 10 years, respectively.

In a study with 12.3 years of mean follow-up, cancer-related mortality was 1.55-fold higher in individuals who had a CAC score ≥1000 at baseline compared with those who had a CAC score of 0 at baseline, after adjustment for age, sex, and risk factors.

In 9388 US and Finnish individuals with longitudinal measurement of CVD risk factors and carotid intima-media thickness, CVH declined from childhood to adulthood and was associated with thickening of the intima-media thickness.

In a European registry of high-volume percutaneous coronary intervention centers, the COVID-19 pandemic was associated with a significant increase in door-to-balloon and total ischemia times. Door-to-balloon time >30 minutes was 57.0% in the period of March to April 2020 compared with 52.9% in March to April 2019 (P=0.003), whereas total ischemia time >12 hours was 11.7% in the 2020 period compared with 9.1% in 2019 (P=0.001).

In a retrospective cohort study of Medicare fee-for-service patients (N=453 783) who were diagnosed with coronary artery disease, patients that received care at the most socioeconomically deprived practices had higher odds of being admitted for unstable angina (adjusted OR, 1.46) and higher 30-day mortality rates after acute myocardial infarction (adjusted OR, 1.31). After additional adjustment for patient-level area deprivation index, these associations were attenuated (unstable angina adjusted OR, 1.20; 30-day mortality after myocardial infarction adjusted OR, 1.31).

A pooled analysis of 21 randomized percutaneous coronary intervention trials including 32 877 patients (28% females) found that female sex was an independent risk factor for major adverse cardiovascular events (HR, 1.14) and ischemia-driven target lesion vascularization (HR, 1.23) but not of all-cause or cardiovascular mortality (HR, 0.91 and 0.97, respectively).

The lifetime risk of HF remains high, with variation across racial and ethnic groups ranging from 20% to 45% after 45 years of age.

Secular trends show that the incidence of HF with preserved ejection fraction is increasing and, in contrast, the incidence of HF with reduced ejection fraction is decreasing, whereas both HF subtypes have similar all-cause mortality rates.

Contemporary HF with reduced ejection fraction guideline-directed medical therapy is estimated to reduce the hazard of cardiovascular death or HF hospitalization by up to 62% compared with limited conventional therapy.

The number of elderly patients with calcific aortic stenosis is projected to more than double by 2050 in both the United States and Europe according to a simulation model in 7 decision analysis studies.

The pooled prevalence of all aortic stenosis in the elderly is 12.4%, and the prevalence of severe aortic stenosis is 3.4%. The annual volume of transcatheter aortic valve replacement (TAVR) has increased each year since 2011. After the US Food and Drug Administration approval of TAVR for low-risk patients in 2019, the TAVR volume exceeded all forms of surgical aortic valve replacement (n=72 991 versus n=57 626). From 2011 through 2018, extreme- and high-risk patients remained the largest cohort undergoing TAVR, but in 2019, the intermediate-risk cohort was the largest, and low-risk patients with a median 75 years of age increased to 8395, making up 11.5% of all patients undergoing TAVR.

In 2018, there were an estimated ≈1 015 000 total venous thromboembolism cases in the United States.

In addition, 2019 data show that 37 571 deaths (any mention) resulted from pulmonary embolism and 27 574 deaths (any mention) resulted from pulmonary hypertension.

In the COVID-19 scenario, the incidence of venous thromboembolism was up to 31% in hospitalized patients. Among them, those who were admitted to the intensive care unit had a 2- to 3-fold greater risk of developing deep vein thrombosis or pulmonary embolism.

From 2011 to 2019, the global prevalence of peripheral artery disease was 5.56% with a higher prevalence in high- compared with low- to middle-income countries (7.37% versus 5.09%, respectively). In 2015, it was estimated that 236.62 million people ≥25 years of age were living with peripheral artery disease.

In an analysis of 393 017 patients who underwent lower extremity arterial revascularization, 50 750 (12.9%) had at least 1 subsequent hospitalization for major adverse limb events.

In a population-based screening study of 14 989 participants 60 to 74 years of age, male sex (OR, 1.9), hypertension (OR, 1.8), and family history (OR, 1.6) were associated with a heightened risk of ascending thoracic aortic aneurysm. Diabetes was associated with a lower risk (OR, 0.8).

Compared with 2019, a lower proportion of cases received bystander cardiopulmonary resuscitation in 2020, and use of automated external defibrillators was lower. There were also longer emergency medical services response times and lower survival to hospital discharge. Those are likely related to the COVID-19 pandemic.

In a Get With The Guidelines–HF study, inclusion in Medicare Advantage led to a higher proportion of discharge to home with no difference in mortality compared with fee-for-service programs.

In data from the PINNACLE Registry (Practice Innovation and Clinical Excellence), only about two-thirds of the individuals were treated with appropriate statin therapy as recommended in the American College of Cardiology/AHA guidelines. In addition, higher income was associated with higher likelihood of appropriate statin therapy.

As per the Society of Thoracic Surgeons/American College of Cardiology transcatheter valve therapy registry data, TAVR volumes continue to grow, with 13 723 TAVR procedures in 2011 to 2013 and 72 991 TAVR procedures in 2019. In 2019, 669 sites were performing TAVR. In 2019, TAVR volumes (n=72 991) exceeded the volumes for all forms of surgical aortic valve replacement (n=57 626).

In 2020, 3658 heart transplantations were performed in the United States, the most ever. The highest number of heart transplantations were performed in the states of California (496), Texas (302), Florida (288), and New York (250).

A global survey of 909 inpatient and outpatient centers performing cardiovascular diagnostic procedures in 108 countries compared procedural volumes for common cardiovascular diagnostic procedures between March 2019 and March 2020/April 2020. This survey indicated that cardiovascular diagnostic procedures decreased by 64% from March 2019 to April 2020.

The average annual direct and indirect cost of CVD in the United States was an estimated $378.0 billion in 2017 to 2018.

The estimated direct costs of CVD in the United States increased from $103.5 billion in 1996 to 1997 to $226.2 billion in 2017 to 2018.

By event type, hospital inpatient stays accounted for the highest direct cost ($99.6 billion) in 2017 to 2018 in the United States.

ACC NCDR’s Chest Pain–MI Registry (formerly the ACTION Registry)—quality information for AMI

ARIC—CHD and HF incidence rates

BRFSS—ongoing telephone health survey system

GBD—global disease prevalence, mortality, and healthy life expectancy

GCNKSS—stroke incidence rates and outcomes within a biracial population

GWTG—quality information for resuscitation, HF, and stroke

HCUP—hospital inpatient discharges and procedures

MEPS—data on specific health services that Americans use, how frequently they use them, the cost of these services, and how the costs are paid

NAMCS—physician office visits

NHAMCS—hospital outpatient and ED visits

NHANES—disease and risk factor prevalence and nutrition statistics

NHIS—disease and risk factor prevalence

NVSS—mortality for the United States

USRDS—kidney disease prevalence

WHO—mortality rates by country

YRBS—health-risk behaviors in youth and young adults

Multiple independent investigations (summaries of which are provided in this chapter) have confirmed the importance of having ideal levels of these components, along with the overall concept of CVH. Findings include strong inverse, stepwise associations in the United States of the number of CVH components at ideal levels with all-cause mortality, CVD mortality, IHD mortality, CVD, and HF; with subclinical measures of atherosclerosis such as carotid IMT, arterial stiffness, and CAC prevalence and progression; with physical functional impairment and frailty; with cognitive decline and depression; and with longevity.^3–8 Similar relationships have also been seen in non-US populations.^3,4,9–22

A large Hispanic/Latino cohort study in the United States confirmed the associations between CVD and status of CVH components in this population and found that the levels of CVH components compared favorably with existing national estimates; however, some of the associations varied by sex and heritage.⁴

A study of Black people found that risk of incident HF was 61% lower among those with ≥4 ideal CVH components than among those with 0 to 2 ideal components.⁵

Ideal health behaviors and ideal health factors are each independently associated with lower CVD risk in a stepwise fashion; across any level of health behaviors, health factors are associated with incident CVD, and conversely, across any level of health factors, health behaviors are associated with incident CVD.²³

Analyses from the US Burden of Disease Collaborators demonstrated that poor levels of each of the 7 CVH components resulted in substantial mortality and morbidity in the United States in 2010. The leading risk factor related to overall disease burden was suboptimal diet, followed by tobacco smoking, high BMI, raised BP, high FPG, and physical inactivity.²⁴

A meta-analysis of 9 prospective cohort studies involving 12 878 participants reported that having the highest number of ideal CVH components was associated with a lower risk of all-cause mortality (RR, 0.55 [95% CI, 0.37–0.80]), cardiovascular mortality (RR, 0.25 [95% CI, 0.10–0.63]), CVD (RR, 0.20 [95% CI, 0.11–0.37]), and stroke (RR, 0.31 [95% CI, 0.25–0.38]) compared with having the lowest number of ideal components.²⁵

The adjusted PAFs for CVD mortality for individual components of CVH have been reported as follows²⁶:

Several studies have been published in which investigators have assigned individuals a CVH score ranging from 0 to 14 on the basis of the sum of points assigned to each component of CVH (poor=0, intermediate=1, ideal=2 points). With this approach, data from the REGARDS cohort were used to demonstrate an inverse stepwise association between a higher CVH score component and a lower incidence of stroke. On the basis of this score, every unit increase in CVH was associated with an 8% lower risk of incident stroke (HR, 0.92 [95% CI, 0.88–0.95]), with a similar effect size for White (HR, 0.91 [95% CI, 0.86–0.96]) and Black (HR, 0.93 [95% CI, 0.87–0.98]) participants.²⁷ CVH score and components were also shown to predict MACEs (first occurrence of MI, stroke, acute ischemic syndrome, coronary revascularization, or death) over a median follow-up of 12 years in a biracial community-based population.²⁸

By combining the 7 CVH component scores and categorizing the total score to define overall CVH (low, 0–8 points; moderate, 9–11 points; high, 12–14 points), a report pooled NHANES 2011 to 2016 data and individual-level data from 7 US community-based cohort studies to estimate the age-, sex-, and race and ethnicity–adjusted PAF of major CVD events (nonfatal MI, stroke, HF, or CVD death) associated with CVH and found that 70.0% (95% CI, 56.5%–79.9%) of major CVD events in the United States were attributable to low and moderate CVH.²⁹ According to the authors’ estimates, 2.0 (95% CI, 1.6–2.3) million major CVD events could potentially be prevented each year if all US adults attain high CVH, and even a partial improvement in CVH scores to the moderate level among all US adults with low overall CVH could lead to a reduction of 1.2 (95% CI, 1.0–1.4) million major CVD events annually.

A report from the Framingham Offspring Study showed increased risks of subsequent hypertension, diabetes, CKD, CVD, and mortality associated with having a shorter duration of ideal CVH in adulthood.³⁰

The Cardiovascular Lifetime Risk Pooling Project showed that adults with all optimal risk factor levels (similar to having ideal CVH factor levels of cholesterol, blood sugar, and BP, as well as not smoking) have substantially longer overall and CVD-free survival than those who have poor levels of ≥1 of these CVH factors. For example, at an index age of 45 years, males with optimal risk factor profiles lived on average 14 years longer free of all CVD events and 12 years longer overall than people with ≥2 risk factors.³¹

Better CVH as defined by the AHA is associated with lower incidence of HF,^3,5–7,22 less subclinical vascular disease,^{8,15,17,33,34} better global cognitive performance and cognitive function,^16,35,36 lower hazard of subsequent dementia,^37,38 lower prevalence³⁹ and incidence⁴⁰ of depressive symptoms, lower loss of physical functional status,⁴¹ longer leukocyte telomere length,⁴² less ESRD,⁴³ less pneumonia, less chronic obstructive pulmonary disease,⁴⁴ less VTE/PE,⁴⁵ lower prevalence of aortic sclerosis and stenosis,⁴⁶ lower risk of calcific aortic valve stenosis,⁴⁷ better prognosis after MI,⁴⁸ lower risk of AF,⁴⁹ and lower odds of having elevated resting heart rate.⁵⁰ Using the CVH scoring approach, the FHS demonstrated significantly lower odds of prevalent hepatic steatosis associated with more favorable CVH scores, and the decrease of liver fat associated with more favorable CVH scores was greater among people with a higher GRS for NAFLD.⁵¹ In addition, a study based on NHANES data showed significantly decreased odds of ocular diseases (OR, 0.91 [95% CI, 0.87–0.95]), defined as age-related macular degeneration, any retinopathy, and cataract or glaucoma, and odds of diabetic retinopathy (OR, 0.71 [95% CI, 0.66–0.76]) associated with each unit increase in CVH among US adults.⁵²

In addition, a study among a sample of Hispanic/Latino people residing in the United States reported that greater positive psychological functioning (dispositional optimism) was associated with higher CVH scores as defined by the AHA.⁵³ A study in college students found that both handgrip strength and muscle mass were positively associated with greater numbers of ideal CVH components,⁵⁴ and a cross-sectional study found that greater cardiopulmonary fitness, upper-body flexibility, and lower-body muscular strength were associated with better CVH components in perimenopausal females.⁵⁵ Furthermore, higher quality of life scores were associated with better CVH metrics,⁵⁶ providing additional evidence to support the benefits of ideal CVH on general health and quality of life.

According to NHANES 1999 to 2006 data, several social risk factors (low family income, low education level, underrepresented racial groups, and single-living status) were related to lower likelihood of attaining better CVH as measured by Life’s Simple 7 scores.⁵⁷ In addition, neighborhood factors and contextual relationships have been found to be related to health disparities in CVH, but more research is needed to better understand these complex relationships.⁵⁸ A study focused on people with serious mental illness found that individuals of underrepresented races and ethnicities had significant lower CVH scores based on 5 of the Life’s Simple 7 components.⁵⁹

Having more ideal CVH components in middle age has been associated with lower non-CVD and CVD health care costs in later life.⁶⁰ An investigation of 4906 participants in the Cooper Center Longitudinal Study reported that participants with ≥5 ideal CVH components exhibited 24.9% (95% CI, 11.7%–36.0%) lower median annual non-CVD costs and 74.5% (95% CI, 57.5%–84.7%) lower median CVD costs than those with ≤2 ideal CVH components.⁶⁰ A report from a large, ethnically diverse insured population found that people with 6 or 7 and those with 3 to 5 of the CVH components in the ideal category had a $2021 and $940 lower annual mean health care expenditure, respectively, than those with 0 to 2 ideal health components.⁶¹

The national prevalence estimates for children (12–19 years of age) and adults (≥20 years of age) who meet ideal, intermediate, and poor levels of each of the 7 CVH components are displayed in Chart 2-1.⁶² The most current estimates at the time of publication were based on data from NHANES 2017 to 2018. NHANES 2017 to 2018 survey changed the PA assessments for children, so the PA status for children was updated according to data from respondents who were 18 to 19 years of age.

For most components of CVH, prevalence of ideal levels is higher in US children (12–19 years of age) than in US adults (≥20 years of age), except for the Healthy Diet Score, for which prevalence of ideal levels in children is lower than in adults. For PA, the contrast for adults versus children is not clear because the prevalence estimate for children was from a subgroup of children only.

Among US children (12–19 years of age; Chart 2-1), the unadjusted prevalence of ideal levels of CVH components currently varies from <1% for the Healthy Diet Score (ie, <1 in 100 US children meets at least 4 of the 5 dietary components) to >79% for smoking, BP, and diabetes components (95.7%, 89.1%, and 79.0% respectively; unpublished AHA tabulation).

Among US adults (Chart 2-1), the lowest prevalence of ideal levels for CVH components is <1% for the Healthy Diet Score in adults ≥20 years of age. The highest prevalence of ideal levels for a CVH component is for smoking (79.8% of adults report never having smoked or being a former smoker who has quit for >12 months). In 2017 to 2018, 52.4% of adults had ideal levels of TC (<200 mg/dL).

Age-standardized and age-specific prevalence estimates for ideal CVH and for ideal levels of individual CVH components for 2017 to 2018 are displayed in Table 2-2.

In 2017 to 2018, all individual components of CVH among adults were highest in the youngest age groups (20–39 years of age) and were lowest in the oldest age group (≥60 years of age), except smoking and the Healthy Diet Score, for which prevalence of ideal levels was highest in older adults. For the Healthy Diet Score, all age groups had a prevalence of ideal level <1% according to the 2017 to 2018 NHANES data.

Chart 2-2 displays the unadjusted prevalence estimates of ideal levels of CVH components for the population of US children (12–19 years of age) by race and ethnicity.

Chart 2-3 displays the adjusted prevalence estimates of ideal levels of CVH components for the population of US adults ≥20 years of age by race and ethnicity.

The trends in prevalence of meeting ideal criteria for the individual components of CVH from 1999 to 2000 to 2017 to 2018 (for diet, trends from 2003–2004 through 2017–2018) are shown in Chart 2-4 for children (12–19 years of age) and in Chart 2-5 for adults (≥20 years of age).

The leading risk factors for YLLs from 1990 to 2019 in the United States are presented in Table 2-3.

The leading causes of YLLs from 1990 to 2019 in the United States are presented in Table 2-4.

The leading causes of YLDs from 1990 to 2019 in the United States are presented in Table 2-6.

The leading global YLL risk factors from 1990 to 2019 are presented in Table 2-7.

The leading global YLL causes from 1990 to 2019 are presented in Table 2-8.

The leading global risk factors for YLDs from 1990 to 2019 are presented in Table 2-9.

The leading global causes of YLDs from 1990 to 2019 are presented in Table 2-10.

The large number of individuals in the United States who contracted severe illness attributable to COVID-19 resulted in a huge mortality toll, with disproportionate rates of deaths occurring among US counties with metropolitan areas and with higher proportions of the population who are NH Black and Hispanic people and in poverty.

As a result of the high COVID-19 mortality rates, life expectancy in the United States for 2020 has been estimated to decline with disproportionate impacts on populations with high COVID-19 mortality rates.

Provisional US life expectancy estimates for January to June 2020⁶⁴ indicate that between 2019 and the first half of 2020, life expectancy (at birth) decreased from 74.7 to 72.0 years (−2.7 years) for NH Black individuals. Life expectancy decreased from 81.8 to 79.9 years (−1.9 years) for Hispanic individuals and decreased from 78.8 to 78.0 years (−0.8 year) for NH White individuals.

Renewed efforts to maintain and improve CVH will be foundational to successful reductions in mortality and disability in the United States and globally. Individuals with more favorable levels of CVH have significantly lower risk for several of the leading causes of death and YLD, including IHD,²³ Alzheimer disease,⁶⁵ stroke,^66,67 CKD,⁶⁸ diabetes,^69,70 and breast cancer^71,72 (Tables 2-4 and 2-6). In addition, 6 of the 10 leading US risk factors for YLL and 4 of the 10 leading risk factors for YLD in 2019 were components of CVH (Tables 2-3 and 2-5). Taken together, these data demonstrate the tremendous importance of continued efforts to improve CVH.

The expanding efforts of the AHA and American Stroke Association in areas of brain health are also well poised to drive toward improvement in several leading causes of death and disability that influence YLLs and YLDs, including stroke, Alzheimer disease, depression and anxiety disorders, and alcohol and substance use disorders.

Despite improvements observed in CVH and brain health over the past decade, further progress is needed to more fully realize these benefits for all Americans. Details are described in the AHA presidential advisory on brain health.⁷³

Renewal of efforts to improve CVH is a continuing challenge that requires collaboration throughout the global community in ways that aim targeted skills and resources at improving the top causes and risk factors for death and disability in countries. Such efforts are required in countries at all income levels with an emphasis on efforts to halt the continued worsening of the components of CVH (Tables 2-7 through 2-10).

Many challenges exist related to implementation of prevention and treatment programs in international settings; some challenges are unique to individual countries/cultures, whereas others are universal. Partnerships and collaborations with local, national, regional, and global partners are foundational to effectively addressing relevant national health priorities in ways that facilitate contextualization within individual countries and cultures.

Prevalence of cigarette use in the past 30 days for middle and high school students by sex and race and ethnicity in 2020 is shown in Chart 3-1.

In 2020⁷:

Of youth who smoked cigarettes in the past 30 days in 2019, 28.9% (95% CI, 23.1%–35.5%) of middle and high school students (corresponding to 330 000 users) reported smoking cigarettes on 20 to 30 days of the past 30 days.⁸

In 2020, tobacco use within the past month for middle and high school students varied by race and ethnicity: The prevalence of past 30-day cigarette use was 3.7% (95% CI, 2.8%–4.8%) in NH White youth compared with 2.5% (95% CI, 1.8%–3.5%) in NH Black youth and 3.6% (95% CI, 2.6%–4.9%) in Hispanic youth. For cigars, the respective percentages were 2.8% (95% CI, 2.1%–3.7%), 6.5% (95% CI, 5.2%–8.2%), and 4.0% (95% CI, 2.9%–5.4%).⁷

The percentage of high school (19.6% or 3 020 000 users) and middle school (4.7% or 550 000 users) students who used e-cigarettes in the past 30 days exceeded the proportion using cigarettes in 2020 (Chart 3-1).⁷

According to the NHIS 2019 data, among adults ≥18 years of age⁹:

According to data from BRFSS 2019, the state with the highest age-adjusted percentage of current cigarette smokers was West Virginia (25.4%). The states with the lowest age-adjusted percentage of current cigarette smokers were Utah (7.9%) and California (10.1%; Chart 3-2).¹⁰

In 2019, smoking prevalence was higher among adults ≥18 years of age who reported having a disability or activity limitation (21.1%) than among those reporting no disability or limitation (13.3%).⁹

Among individuals who reported cigarette use every day or some days, 34.5% reported having severe generalized anxiety disorder, 27.0% reported having moderate generalized anxiety disorder, and 21.5% reported having mild generalized anxiety disorder compared with 12.0% who reported having no/minimal generalized anxiety disorder.⁹

Among females who gave birth in 2017, 6.9% smoked cigarettes during pregnancy. Smoking prevalence during pregnancy was greatest for females 20 to 24 years of age (9.9%), followed by females 15 to 19 years of age (8.3%) and 25 to 29 years of age (7.9%).¹¹ Rates were highest among NH American Indian or Alaska Native females (15%) and lowest in NH Asian females (1%). With respect to differences by education, cigarette smoking prevalence was highest among females who completed high school (12.2%), and lowest among females with a master’s degree and higher (0.3%).

E-cigarette prevalence in 2017 is shown in Chart 3-3. Comparing e-cigarette prevalence across the 50 states shows that the average age-adjusted prevalence was 5.3%. The lowest age-adjusted prevalence was observed in California (3.2%), and the highest prevalence was observed in Oklahoma (7.5%). The age-adjusted prevalence was 1.3% in Puerto Rico.¹⁰

According to the 2019 NSDUH, ≈1.60 million people ≥12 years of age had smoked cigarettes for the first time within the past 12 months compared with 1.83 million in 2018 (2019 NSDUH Table 4.2B).¹² Of new smokers in 2019, 541 000 were 12 to 17 years of age, 672 000 were 18 to 20 years of age, and 292 000 were 21 to 25 years of age; only 90 000 were ≥26 years of age when they first smoked cigarettes.

The number of new smokers 12 to 17 years of age in 2019 (541 000) decreased from 2018 (571 000). The number of new smokers 18 to 25 years of age in 2019 (964 000) also decreased from 2018 (1.14 million) (2019 NSDUH Table 4.2B).¹²

According to data from the PATH Study between 2013 and 2016, in youth 12 to 15 years of age, use of an e-cigarette was independently associated with new ever use of combustible cigarettes (OR, 4.09 [95% CI, 2.97–5.63]) and past 30-day use (OR, 2.75 [95% CI, 1.60–4.73]) at 2 years of follow-up. For youth who tried another non–e-cigarette tobacco product, a similar strength of association for cigarette use at 2 years was observed.¹³

Per NSDUH data for individuals 12 to 17 years of age, overall, the lifetime use of tobacco products declined from 13.4% to 12.8% between 2018 and 2019, with lifetime cigarette use declining from 9.6% to 9.0% during the same time period (2019 NSDUH Tables 2.1B and 2.2B).¹²

According to NSDUH data, the lifetime use of tobacco products in individuals ≥18 years of age did not decline significantly between 2018 (66.3%) and 2019 (65.8%). Lifetime cigarette use declined in a similar interval from 60.3% to 59.5% (2019 NSDUH Tables 2.1B). Similar to the patterns in youth, lifetime risk of tobacco products varied by demographic factors (2019 NSDUH Table 2.8B)¹²:

In 2019, the lifetime use of smokeless tobacco for adults ≥18 years of age was 16.6% (2019 NSDUH Table 2.4B).¹²

On the basis of weighted NHIS data (2019), the current smoking status among males 18 to 24 years of age declined from 28.0% in 2005 to 15.3% in 2019; for females 18 to 24 years of age, smoking declined from 20.7% to 12.7% over the same time period.⁹

According to data from the BRFSS, the prevalence of e-cigarette use increased from 4.3% to 4.5% between 2016 and 2019 in US adults. Increases in e-cigarette use over this period were significant for middle-aged adults, females, and former smokers.¹⁷

A 2010 report of the US Surgeon General on how tobacco causes disease summarized an extensive body of literature on smoking and CVD and the mechanisms through which smoking is thought to cause CVD.¹⁸ There is a sharp increase in CVD risk with low levels of exposure to cigarette smoke, including secondhand smoke, and a less rapid further increase in risk as the number of cigarettes per day increases. Similar health risks for CHD events were reported in a systematic review of regular cigar smoking.¹⁹

Smoking is an independent risk factor for CHD and appears to have a multiplicative effect with the other major risk factors for CHD: high serum levels of lipids, untreated hypertension, and diabetes.¹⁸

Cigarette smoking and other traditional CHD risk factors might have a synergistic interaction in HIV-positive individuals.²⁰

Among the US Black population, cigarette use is associated with elevated measures of subclinical PAD in a dose-dependent manner. Current smokers had an increased adjusted odds of ABI <1 (OR, 2.2 [95% CI, 1.5–3.3]).²¹

A meta-analysis of 75 cohort studies (≈2.4 million individuals) demonstrated a 25% greater risk for CHD in female smokers than in male smokers (RR, 1.25 [95% CI, 1.12–1.39]).²²

Cigarette smoking is a risk factor for both ischemic stroke and SAH in adjusted analyses and has a synergistic effect on other stroke risk factors such as oral contraceptive use.²³

A meta-analysis comparing pooled data of ≈3.8 million smokers and nonsmokers found a similar risk of stroke associated with current smoking in females and males.²⁴

Current smokers have a 2 to 4 times increased risk of stroke compared with nonsmokers or those who have quit for >10 years.^23,25 Among JHS participants without a history of stroke (N=4410), risk of stroke was higher among current smokers compared with individuals who never smoked (HR, 2.48; 95% CI, 1.60–3.83).²⁶

A meta-analysis of 26 studies reported that compared with never smoking, current smoking (RR, 1.75 [95% CI, 1.54–1.99]) and former smoking (RR, 1.16 [95% CI, 1.08–1.24]) were associated with increased risk of HF.²⁷ In MESA, compared with never smoking, current smoking was associated with an adjusted doubling in incident HF (HR, 2.05 [95% CI, 1.36–3.09]). The increased risk was similar for HFpEF (HR, 2.51) and HFrEF (HR, 2.58).²⁸

Short-term exposure to hookah smoking is associated with a significant increase in BP and heart rate and changes in cardiac function and blood flow, similar to those associated with cigarette smoking.²⁹ The short-term vascular impairment associated with hookah smoking is masked by the high levels of carbon monoxide–—a vasodilator molecule—released from the charcoal briquettes used to heat the flavored tobacco product.³⁰ In a recent meta-analysis of 42 studies, compared with nonsmokers, hookah smokers had significantly lower HDL-C and higher LDL-C, triglycerides, and fasting glucose.³¹ The long-term effects of hookah smoking remain unclear.

Current use of smokeless tobacco was associated with an adjusted 1.27-fold increased risk of CVD events compared with never using. The CVD rate was 11.3 per 1000 person-years in never users and 21.4 in current users of smokeless tobacco.³²

The long-term CVD risks associated with e-cigarette use are not known because of a lack of longitudinal data.^33,34 However, e-cigarette use has been linked to elevated levels of preclinical biomarkers associated with cardiovascular injury such as markers for sympathetic activation, oxidative stress, inflammation, thrombosis, and vascular dysfunction.³⁵ In addition, daily and some-day use of e-cigarettes may be associated with MI and CHD.^36,37

Dual use of e-cigarettes and combustible cigarettes was associated with significantly higher odds of CVD (OR, 1.36 [95% CI, 1.18–1.56]) compared with exclusive combustible cigarette use.³⁷ The association of dual use (relative to exclusive cigarette use) with CVD was 1.57 (95% CI, 1.18–2.07) for daily e-cigarette users and 1.31 (95% CI, 1.13–1.53) for occasional e-cigarette users.

In a pooled analysis of data collected from 10 randomized trials (N=2564), smokers had a higher risk of death or HF hospitalization (HR, 1.49 [95% CI, 1.09–2.02]), as well as reinfarction (HR, 1.97 [95% CI, 1.17–3.33) after primary PCI in STEMI.³⁸

Genetic factors contribute to smoking behavior; in analyses of up to 346 813 participants, common and rare variants in dozens of loci have been found to be associated with smoking initiation, number of cigarettes smoked per day, and smoking cessation.^39,40

Genetics might also modify adverse CVH outcomes among smokers, with variation in ADAMTS7 associated with loss of cardioprotection in smokers.⁴¹

Mendelian randomization analysis has linked genetic liability to smoking to ASCVD, including increased risk of PAD (OR, 2.13 [95% CI, 1.78–2.56]; P=3.6×10⁻¹⁶), CAD (OR, 1.48 [95% CI, 1.25–1.75]; P=4.4×10⁻⁶), and stroke (OR, 1.40 [95% CI, 1.02–1.92]; P=0.04).⁴²

Such legislation is likely to reduce the rates of smoking during adolescence—a time during which the majority of smokers start smoking—by limiting access because most people who buy cigarettes for adolescents are <21 years of age.

In addition, in several towns where Tobacco 21 laws were enacted before federal legislation, reductions of up to 47% in smoking prevalence among high school students have been reported.⁴⁷ Furthermore, the National Academy of Medicine estimates that the nationwide Tobacco 21 law could result in 249 000 fewer premature deaths, 45 000 fewer lung cancer deaths, and 4.2 million fewer life-years lost among Americans born between 2010 and 2019.⁴⁷

Before the federal minimum age of sale increase, 19 states (Hawaii, California, New Jersey, Oregon, Maine, Massachusetts, Illinois, Virginia, Delaware, Arkansas, Texas, Vermont, Connecticut, Maryland, Ohio, New York, Washington, Pennsylvania, and Utah), Washington, DC, and at least 470 localities (including New York City, NY; Chicago, IL; San Antonio, TX; Boston, MA; Cleveland, OH; and both Kansas Cities [Kansas and Missouri]) passed legislation setting the minimum age for the purchase of tobacco to 21 years.⁴⁸

According to NHIS 2017 data, 61.7% of adult ever-smokers had stopped smoking; the quit rate has increased 6 percentage points since 2012 (55.1%).⁴⁹

Data from clinical settings suggest wide variation in counseling practices related to smoking cessation. In a study based on national registry data, only 1 in 3 smokers who visited a cardiology practice received smoking cessation assistance.⁵²

According to cross-sectional MEPS data from 2006 to 2015, receiving advice to quit increased over time from 60.2% in 2006 to 2007 to 64.9% in 2014 to 2015. In addition, in 2014 to 2015, use of prescription smoking cessation medicine was significantly lower among NH Black (OR, 0.51 [95% CI, 0.38–0.69]), NH Asian (OR, 0.31 [95% CI, 0.10–0.93]), and Hispanic (OR, 0.53 [95% CI, 0.36–0.78]) individuals compared with White individuals. Use of prescription smoking cessation medicine was also significantly lower among those without health insurance (OR, 0.58 [95% CI, 0.41–0.83]) and higher among females (OR, 1.28 [95% CI, 1.10–1.52]).⁵³ In 2014 to 2015, receipt of doctor’s advice to quit among US adult smokers was significantly lower in NH Black (59.7% [95% CI, 56.1%–63.1%]) and Hispanic (57.9% [95% CI, 53.5%–62.2%]) individuals compared with NH White individuals (66.6% [95% CI, 64.1%–69.1%]).

Smoking cessation reduces the risk of cardiovascular morbidity and mortality for smokers with and without CHD.

Among 726 smokers included in the Wisconsin Smokers Health Study, smoking cessation was associated with less progression of carotid plaque but not IMT.⁵⁸

Cessation medications (including sustained-release bupropion, varenicline, nicotine gum, lozenge, nasal spray, and patch) are effective for helping smokers quit.^59,60

EVITA was an RCT that examined the efficacy of varenicline versus placebo for smoking cessation among smokers who were hospitalized for ACS. At 24 weeks, rates of smoking abstinence and reduction were significantly higher among patients randomized to varenicline. The abstinence rates at 24 weeks were higher in the varenicline (47.3%) than the placebo (32.5%) group (P=0.012; number needed to treat, 6.8). Continuous abstinence rates and reduction rates (≥50% of daily cigarette consumption) were also higher in the varenicline group.⁶¹

The EAGLES trial⁶² demonstrated the efficacy and safety of 12 weeks of varenicline, bupropion, or nicotine patch in motivated-to-quit patients who smoked with major depressive disorder, bipolar disorder, anxiety disorders, posttraumatic stress disorder, obsessive-compulsive disorder, social phobia, psychotic disorders including schizophrenia and schizoaffective disorders, and borderline personality disorder. Of note, these participants were all clinically stable from a psychiatric perspective and were believed not to be at high risk for self-injury.⁶²

Extended use of a nicotine patch (24 compared with 8 weeks) has been demonstrated to be safe and efficacious in randomized clinical trials.⁶³

An RCT demonstrated the effectiveness of individual- and group-oriented financial incentives for tobacco abstinence through at least 12 months of follow-up.⁶⁴

In addition to medications, smoke-free policies, increases in tobacco prices, cessation advice from health care professionals, and quit lines and other counseling have contributed to smoking cessation.^51,65

Mass media antismoking campaigns such as the CDC’s Tips campaign (Tips From Former Smokers) have been shown to reduce smoking-attributable morbidity and mortality and are cost-effective. Investigators estimated that the Tips campaign cost about $48 million, saved ≈179 099 QALYs, and prevented ≈17 000 premature deaths in the United States.⁶⁶

Despite states having collected $25.6 billion in 2012 from the 1998 Tobacco Master Settlement Agreement and tobacco taxes, <2% of those funds are spent on tobacco prevention and cessation programs.⁶⁷

A randomized trial of e-cigarettes and behavioral support versus nicotine-replacement therapy and behavioral support in adults attending the UK National Health Service stop-smoking services found that 1-year cigarette abstinence rates were 18% in the e-cigarette group compared with 9.9% in the nicotine-replacement therapy group (RR, 1.83 [95% CI, 1.30–2.58]; P<0.001). However, among participants abstinent at 1 year, in the nicotine-replacement therapy group, only 9% were still using nicotine-replacement therapy, whereas 80% of those in the e-cigarette group were still using e-cigarettes.⁶⁸

In a meta-analysis of 55 observational studies and 9 RCTs, e-cigarettes were not associated with increased smoking cessation, but e-cigarette provision was associated with increased smoking cessation.⁶⁹

According to the 2020 Surgeon General’s report on smoking cessation, >480 000 Americans die as a result of cigarette smoking and >41 000 die of secondhand smoke exposure each year, ≈1 in 5 deaths annually.

Of risk factors evaluated by the US Burden of Disease Collaborators, tobacco use was the second leading risk factor for death in the United States and the leading cause of DALYs, accounting for 11% of DALYs, in 2016.⁷⁰ Overall mortality among US smokers is 3 times higher than that for never-smokers.⁵⁴

On average, on the basis of 2016 data, male smokers die 12 years earlier than male never-smokers, and female smokers die 11 years earlier than female never-smokers.^16,71

Increased CVD mortality risks persist for older (≥60 years of age) smokers as well. A meta-analysis of 25 studies comparing CVD risks in 503 905 cohort participants ≥60 years of age reported an HR for cardiovascular mortality of 2.07 (95% CI, 1.82–2.36) compared with never-smokers and 1.37 (95% CI, 1.25–1.49) compared with former smokers.⁷²

In a sample of Native American individuals (SHS), among whom the prevalence of tobacco use is highest in the United States, the PAR for total mortality was 18.4% for males and 10.9% for females.⁷³

Since the first report on the dangers of smoking was issued by the US Surgeon General in 1964, tobacco control efforts have contributed to a reduction of 8 million premature smoking-attributable deaths.⁷⁴

If current smoking trends continue, 5.6 million US children will die of smoking prematurely during adulthood.¹⁸

Electronic nicotine delivery systems are battery-operated devices that deliver nicotine, flavors, and other chemicals to the user in an aerosol without any combustion. Although e-cigarettes—the most common form of electronic nicotine delivery systems—were introduced into the United States only around 2007, there are currently >450 e-cigarette brands and vaping products on the market, and sales in the United States were projected to be $2 billion in 2014. Juul came on the market in 2015 and has rapidly become the most popular vaping product sold in the United States. The popularity of the Juul likely relates to several factors, including its slim and modern design, appealing flavors, and intensity of nicotine delivery, which approximates the experience of combustible cigarettes.⁷⁵ Besides e-cigarettes and Juul, e-hookahs (ie, e-waterpipes) are a new category of vaping devices recently patented by Philip Morris in 2019.^76,77 Unlike e-cigarettes and Juul, e-hookahs are used through traditional water pipes, allowing the flavored aerosol to pass through the water-filled bowl before being inhaled.⁷⁸ The popularity of e-hookahs is driven in part by unsubstantiated claims that the presence of water “filters out toxins,” rendering e-hookahs as healthier tobacco alternatives.^79,80

E-cigarette use has become prevalent among never-smokers. In 2016, an estimated 1.9 million tobacco users exclusively used e-cigarettes in the United States. Of these exclusive e-cigarette users, 60% were <25 years of age.⁸¹

Current e-cigarette user prevalence for 2017 in the United States is shown in Chart 3-3.

According to the NYTS, in 2020, e-cigarettes were the most commonly used tobacco products in youth: In the past 30 days, 4.7% (550 000) of middle school and 19.6% (3.0 million) of high school students endorsed use (Chart 3-1).⁷ An exponential increase in current e-cigarette use in high school students was observed between 2011 (1.5%) and 2020 (19.6%).^7,82 A significant increase in current e-cigarette use also was observed for middle school students, for whom the corresponding values were 0.6% and 4.7% in the 2 periods.^2,7 Among high school students, rates of use were slightly higher among males (20.4%) than females (18.7%) and most pronounced among NH White students (23.2%). In middle school students, rates of use were approximately equal between males (4.5%) and females (4.8%) and in Hispanic students (7.1%).⁷