Cigarette Smoking, Cessation, and Risk of Heart Failure With Preserved and Reduced Ejection Fraction

J Am Coll Cardiol. 2022 Jun 14;79(23):2298-2305. doi: 10.1016/j.jacc.2022.03.377.


Background: Smoking is well-recognized as a risk factor for heart failure (HF). However, few studies have evaluated the prospective association of cigarette smoking and smoking cessation with heart failure with preserved ejection fraction (HFpEF) and heart failure with reduced ejection fraction (HFrEF) as distinct phenotypes.

Objectives: The aim of this study was to quantify the association of cigarette smoking and smoking cessation with the incidence of HFpEF and HFrEF.

Methods: In 9,345 ARIC (Atherosclerosis Risk In Communities) study White and Black participants without history of HF at baseline in 2005 (age range 61-81 years), we quantified the associations of several established cigarette smoking parameters (smoking status, pack-years, intensity, duration, and years since cessation) with physician-adjudicated incident acute decompensated HF using multivariable Cox models.

Results: Over a median follow-up of 13.0 years, there were 1,215 incident HF cases. Compared with never smokers, current cigarette smoking was similarly associated with HFpEF and HFrEF, with adjusted HRs ∼2. There was a dose-response relationship for pack-years of smoking and HF. A more extended period of smoking cessation was associated with a lower risk of HF, but significantly elevated risk persisted up to a few decades for HFpEF and HFrEF.

Conclusions: All cigarette smoking parameters consistently showed significant and similar associations with HFpEF and HFrEF. Smoking cessation significantly reduced the risk of HF, but excess HF risk persisted for a few decades. Our results strengthened the evidence that smoking is an important modifiable risk factor for HF and highlighted the importance of smoking prevention and cessation for the prevention of HF, including HFpEF.

Keywords: cigarette smoking; heart failure with preserved ejection fraction; heart failure with reduced ejection fraction; smoking cessation.

Publication types

  • Research Support, N.I.H., Extramural

MeSH terms

  • Cigarette Smoking*
  • Heart Failure* / epidemiology
  • Heart Failure* / etiology
  • Humans
  • Prognosis
  • Proportional Hazards Models
  • Risk Factors
  • Stroke Volume / physiology