Smoking and its cessation similarly associated with HFpEF and HFrEF

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

Literature - Ding N, Shah AM, Blaha MJ, et al. - J Am Coll Cardiol. 2022 Jun;79(23):2298-2305. doi: 10.1016/j.jacc.2022.03.377

Introduction and methods


Smoking is an important modifiable risk factor for HF and the percentage of HF attributable to smoking is 14% [1]. Recent systematic reviews have shown that current and former smokers have an increased risk of HF [2,3]. However, few studies have studied the association between smoking and smoking cessation with the incidence of the 2 phenotypes of HF: HFrEF and HFpEF [4-8]. Moreover, these studies have shown conflicting results.

Aim of the study

The aim of this study was to investigate the association of cigarette smoking and smoking cessation with the incidence of HF, overall and for HFrEF and HFpEF separately.


The researchers used data from a prospective cohort consisting of 15,792 Americans aged 45-64 years from 4 communities (ARIC study). For this substudy, data were analyzed from 9345 participants who were alive in early 2005, had no HF, and whose follow-up data were available with no missing values. Information on smoking (smoking status, number of pack years, intensity, duration, and number of years since cessation) was limited to cigarette smoking and was obtained during 7 visits to the study center and through (semi-)annual telephone interviews during the period 1987-2019. Median follow-up was 13.0 years.


Definite and probable cases of acute decompensated HF were identified on the basis of medical records. The phenotypes of HF – HFrEF and HFpEF – were classified according to LVEF (LVEF < 50% or ≥ 50%, respectively).

Main results

  • The crude incidence rate of HF was 11.3 per 1000 person-years. The age-, sex-, and race-adjusted incidence of HF was 9.7 per 1000 person-years for never smokers, 13.5 per 1000 person-years for former smokers, and 20.1 per 1000 person-years for current smokers. The adjusted incidence rate of HFrEF and HFpEF was largely similar within each smoking category.
  • Compared with never smokers, current smokers (adjusted HR: 2.36; 95%CI: 1.92-2.90) and former smokers (adjusted HR: 1.36; 95%CI: 1.19-1.55) had an increased risk of HF; similar results were found for HFrEF and HFpEF separately.
  • There was a dose-response relationship between the number of pack years and the incidence of HF (HRs per 10 pack-years increment were 1.16, [95%CI:1.12-1.20] and 1.09 [95%CI:1.05-1.13] for HFpEF and HFrEF, respectively).
  • As the smoking cessation period increased, the risk of HF decreased, but a statistically significant increased risk persisted up to 20-<30 years after smoking cessation; a similar pattern was seen for HFrEF and HFpEF separately, although for HFrEF the HR in smoking cessation 20-<30 years was not statistically significant.
  • Risk for both phenotypes of HF was ~50% lower among those who remained abstinent for >30 years compared with current smokers.


All parameters of cigarette smoking consistently showed statistically significant and similar associations with HFrEF and HFpEF. Smoking cessation substantially reduced the risk of HF, but an increased risk of HF persisted for several decades. The results highlight that smoking is an important modifiable risk factor for HF and that smoking prevention and cessation are important to prevent HF.


1. Dunlay SM, Weston SA, Jacobsen SJ, Roger VL. Risk factors for heart failure: a population-based case-control study. Am J Med. 2009;122:1023-1028.

2. Lee H, Son Y-J. Influence of smoking status on risk of incident heart failure: a systematic review and meta-analysis of prospective cohort studies. Int J Environ Res Public Health. 2019;16:2697.

3. Aune D, Schlesinger S, Norat T, Riboli E. Tobacco smoking and the risk of heart failure: a systematic review and meta-analysis of prospective studies. Eur J Prev Cardiol. 2019;26:279-288.

4. Eaton CB, Pettinger M, Rossouw J, et al. Risk factors for incident hospitalized heart failure with preserved versus reduced ejection fraction in a multiracial cohort of postmenopausal women. Circ Heart Fail. 2016;9(10):e002883.

5. Brouwers FP, de Boer RA, van der Harst P, et al. Incidence and epidemiology of new onset heart failure with preserved vs. reduced ejection fraction in a community-based cohort: 11-year follow-up of PREVEND. Eur Heart J. 2013;34:1424-1431.

6. Watson M, Dardari Z, Kianoush S, et al. Relation between cigarette smoking and heart failure (from the Multiethnic Study of Atherosclerosis). Am J Cardiol. 2019;123:1972-1977.

7. Noel CA, LaMonte MJ, Roberts MB, et al. Healthy lifestyle and risk of incident heart failure with preserved and reduced ejection fraction among post-menopausal women: The Women’s Health Initiative study. Prev Med. 2020;138:106155.

8. Ho JE, Enserro D, Brouwers FP, et al. Predicting heart failure with preserved and reduced ejection fraction: the International Collaboration on Heart Failure Subtypes. Circ Heart Fail. 2016;9(6).

Find this article online at J Am Coll Cardiol.

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