The age-standardized burden of tobacco-attributable early-onset ischemic heart disease declined substantially between 1990 and 2023, but absolute DALYs and deaths increased and disparities by development level and sex persisted.
Key Findings
Results
Absolute tobacco-attributable burden from early-onset IHD increased globally between 1990 and 2023 despite declining age-standardized rates.
Tobacco-attributable DALYs increased from 15.21 to 17.12 million between 1990 and 2023.
Tobacco-attributable deaths increased from 342,900 to 386,300 over the same period.
The study covered 204 countries and territories using Global Burden of Disease Study 2023 data.
The divergence between rising absolute numbers and falling rates reflects population growth and aging.
Results
Age-standardized disability-adjusted life years rate (ASDR) for tobacco-attributable early-onset IHD declined significantly from 1990 to 2023.
ASDR declined from 381.54 to 221.82 per 100,000.
The estimated annual percentage change (EAPC) was -1.84% (95% CI: -1.94 to -1.73).
This represents a substantial proportional reduction in age-standardized burden over the 33-year period.
Results
Age-standardized mortality rate (ASMR) for tobacco-attributable early-onset IHD also declined significantly from 1990 to 2023.
ASMR declined from 8.69 to 4.96 per 100,000.
The EAPC was -1.88% (95% CI: -1.98 to -1.77).
This decline paralleled the ASDR decline, suggesting improvements in both fatal and non-fatal burden per capita.
Results
Males had persistently higher tobacco-attributable early-onset IHD rates than females throughout the study period.
Male rates remained higher than female rates across the full study period from 1990 to 2023.
The sex disparity persisted even in a sensitivity analysis restricted to both sexes aged 40–54 years.
The findings highlight males as a particularly high-risk group for targeted tobacco control interventions.
Results
Age-period-cohort analyses revealed significant favorable net drifts and lower rate ratios in more recent time periods and birth cohorts.
APC models characterized age, period, and cohort patterns of the tobacco-attributable burden.
Net drifts were significantly favorable, indicating overall declining trends beyond what age alone explains.
More recent calendar periods and later birth cohorts showed lower period and cohort rate ratios.
This suggests that successive generations have experienced progressively lower tobacco-attributable IHD risk.
Results
Bayesian age-period-cohort projections to 2050 suggest continued decline in ASDR but stable or slightly increased ASMR with widening uncertainty.
Bayesian APC models were used to project age-standardized rates forward to 2050.
ASDRs were projected to continue declining through 2050.
ASMR estimates were projected to be stable or slightly increased, with widening uncertainty intervals toward 2050.
The diverging projections for ASDR and ASMR suggest complexity in future mortality trends.
Results
Disparities in tobacco-attributable early-onset IHD burden persisted according to level of sociodemographic development.
Burden disparities were found across countries stratified by Socio-demographic Index (SDI) level.
Low- and middle-SDI settings were identified as particularly high-risk contexts.
The authors call for stronger tobacco control and integrated cardiovascular prevention specifically in low- and middle-SDI settings.
The analysis covered 204 countries and territories, enabling cross-national comparisons by development level.
What This Means
This research suggests that while the risk of dying from or being disabled by tobacco-related heart disease among younger adults (early-onset ischemic heart disease) has dropped substantially on a per-person basis since 1990, the total number of people affected has actually risen. Between 1990 and 2023, age-adjusted death rates fell by roughly half and disability rates fell by about 40%, yet the actual number of deaths rose from about 343,000 to 386,000 per year, and total years of healthy life lost climbed from 15.2 to 17.1 million. This gap between improving rates and worsening absolute numbers is largely driven by population growth and aging worldwide.
The study also found persistent inequalities. Men consistently bore a higher burden than women, even when the comparison was limited to the same narrow age group (40–54 years). People living in lower-income countries faced greater risks and had less improvement over time compared to wealthier nations. Looking at trends by birth cohort, people born more recently tend to have lower tobacco-attributable heart disease risk than those born earlier, suggesting that tobacco control efforts over recent decades have had a real impact. Projections to 2050 suggest disability rates will continue to fall, but mortality rates may plateau or even rise slightly, with considerable uncertainty.
This research suggests that global tobacco control has made measurable progress, but is not sufficient. The rising absolute death toll means that population-level gains are being offset by sheer numbers of people at risk, particularly in lower-income settings and among men. The authors conclude that stronger tobacco control policies and integrated heart disease prevention programs are urgently needed, especially targeting high-risk males and communities in low- and middle-income countries, to translate the per-person improvements into actual reductions in lives lost.
Ouyang X, Chen X, He F, Li Q, Lin X, Qiu K, et al.. (2026). Tobacco-Attributable Burden of Early-Onset Ischemic Heart Disease From 1990 to 2023: A Global Analysis Using GBD 2023 and Age-Period-Cohort Modeling.. Clinical cardiology. https://doi.org/10.1002/clc.70451