Tobacco and the decline of heart disease

In the January 5, 2012 issue of the New England Journal of Medicine Drs. Nabel and Braunwald presented a review of the history of the decline of deaths from coronary heart disease in the second half of the Twentieth Century.  That paper chronicled the progress we have made in understanding the causes of heart disease and in fashioning various cures.  The paper included a striking line graph of death rates from heart disease in the past 70 years, showing the peak in about 1970, followed by a steady decline of about 75% through 2009.  Advances in hypertension control, cholesterol management, ICU treatments, and various other drugs, devices, and surgical techniques were all highlighted.

I was struck by the nearly complete absence of discussion of tobacco control in that review.  In fact, the word “tobacco” appeared only once in the paper, near the end, where tobacco was mentioned among the future challenges for global health.  We cannot fully motivate other countries to control tobacco unless we can clearly describe the impact of tobacco control on cardiovascular mortality in our own country.  In 1965 about 44% of U.S. adults smoked, but by 2009 only 22% smoked.  Assuming a 2.5-fold increased risk for cardiovascular mortality from tobacco smoking,that historic reduction in smoking caused a 20% reduction in cardiovascular mortality, which is a substantial proportion of the dramatic decline in heart disease deaths since 1970.  Surely the 1964 Surgeon General’s report  and the subsequent halving of tobacco smoking in the U.S. were as impactful as were internal defibrillators, fibrinolysis, or several of the other factors that were highlighted in that otherwise comprehensive review.

It is striking how easily we forget the obvious.  We have made great strides in tobacco control, but one in every five adults still smokes in the US.  Our great strides are only a good start, really.  As we look forward to even better progress in heart disease we should not fail to highlight the low hanging fruit of continued progress in tobacco control.