Heart Disease and Stroke Statistics—2023 Update: A Report From the American Heart Association

Table of Contents

Each chapter listed here is a hyperlink. Click on the chapter name to be taken to that chapter.

Summary

Each year, the American Heart Association, in conjunction with the National Institutes of Health and other government agencies, brings together in a single document the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors in the AHA’s Life’s Essential 8 (Figure),¹ which include core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions. Cardiovascular disease produces immense health and economic burdens in the United States and globally. The Statistical Update also presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular heart disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs). Since 2007, the annual versions of the Statistical Update have been cited >20 000 times in the literature.

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Each annual version of the Statistical Update undergoes revisions to include the newest nationally representative available data, add additional relevant published scientific findings, remove older information, add new sections or chapters, and increase the number of ways to access and use the assembled information. This year-long process, which begins as soon as the previous Statistical Update is published, is performed by the AHA Statistics Committee faculty volunteers and staff and government agency partners. Below are a few highlights from this year’s Statistical Update. Please see each chapter for references, confidence intervals for statistics reported below, and additional information.

Cardiovascular Health (Chapter 2)

• From 2013 to March 2020, the overall CVH score combining health scores of all 8 components of the Life’s Essential 8 was, on average, 73.6 for all US children between 16 and 19 years of age. The corresponding mean overall CVH score was 78.4 for NH Asian, 74.1 for NH White, and 71.3 for NH Black children. During the same period, the mean overall CVH score was 65.2 for all US adults, with a mean score of 69.6 for NH Asian, 66.0 for NH White, and 59.7 for NH Black adults.

• A report based on data from the UK Biobank found that having ideal CVH over poor CVH attenuated the all-cause and cardiometabolic disease–related mortality for males and females and was associated with life expectancy gains of 5.50 years for males and 4.20 years for females, at an index age of 45 years, among participants with cardiometabolic diseases and correspondingly 4.55 years in males and 4.89 years in females for people without cardiometabolic diseases.

• As of July 1, 2022, the cumulative number of COVID-19 (coronavirus disease 2019) deaths in the United States was 1 014 620, which equates to ≈306 deaths per 100 000 people. In metropolitan areas in the United States, the cumulative COVID-19 death rate was ≈292 deaths per 100 000 compared with ≈392 deaths per 100 000 in nonmetropolitan areas. In US counties with a high percentage (>17.3%) of the population in poverty, the cumulative COVID-19 death rate was ≈394 deaths per 100 000 compared with ≈248 deaths per 100 000 in counties with a low percentage (0.0%–12.3%) of the population that is living in poverty. As a result of the high COVID-19 mortality rates, life expectancy (at birth) in the United States decreased from 78.8 years in 2019 to 77.0 years in 2020 (−1.8 years) overall, and the corresponding life expectancy decreased from 76.3 to 74.2 years (−2.1 years) in males and decreased from 81.4 to 79.9 years (−1.5 years) in females.

Smoking/Tobacco Use (Chapter 3)

• The prevalence of cigarette use in the past 30 days among middle and high school students in the United States was 1.0% and 1.9%, respectively, in 2021.

• 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. In 2020, substantially higher tobacco use prevalence rates were observed in American Indian/Alaska Native and lesbian, gay, and bisexual adults compared with White and heterosexual/straight adults (27.1% American Indian/Alaska Native versus 13.3% White; 16.1% lesbian, gay, and bisexual versus 12.3% heterosexual/straight adults).

• Electronic cigarettes were the most commonly used tobacco product among adolescents in 2021; the prevalence of use in the past 30 days among middle and high school students in the United States was 2.8% and 11.3%, respectively, with the majority of adolescent users using flavored electronic cigarettes (85.8% of high school students and 79.2% of middle school students).

Physical Activity and Sedentary Behavior (Chapter 4)

• According to parental report in 2019 to 2020, the nationwide prevalence of youth 6 to 17 years of age who were active ≥60 minutes every day of the week was 20.6%.

• According to self-report in 2018, the age-adjusted proportion of adults who reported meeting the aerobic PA guidelines for Americans (≥150 min/wk of moderate PA, ≥75 min/wk of vigorous PA, or an equivalent combination of the two) through leisure-time activities was 54.2%.

• Among 67 762 adults with >20 years of follow-up, 8.7% of all-cause mortality was attributed to a PA level of <150 min/wk of moderate-intensity PA.

Nutrition (Chapter 5)

• The first study to use the AHA’s Life’s Essential 8 to quantify the CVH levels of adults and children in the United States included data from 23 409 individuals 2 through 79 years of age (13 521 adults and 9888 children) participating in NHANES (National Health and Nutrition Examination Survey). The adults in the study population represent 201 728 000 adults, and the children in the study represent 74 435 000 children. The composite CVH score ranges from 0 (lowest) to 100 (highest). Of the 8 metrics, diet was among the 4 with the lowest scores. The range of scores for diet across demographic groups was 23.8 to 47.7. Among children 2 to 5 years of age, a mean diet score of 61.1 was observed. The score for children 12 to 19 years of age was 28.5.

• A meta-analysis of 38 prospective cohort studies showed that the relative risk (RR) for the highest versus the lowest categories of Mediterranean diet adherence was 0.79 for total CVD mortality, 0.73 for CHD incidence, 0.83 for CHD mortality, 0.80 for stroke incidence, 0.87 for stroke mortality, and 0.73 for myocardial infarction incidence.

• Compared with a usual Western diet, a Dietary Approaches to Stop Hypertension–type dietary pattern with low sodium reduced systolic blood pressure (SBP) by 5.3, 7.5, 9.7, and 20.8 mm Hg in adults with baseline SBP <130, 130 to 139, 140 to 149, and ≥150 mm Hg, respectively.

Overweight and Obesity (Chapter 6)

• According to data from NHANES from 2017 until March 2020, among US children and adolescents 2 to 19 years of age, the prevalence of being either overweight or obese was 36.8%, with obesity prevalence of 19.8%. The highest prevalence of obesity was seen among Hispanic male and NH Black female youth.

• According to data from NHANES from 2017 until March 2020, the age-adjusted prevalence of overweight or obesity among adults ≥20 years of age in the United States was 71.2%, and the prevalence of obesity was 41.4%. The highest prevalence of obesity was among NH Black females.

• A large umbrella review in 2021 found that every 5–kg/m² increase in body mass index was associated with a 15% increased risk for CHD, 23% increased risk for atrial fibrillation (AF), 41% increased risk for HF, and 49% increased risk for hypertension.

High Blood Cholesterol and Other Lipids (Chapter 7)

• Among adolescents in 2017 to 2020, low-density lipoprotein cholesterol (LDL-C) levels ≥130 mg/dL occurred in 5.0% of male adolescents and 4.6% of female adolescents, LDL-C levels <40 mg/dL occurred in 19.3% of male adolescents and 8.6% of female adolescents, and triglycerides ≥130 mg/dL occurred in 7.2% of male adolescents and 6.2% of female adolescents.

• In 2017 to 2020, among adults, total cholesterol ≥200 mg/dL occurred in 32.8% of males and 36.2% of females, LDL-C ≥130 mg/dL occurred in 25.6% of males and 25.4% of females, and high-density lipoprotein cholesterol <40 mg/dL occurred in 24.9% of males and 9.3% of females.

High Blood Pressure (Chapter 8)

• With the use of the most recent 2017 definition, the age-adjusted prevalence of hypertension among US adults ≥20 years of age was estimated to be 46.7% in NHANES in 2017 to 2020 (50.4% for males and 43.0% for females). This equates to an estimated 122.4 million adults ≥20 years of age who have high blood pressure (62.8 million males and 59.6 million females). A higher percentage of males than females had hypertension up to 64 years of age, but for those ≥65 years of age, the percentage of females with hypertension was higher than for males.

• In an individual patient meta-analysis of 33 trials including 260 447 participants with 15 012 cancer events, no associations were identified between any antihypertensive drug class and risk of any cancer (hazard ratio [HR], 0.99 for angiotensin-converting enzyme inhibitors; HR, 0.96 for angiotensin receptor blockers; HR, 0.98 for β-blockers; HR, 1.01 for thiazides), except for calcium channel blockers (HR, 1.06). In a network meta-analysis comparing each drug class with placebo, no drug class was associated with an excess cancer risk (HR, 1.00 for angiotensin-converting enzyme inhibitors; HR, 0.99 for angiotensin receptor blockers; HR, 0.99 for β-blockers; HR, 1.04 for calcium channel blockers; HR, 1.00 for thiazides).

• In an open-label, cluster-randomized trial involving 20 995 individuals from 600 villages in rural China, the use of a salt substitute (75% sodium chloride and 25% potassium chloride by mass) compared with the use of regular salt (100% sodium chloride) resulted in a lower incidence of stroke (RR, 0.86), all-cause mortality (RR, 0.88), and major adverse cardiovascular event (RR, 0.87). There was no increase in rates of hyperkalemia with use of the salt substitute (RR, 1.04).

Diabetes (Chapter 9)

• Overall, on the basis of 2017 to 2020 data, 29.3 million adults (10.6%) in the United States had diagnosed diabetes.

• Data from the CALIBER UK cohort show the most common initial CVD complications for those with diabetes to be peripheral artery disease (16.2%) and HF (14.1%), followed by stable angina (11.9%), nonfatal myocardial infarction (11.5%), and stroke (10.3%).

• Data from the US Diabetes Collaborative Registry of 74 393 adults with diabetes demonstrate a prevalence of 74% with hemoglobin A1c <7%, 40% with blood pressure <130/80 mm Hg, and 49% with LDL-C <100 mg/dL (<70 mg/dL if with atherosclerotic cardiovascular disease), but only 15% at target for all 3 factors.

Metabolic Syndrome (Chapter 10)

• From 1999 to 2018, the prevalence of metabolic syndrome among US youths remained stable at 4.36%. Among adults, the prevalence of metabolic syndrome increased from 36.2% to 47.3%.

• According to the data from NHANES 1999 to 2018, the prevalence of metabolic syndrome among youths 12 to 19 years of age was 4.34% for NH White, 3.66% for NH Black, 7.70% for Mexican American, 4.84% for other Hispanic, and 1.84 for other race youths.

• In 2017 to 2018, Mexican American adults generally had the highest prevalence of metabolic syndrome at 52.2%, whereas NH White adults had 46.6%, NH Black adults had 47.6%, other Hispanic adults had 45.9%, and Asian/other adults had 46.7%.

Adverse Pregnancy Outcomes (Chapter 11)

• Rates of overall hypertensive disorders of pregnancy are increasing. Analysis of delivery hospitalizations from the National Readmission Database reported a rate of hypertensive disorders of pregnancy of 912.4 per 10 000 delivery hospitalizations in 2014 compared with 528.9 in 1993 in the United States.

• Specific aspirin dosage and preeclampsia prevention were studied in 23 randomized trials (32 370 females). Females assigned at random to 150 mg experienced a 62% reduction in risk of preterm preeclampsia (RR, 0.38). Aspirin doses <150 mg produced no significant reductions. The number needed to treat with 150 mg of aspirin was 39. There was a maximum 30% reduction in risk of all gestational age preeclampsia at all aspirin doses.

• In a cohort of 595 pregnant females in 4 US cities, perceived discrimination (self-reported as based on sex, race, income level or social status, age, and physical appearance) was associated with development of gestational diabetes. Gestational diabetes occurred in 12.8% of females in the top quartile of a self-reported discrimination scale versus 7.0% in all others (adjusted odds ratio [OR], 2.11, adjusted for age, income, parity, race and ethnicity, and study site); 22.6% of this association was statistically mediated by obesity.

Kidney Disease (Chapter 12)

• The 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) in 2015 to 2018 was 14.9%.

• In 2019, the age-, race-, and sex-adjusted prevalence of end-stage renal disease in the United States was 2302 per 1 million people, an increase of 1.4% over 2018.

• Total hospitalization expenditures in Medicare fee-for-service beneficiaries with end-stage renal disease was $12.2 billion in 2019, and outpatient spending was $13.1 billion in 2019.

Sleep (Chapter 13)

• The proportion of adults reporting insufficient sleep (<7 hours) in 2020 was 32.8%.

  • – Older adults, >65 years of age, report the lowest prevalence of insufficient sleep.

  • – NH Black adults had the highest percentage of respondents reporting sleeping <7 h/night (43.5%), whereas NH Asian adults (30.5%) and NH White adults (30.7%) had the lowest percentage of respondents reporting sleeping <7 hours.

• Females report never or some of the days feeling well rested on awakening in the past days more frequently than males (46.9% versus 40.4%).

• Data from the MIDUS study (Midlife in the United States) examined the association of a composite sleep health measure (sleep regularity, satisfaction, alertness, timing, efficiency, and duration) with risk of HD (yes/no to a question on diagnosis of HD). Each unit increase in the self-reported sleep health composite was associated with a 54% higher risk of HD, whereas the objectively measured actigraphy sleep health composite was associated with 141% higher risk.

Total Cardiovascular Disease (Chapter 14)

• On the basis of NHANES 2017 to March 2020 data, the prevalence of CVD (comprising CHD, HF, stroke, and hypertension) in adults ≥20 years of age was 48.6% overall (127.9 million in 2020) and increases with age in both males and females.

• On the basis of 2020 mortality data, HD and stroke currently claim more lives each year than cancer and chronic lower respiratory disease combined. In 2020, 207.1 of 100 000 people died of HD and stroke.

• In 2020, 19.05 million deaths were estimated for CVD globally, which amounted to an increase of 18.71% from 2010. The age-standardized death rate per 100 000 population was 239.80, which represents a decrease of 12.19% from 2010. Overall, the crude prevalence of CVD was 607.64 million cases in 2020, an increase of 29.01% compared with 2010. However, the age-standardized prevalence rate was 7354.05 per 100 000, an increase of 0.73% from 2010.

Stroke (Cerebrovascular Diseases) (Chapter 15)

• An analysis of data from the GBD 2019 study found that from 1990 to 2019, the absolute number of incident strokes increased by 70.0, whereas the age-standardized incidence rate for total stroke decreased by 17.0%. The age-standardized incidence rate for ischemic stroke decreased by 10% and intracerebral hemorrhage decreased by 29% during the same period.

• A meta-analysis of 11 clinical trials from 1970 to 2021 with 20 163 patients with stroke found that intensive LDL-C–lowering statin-based therapies reduced the risk of recurrent ischemic stroke (RR, 0.88) compared with less intensive LDL-C–lowering statin-based therapies. This relationship was even stronger in populations with atherosclerosis (RR, 0.79).

• In a meta-analysis of 66 trials of SBP-lowering interventions including 324 812 participants and 11 437 strokes over an average follow-up of 3.3 years, SBP lowering was associated with 21% lower odds of stroke compared with control. In meta-analyses of stroke types, SBP lowering was associated with 14% lower odds of ischemic stroke (6 trials), 28% lower odds of hemorrhagic stroke (6 trials), and 28% lower odds of fatal or disabling stroke (18 trials).

Brain Health (Chapter 16)

• The GBD study estimated secular trends from 1990 to 2017 in dementia prevalence, incidence, disability-adjusted life-years (DALYs), and mortality globally and for high-income countries. Globally, prevalent cases increased by 119%, annual incident cases increased by 113%, DALYs increased by 115%, and annual deaths increased by 146%. However, global age-standardized prevalence decreased by 4%, age-standardized annual incidence decreased by 5%, age-standardized DALYs decreased by 6%, and age-standardized annual mortality decreased by 4%. For high-income countries, percent increases in absolute burden measures were smaller than globally: Prevalent cases increased by 93%, annual incident cases increased by 87%, DALYs increased by 90%, and annual deaths increased by 126%. The age-standardized prevalence in high-income countries decreased by 5%, age-standardized annual incidence rate decreased by 6%, age-standardized DALYs decreased by 7%, and age-standardized annual mortality rate decreased by 4%.

• Among 229 976 participants in the UK Biobank, with 2143 cases of incident dementia over a median follow-up of 9 years, each 1-point increment in Life's Simple 7 score was associated with an 11% lower hazard of dementia (HR, 0.89). Each 1-point increment in the biological component score (based on blood pressure, cholesterol, and glucose) was associated with a 7% lower hazard of dementia (HR, 0.93). However, a 1-point increment in the lifestyle component score (based on smoking, body mass index, diet, and physical activity) was not associated with dementia (HR, 0.99).

• In the HRS (Health and Retirement Study), cognitive impairment-free life expectancy at 55 years of age was estimated as 23.0 years for participants with no hypertension, HD, diabetes, or stroke; 21.2 years for those with any 1 of those conditions; 18.1 years for those with any 2 conditions; and 14.0 years for those with any 3 or all 4 conditions. The association of CVD burden with lower cognitive impairment-free life expectancy was also observed at 65, 75, and 85 years of age, with lower absolute life expectancies.

Congenital Cardiovascular Defects and Kawasaki Disease (Chapter 17)

• 2020 mortality related to congenital cardiovascular defects was 2817 deaths in the United States, an 11.9% decrease from the number of deaths in 2010.

• Socioeconomic status (SES) is a major contributor to identified differences in infant mortality among infants with critical congenital cardiovascular defects, with greater mortality among socioeconomically deprived patients (OR, 1.7).

Since May 2020, the Centers for Disease Control and Prevention has been tracking reports of multisystem inflammatory syndrome in children. As of March 1, 2022, 7459 cases and 63 attributable deaths (0.84%) have been reported. Median age of cases was 9 years; 58% of cases have occurred in children who are Hispanic or Latino (1846 cases) or Black (2206 cases); 98% tested positive for SARS-2 (severe acute respiratory syndrome coronavirus 2; reverse transcriptase–polymerase chain reaction, serology, or antigen test); and 60% of reported patients were male.

Disorders of Heart Rhythm (Chapter 18)

• An analysis of the Korea National Health Insurance Service (N=66 692) classified individuals by exercise status before and after AF diagnosis. Those who maintained exercise were significantly less likely to have ischemic stroke (HR, 0.86), HF (HR, 0.92), or mortality (HR, 0.61) than those who continued to abstain from exercise after AF diagnosis.

• The study of social determinants and AF remains limited. In a limited-sized cohort (N=339) followed up for a median of 2.6 years (range, 0–3.4 years), individuals in the lowest income category (≤$19 999/y) had a 2.0-fold greater hospitalization risk (OR, 2.11) compared with those in the highest income category (≥$100 000/y).

• A multicenter trial randomized individuals with at least 1 stroke risk factor and without AF in a 1:3 ratio to receive long-term rhythm monitoring with an implanted loop recorder (n=1501) or usual care (n=4503). Over a median follow-up of 64.5 months, those randomized to monitoring were 3-fold more likely to be diagnosed with AF (HR, 3.17).

Sudden Cardiac Arrest, Ventricular Arrhythmias, and Inherited Channelopathies (Chapter 19)

• Recent data describing cardiac arrest or sudden cardiac death after an acute myocardial infarction suggest that contemporary short-term (3-month) risk is 0.29% or 116 per 100 000 person-years.

• Laypeople in the United States initiated cardiopulmonary resuscitation in 40.2% of out-of-hospital cardiac arrests in 2021.

• In the United States, individuals from underrepresented racial and ethnic groups are at substantially higher risk of sudden cardiac arrest and experience worse survival and neurological outcomes after sudden cardiac arrest compared with White individuals. In the ARIC study (Atherosclerosis Risk in Communities), the sex-adjusted HR for sudden cardiac death comparing Black with White participants was 2.12, and the fully adjusted HR was 1.38. In San Francisco, Black females had a 2.55 higher incidence of sudden arrhythmic death than White females.

Subclinical Atherosclerosis (Chapter 20)

• In a study-level meta-analysis involving 10 867 participants (6699 HIV positive, 4168 HIV negative; mean age, 52 years; 86% male; 32% Black), the prevalence of noncalcified plaque was 49% in HIV-positive individuals versus 20% in HIV-negative individuals (OR, 1.23).

• In individuals without diabetes or CVD, higher hemoglobin A1c was associated with the extent of subclinical atherosclerosis assessed by intima-media thickness; atherosclerotic plaque of the carotids, abdominal aorta, and iliofemoral arteries; and coronary artery calcification (OR, 1.05, 1.27, 1.27, 1.36, 1.80, 1.87, and 2.47 for hemoglobin A1c 4.9%–5.0%, 5.1%–5.2%, 5.3%–5.4%, 5.5%–5.6%, 5.7%–5.8%, 5.9%–6.0%, and 6.1%–6.4%, respectively; reference hemoglobin A1c ≤4.8%).

• In the Rotterdam Study of older adults, the presence of intraplaque hemorrhage (but not calcification or lipid-rich core) by high-resolution magnetic resonance imaging demonstrated an association with incident stroke and CHD (HR, 2.42 and 1.95, respectively).

Coronary Heart Disease, Acute Coronary Syndrome, and Angina Pectoris (Chapter 21)

• According to data from the 2005 to 2014 ARIC study, the estimated annual incidence of myocardial infarction is 605 000 new attacks and 200 000 recurrent attacks. Of these 805 000 first and recurrent events, it is estimated that 170 000 are silent.

• An NIS (National Inpatient Sample) analysis of sex differences spanning 2004 to 2015 identified 7 026 432 hospitalizations for acute myocardial infarction. Compared with males, females were less likely to undergo coronary angiography (adjusted OR, 0.92) and percutaneous coronary intervention (adjusted OR, 0.82), Females had a higher risk of mortality (adjusted OR, 1.03) compared with males.

• In 2020, CHD age-adjusted death rates per 100 000 were 128.5 for NH White males, 153.6 for NH Black males, and 102.2 for Hispanic males. For NH White females, the rate was 63.8; for NH Black females, it was 85.9; and for Hispanic females, it was 54.2.

Cardiomyopathy and Heart Failure (Chapter 22)

• On the basis of data from NHANES 2017 to 2020, ≈6.7 million Americans ≥20 years of age had HF, which is increased from ≈6.0 million according to NHANES 2015 to 2018.

• The lifetime risk of HF at 50 years of age increased among participants of the FHS (Framingham Heart Study) when comparing two 25-year epochs (1965–1989 versus 1990–2014) from 18.9% to 22.6% in females and 19.1% to 25.3% in males.

• Some data suggest that improvements in survival in individuals with HF could be leveling off over time. Data from the Rochester Epidemiology Project in Olmsted County, Minnesota, showed improved survival after HF diagnosis between 1979 and 2000; however, estimated 5-year mortality for those with HF did not decline from 2000 to 2010 and remained high (52.6% overall; 24.4% for those 60 years of age; and 54.4% for those 80 years of age).

Valvular Diseases (Chapter 23)

• 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 was 12.4%, and the prevalence of severe aortic stenosis was 3.4%.

• In 1000 patients with severe aortic stenosis at low surgical risk randomized in the PARTNER 3 trial (Placement of Aortic Transcatheter Valve 3) to either balloon-expandable transcatheter aortic valve replacement (TAVR) or surgical aortic valve replacement, the primary composite end point (death, stroke, or rehospitalization) rate was significantly lower in the TAVR versus surgical aortic valve replacement group (8.5% versus 15.1%; absolute difference, −6.6 percentage points for noninferiority; HR, 0.54). At 2 years, the primary end point was significantly reduced after TAVR compared with surgical aortic valve replacement (11.5% versus 17.4%; HR, 0.63), although TAVR valve thrombosis at 2 years was increased (2.6%; 13 events) compared with surgery (0.7%; 3 events).

• Among 96 256 transfemoral TAVR procedures, adjusted 30-day mortality was higher at institutions with low procedural volume (3.19%) than at institutions with high procedural volume (2.66%; OR, 1.21).

Venous Thromboembolism (Deep Vein Thrombosis and Pulmonary Embolism), Chronic Venous Insufficiency, Pulmonary Hypertension (Chapter 24)

• In 2019, there were an estimated ≈393 000 cases of pulmonary embolism, ≈643 000 cases of deep vein thrombosis, and ≈1 036 000 total venous thromboembolism cases in the United States.

• In patients with COVID-19, there is a double risk of death after venous thromboembolism. In those admitted to the intensive care unit, this risk is 2.63 times higher, with a 3-fold increase in patients on mechanical ventilation.

• In 2018, there were 578 000 outpatient visits for pulmonary hypertension as the principal diagnosis. In addition, there were 14 000 hospital discharges with pulmonary hypertension as the principal diagnosis.

Peripheral Artery Disease and Aortic Diseases (Chapter 25)

• Data from MarketScan and Medicare databases showed that only 33.9% of patients with peripheral artery disease were prescribed statins compared with 51.7% of patients with coronary artery disease, and only 24.5% of patients with peripheral artery disease in the MarketScan database achieved a target LDL-C <70 mg/dL.

• Among Medicare beneficiaries, zip codes in the top quartile of amputation rates had a larger mean proportion of Black residents than zip codes in the bottom quartile (17.5% versus 4.4%).

• In older individuals 60 to 74 years of age, male sex (OR, 1.9), hypertension (OR, 1.8), and family history (OR, 1.6) are the strongest contributors to risk of thoracic aortic aneurysm.

Quality of Care (Chapter 26)

• Despite substantial disruptions to cardiovascular care delivery during the COVID-19 pandemic, among patients in the GWTG Registry (Get With The Guidelines) who were hospitalized for HF in 2021, 91.7% received angiotensin-converting enzyme inhibitors/angiotensin receptor blockers or angiotensin receptor-neprilysin inhibitors at discharge; 93.4% received evidence-based specific β-blockers; 99.2% had a measurement of left ventricular function; and 85.5% had a scheduled postdischarge appointment.

• In 18 262 adults with hypertension, the age-adjusted estimated proportion with controlled blood pressure (blood pressure <140/90 mm Hg) improved from 31.8% in 1999 to 2000 to 48.5% in 2007 to 2008, was similar in 2013 to 2014 (53.8%), and then declined to 43.7% in 2017 to 2018.

• In 390 692 patients receiving care at 586 hospitals from July 2008 to December 2013, patients residing in lower-SES neighborhoods had longer median arrival-to-angiography time (lowest quintile of SES, 8.0 hours; highest quintile of SES, 3.4 hours) and a higher rate of fibrinolysis (versus primary angioplasty) for ST-segment–elevation myocardial infarction (lowest quintile of SES, 23.1%; highest quintile of SES, 5.9%) compared with higher-SES neighborhoods. Patients from lower-SES neighborhoods had greater independent risk of in-hospital mortality and major bleeding and a lower quality of discharge care.

Medical Procedures (Chapter 27)

• According to Healthcare Cost and Utilization Project data from the Agency for Healthcare Research and Quality for the year 2018, 481 780 percutaneous coronary interventions were performed on an inpatient basis in the United States.

• Data from the Society of Thoracic Surgeons Adult Cardiac Surgery Database, which voluntarily collects data from ≈80% of all hospitals that perform coronary artery bypass grafts in the United States, indicate that a total of 161 816 procedures involved isolated coronary artery bypass graft in 2019.

• In 2021, 3817 heart transplantations were performed in the United States, the most ever. The highest numbers of heart transplantations were performed in California (529), Texas (359), New York (307), and Florida (263).

Economic Cost of Cardiovascular Disease (Chapter 28)

• The average annual direct and indirect cost of CVD in the United States was an estimated $407.3 billion in 2018 to 2019.

• The estimated direct costs of CVD in the United States increased from $103.5 billion in 1996 to 1997 to $251.4 billion in 2018 to 2019.

• By event type, hospital inpatient stays accounted for the highest direct cost ($111.4 billion) in 2018 to 2019 in the United States.

Conclusions

The AHA, through its Epidemiology and Prevention Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the Statistical Update. The 2023 Statistical Update is the product of a full year’s worth of effort by dedicated volunteer clinicians and scientists, committed government professionals, and AHA staff members, without whom publication of this valuable resource would be impossible. Their contributions are gratefully acknowledged.

Connie W. Tsao, MD, MPH, FAHA, Chair

Seth S. Martin, MD, MHS, FAHA, Vice Chair

Sally S. Wong, PhD, RD, CDN, FAHA, AHA Senior Science and Medicine Advisor, Lead

Debra G. Heard, PhD, AHA Consultant

On behalf of the American Heart Association Council on Epidemiology and Prevention Statistics Committee and Stroke Statistics Subcommittee

Article Information

Acknowledgments

The writing group thanks its colleagues Lucy Hsu and Michael Wolz at the National Heart, Lung, and Blood Institute; the team at the Institute for Health Metrics and Evaluation at the University of Washington; Bryan McNally and Rabab Al-Araji at the CARES (Cardiac Arrest Registry to Enhance Survival) program; Hongyan Ning and Donald Lloyd-Jones at Northwestern University; and Christina Koutras and Fran Thorpe at the American College of Cardiology for their valuable contributions and review.

Footnotes

1. ABOUT THESE STATISTICS

The AHA works with the NHLBI to derive the annual statistics in the AHA Statistical Update. This chapter describes the most important sources and the types of data used from them. For more details, see Chapter 30 of this document, the Glossary.

The surveys and data sources used are the following:

• 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

Disease Prevalence

Prevalence is an estimate of how many people have a condition at a given point or period in time. The CDC/NCHS conducts health examination and health interview surveys that provide estimates of the prevalence of diseases and risk factors. In this Statistical Update, the health interview part of the NHANES is used for the prevalence of CVDs. NHANES is used more than the NHIS because in NHANES AP is based on the Rose Questionnaire; estimates are made regularly for HF; hypertension is based on BP measurements and interviews; and an estimate can be made for total CVD, including MI, AP, HF, stroke, and hypertension.

A major emphasis of the 2023 Statistical Update is to present the latest estimates of the number of people in the United States who have specific conditions to provide a realistic estimate of burden. Most estimates based on NHANES prevalence rates are based on data collected from 2017 to 2020. These are applied to census population estimates for 2020. Differences in population estimates cannot be used to evaluate possible trends in prevalence because these estimates are based on extrapolations of rates beyond the data collection period by use of more recent census population estimates. Trends can be evaluated only by comparing prevalence rates estimated from surveys conducted in different years.

In the 2023 Statistical Update, there is an emphasis on health equity across the various chapters, and global estimates are provided when available.

Risk Factor Prevalence

The NHANES 2017 to 2020 data are used in this Statistical Update to present estimates of the percentage of people with high LDL-C and diabetes. NHANES 2017 to 2020 are used to present estimates of the percentage of people with overweight, obesity, and high TC and HDL-C. BRFSS 2020 and NHIS 2020 data are used for the prevalence of sleep issues. The NHIS 2020 data, BRFSS 2020, and NYTS 2021 are used for the prevalence of cigarette smoking. The prevalence of physical inactivity is obtained from YRBS 2019 and NHIS 2018.

Incidence and Recurrent Attacks

An incidence rate refers to the number of new cases of a disease that develop in a population per unit of time. The unit of time for incidence is not necessarily 1 year, although incidence is often discussed in terms of 1 year. For some statistics, new and recurrent attacks or cases are combined. Our national incidence estimates for the various types of CVD are extrapolations to the US population from the FHS, the ARIC study, and the CHS, all conducted by the NHLBI, as well as the GCNKSS, which is funded by the NINDS. The rates change only when new data are available; they are not computed annually. Do not compare the incidence or the rates with those in past editions of the AHA Statistical Update (also known as the Heart and Stroke Statistical Update for editions before 2005). Doing so can lead to serious misinterpretation of time trends.

Mortality

Mortality data are generally presented according to the underlying cause of death. “Any-mention” mortality means that the condition was nominally selected as the underlying cause or was otherwise mentioned on the death certificate. For many deaths classified as attributable to CVD, selection of the single most likely underlying cause can be difficult when several major comorbidities are present, as is often the case in the elderly population. It is useful, therefore, to know the extent of mortality attributable to a given cause regardless of whether it is the underlying cause or a contributing cause (ie, the “any-mention” status). The number of deaths in 2020 with any mention of specific causes of death was tabulated by the NHLBI from the NCHS public-use electronic files on mortality.

The first set of statistics for each disease in the 2023 Statistical Update includes the number of deaths for which the disease is the underlying cause. Two exceptions are Chapter 8 (High Blood Pressure) and Chapter 22 (Cardiomyopathy and Heart Failure). HBP, or hypertension, increases the mortality risks of CVD and other diseases, and HF should be selected as an underlying cause only when the true underlying cause is not known. In this Statistical Update, hypertension and HF death rates are presented in 2 ways: (1) as nominally classified as the underlying cause and (2) as any-mention mortality.

National and state mortality data presented according to the underlying cause of death were obtained from the CDC WONDER website or the CDC NVSS mortality file.¹ Any-mention numbers of deaths were tabulated from the CDC WONDER website or CDC NVSS mortality file.^1,2

Population Estimates

In this publication, we have used national population estimates from the US Census Bureau³ for 2020 in the computation of morbidity data. CDC/NCHS population estimates for 2020 were used in the computation of death rate data. The Census Bureau website contains these data, as well as information on the file layout.

Hospital Discharges and Ambulatory Care Visits

Estimates of the numbers of hospital discharges and numbers of procedures performed are for inpatients discharged from short-stay hospitals. Discharges include those discharged alive, dead, or with unknown status. Unless otherwise specified, discharges are listed according to the principal (first-listed) diagnosis, and procedures are listed according to all-listed procedures (principal and secondary). These estimates are from the HCUP 2019 NIS. Ambulatory care visit data include patient visits to primary health care professionals’ offices and EDs. Ambulatory care visit data reflect the primary (first-listed) diagnosis. Primary health care professional office visit estimates are from the NAMCS 2018 of the CDC/NCHS. ED visit estimates are from the HCUP 2019 National ED Sample. Readers comparing data across years should note that beginning October 1, 2015, a transition was made from ICD-9 to ICD-10. This should be kept in mind because coding changes could affect some statistics, especially when comparisons are made across these years.

International Classification of Diseases

Morbidity (illness) and mortality (death) data in the United States have a standard classification system: the ICD. Approximately every 10 to 20 years, the ICD codes are revised to reflect changes over time in medical technology, diagnosis, or terminology. If necessary for comparability of mortality trends across the 9th and 10th ICD revisions, comparability ratios computed by the CDC/NCHS are applied as noted.⁴ Effective with mortality data for 1999, ICD-10 is used.⁵ Beginning in 2016, ICD-10-CM is used for hospital inpatient stays and ambulatory care visit data.

Age Adjustment

Prevalence and mortality estimates for the United States or individual states comparing demographic groups or estimates over time are either age specific or age adjusted to the year 2000 standard population by the direct method.⁶ International mortality data are age adjusted to the European standard population. Unless otherwise stated, all death rates in this publication are age adjusted, and are deaths per 100 000 population.

Data Years for National Estimates

In the 2023 Statistical Update, we estimate the annual number of new (incidence) and recurrent cases of a disease in the United States by extrapolating to the US population in 2014 from rates reported in a community- or hospital-based study or multiple studies. Age-adjusted incidence rates by sex and race are also given in this report as observed in the study or studies. For US mortality, most numbers and rates are for 2020. For disease and risk factor prevalence, most rates in this report are calculated from NHANES 2017 to 2020. Because NHANES is conducted only in the noninstitutionalized population, we extrapolated the rates to the total US resident population on July 1, 2020, recognizing that this probably underestimates the total prevalence given the relatively high prevalence in the institutionalized population. The numbers of hospital inpatient discharges for the United States are for 2019. The numbers of visits to primary health care professionals’ offices are for 2018. Except as noted, economic cost estimates are for 2018 to 2019.

Cardiovascular Disease

For data on hospitalizations, primary health care professional office visits, and mortality, total CVD is defined according to ICD codes given in Chapter 14 (Total Cardiovascular Diseases) of the present document. This definition includes all diseases of the circulatory system. Unless otherwise specified, estimates for total CVD do not include congenital CVD. Prevalence of total CVD includes people with hypertension, CHD, stroke, and HF.

Race and Ethnicity

Data published by governmental agencies for some racial groups are considered unreliable because of the small sample size in the studies. Because we try to provide data for as many racial and ethnic groups as possible, we show these data for informational and comparative purposes.

Global Burden of Disease

The AHA works with the Institute for Health Metrics and Evaluation to help derive annual statistics for the AHA Statistical Update. The Global Burden of Diseases, Injuries, and Risk Factors Study is an ongoing global effort to quantify health loss from hundreds of causes and risks from 1990 to the present for all countries. The study seeks to produce consistent and comparable estimates of population health over time and across locations, including summary metrics such as DALYs and healthy life expectancy. Results are made available to policymakers, researchers, governments, and the public with the overarching goals of improving population health and reducing health disparities.

GBD Study 2020, the most recent iteration of the study, was produced by the collective efforts of >7500 researchers in >150 countries. Estimates were produced for 370 causes and 88 risk factors.

During each annual GBD Study cycle, population health estimates are reproduced for the full time series. For GBD Study 2020, estimates were produced for 1990 to 2020 for 204 countries and territories, stratified by age and sex, with subnational estimates made available for an increasing number of countries. Improvements in statistical and geospatial modeling methods and the addition of new data sources may lead to changes in results across GBD Study cycles for both the most recent and earlier years.

For more information about the GBD Study and to access GBD resources, data visualizations, and most recent publications, please visit the study website.⁷

The Statistical Update Supplementary Material includes additional global and regional CVD statistics.

Contacts

If you have questions about statistics or any points made in this Statistical Update, please contact the AHA National Center, Office of Science, Medicine and Health. Direct all media inquiries to News Media Relations at http://newsroom.heart.org/connect or 214-706-1173.

The AHA works diligently to ensure that the Statistical Update is error free. If we discover errors after publication, we will provide corrections at http://www.heart.org/statistics and in the journal Circulation.

2. CARDIOVASCULAR HEALTH

See Tables 2-1 through 2-10

In 2010, the AHA released an Impact Goal that included 2 objectives that would guide organizational priorities over the next decade: “by 2020, to improve the CVH of all Americans by 20%, while reducing deaths from CVDs and stroke by 20%.”¹ The concept of CVH was introduced in this goal and characterized by 7 components (Life’s Simple 7)² that include health behaviors (diet quality, PA, smoking) and health factors (blood cholesterol, BMI, BP, blood glucose). For an individual to have ideal CVH overall, they must have an absence of clinically manifest CVD and the simultaneous presence of optimal levels of all 7 CVH components, including abstinence from smoking, a healthy diet pattern, sufficient PA, normal body weight, and normal levels of TC, BP, and FPG in the absence of medication treatment.

From 2011 to 2021, this chapter in the annual Statistical Update published national prevalence estimates for CVH based on released NHANES data to inform progress toward improvements in the prevalence of CVH based on the metrics of Life’s Simple 7. Because of the SARS-CoV-2 pandemic, NHANES data collection was suspended in March 2020. As a result, data collected from 2019 to March 2020 were combined with the full data collection from 2017 to 2018 to form the most up-to-date nationally representative sample for evaluating CVH.

To update the construct of CVH metrics on the basis of extensive evidence and insights accumulated over the decade after introduction of Life’s Simple 7, the AHA released a presidential advisory in 2022 to introduce an enhanced approach of accessing CVH: the Life’s Essential 8.³ The components of Life’s Essential 8 include updates for the original 7 CVH components to provide metrics in a more refined and continuous scale for better contrasting interindividual differences in CVH at a given point in time and tracking intraindividual changes in CVH over time. Furthermore, sleep health was added into the CVH metrics to better reflect its important role in human biology and sustainment of life, as well as its impact on cardiometabolic health. Table 2-1 summarizes the definitions and scoring algorithms for each of the CVH components under this new approach in both adults and youth.

With this new approach to assess CVH, this chapter now provides statistical updates under both CVH metrics as the health research and clinical practice fields migrate toward the use of Life’s Essential 8. Changes in the leading causes and risk factors for YLDs and YLLs between 1990 and 2019, first added to the 2021 Statistical Update, highlight the influence of the components of CVH on premature death and disability in populations.

Relevance of Ideal CVH

• 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.^4–9 Similar relationships have also been seen in non-US populations.^4,10–24

• 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.⁵

• A study of Black people in the United States found that the risk of incident HF was 61% lower among those with ≥4 ideal CVH components than among those with 0 to 2 ideal components.⁶

• 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.²⁵

• In a cohort of 91 204 participants from mainland China with 1985 incident major CVD events observed over a mean follow-up of 3.7 years, having greater numbers of ideal CVH components (categories ranged from ≤1, 2, 3, to ≥4) was associated with a significant reduction in CVD risk in a stepwise fashion in participants with stage 1 hypertension and similarly in participants with stage 2 hypertension. Moreover, participants with stage 1 hypertension having ≥4 ideal CVH components did not have significantly greater CVD risk compared with all participants without hypertension (HR, 1.04 [95% CI, 0.83–1.31]).²³

• 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.²⁶

• Results using NHANES III mortality data through 2011 estimated the PAFs of CVD mortality for components of CVH under revised definitions as follows²⁷:

  –	47.5% (95% CI, 38.2%–57.3%) for HBP (using thresholds from the 2017 AHA/ACC guideline);
  –	10.7% (95% CI, 4.0%–17.0%) for smoking;
  –	10.1% (95% CI, 2.6%–18.6%) for TC;
  –	5.91% (95% CI, 0.03%–14.1%) for insufficient PA; and
  –	11.6% (95% CI, 6.1%–16.8%) for abnormal glucose levels.
  –	A previous analysis using NHANES III mortality data through 2006 reported an estimated PAF of 13.2% (95% CI, 3.5%–29.2%) for poor diet.28

• Many 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.²⁹ A similar association between CVH score and incidence of stroke was also observed in a large Chinese cohort.³⁰ 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.³¹

• 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.³² 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.³³ Another report from the ARIC study estimated CVD risk and all-cause mortality associated with patterns of overall CVH level (classified as poor, intermediate, and ideal to correspond to 0–2, 3–4, and 5–7 CVH metrics at ideal levels) over time. The authors observed that participants attaining ideal CVH at the first follow-up visit had the lowest levels of CVD risks and mortality regardless of subsequent change in CVH level, and improvement from poor CVH over time was consistently associated with lower CVD risk and mortality subsequently.³⁴ Reduced CVD risk associated with improvement of CVH over time was also observed in the elderly and very elderly populations without CVD.³⁵

• Ideal CVH in parents was associated with greater CVD-free survival in offspring, and maternal CVH was found to be a more robust predictor of an offspring’s CVD-free survival than paternal CVH.³⁶ Furthermore, better maternal CVH at 28 weeks’ gestation during pregnancy was significantly associated with better offspring CVH in early adolescence.³⁷

• 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.³⁸ A large community-based prospective study in China showed that greater CVH was associated with lower lifetime risk of CVD and that improvement in CVH could lower the lifetime risk of CVD and prolong the years of life free from CVD.³⁹ Another report based on a large data set from the UK Biobank found that having ideal CVH over poor CVH attenuated the all-cause and cardiometabolic disease–related mortality for males and females and was associated with life expectancy gains of 5.50 (95% CI, 3.94–7.05) years for males and 4.20 (95% CI, 2.77–5.62) years for females, at an index age of 45 years, among participants with cardiometabolic diseases, and correspondingly 4.55 (95% CI, 3.62–5.48) years in males and 4.89 (95% CI, 3.99–5.79) years in females for people without cardiometabolic diseases.⁴⁰

• Better CVH as defined by the AHA is associated with a lower incidence of HF,^4,6–8,22 less subclinical vascular disease,^{9,15,17,41,42} better global cognitive performance and cognitive function,^16,43 lower hazard of subsequent dementia,^44–46 fewer depressive symptoms,^47–49 longer leukocyte telomere length,⁵⁰ less ESRD,⁵¹ less pneumonia,⁵² less chronic obstructive pulmonary disease,⁵³ lower prevalence of aortic sclerosis and stenosis,⁵⁴ lower risk of calcific aortic valve stenosis,⁵⁵ better prognosis after MI,⁵⁶ lower risk of AF,^57,58 and lower odds of having elevated resting heart rate.⁵⁹ 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.⁶⁰ 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.⁶¹ Better CVH in midlife was associated with a lower prevalence of frailty in a large community-based cohort study.⁶²

• 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.⁶³ A study in college students found that both handgrip strength and muscle mass were positively associated with greater numbers of ideal CVH components,⁶⁴ 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.⁶⁵ Furthermore, higher quality of life scores were associated with better CVH metrics,⁶⁶ 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.⁶⁷ A recent report from the ARIC study found that people of Black race (versus White race: OR, 0.68 [95% CI, 0.57–0.80]), with low income (OR, 0.71 [95% CI, 0.57–0.87]), or with low education (OR, 0.65 [95% CI, 0.53–0.79]) were at higher odds of having worsening CVH over time,⁶⁸ whereas analysis of NHANES data from 2013 to 2016 found that the association between educational attainment and likelihood of ideal CVH differed by race and ethnicity, underscoring the need for elucidating specific barriers preventing achievement of CVH across different racial and ethnic subgroups in the population.⁶⁹

• Other recent reports on CVH disparity include a study focused on people with serious mental illness, which found that individuals of underrepresented races and ethnicities had significantly lower CVH scores based on 5 of the Life’s Simple 7 components,⁷⁰ and data from BRFSS identifying racial and ethnic and geographic disparities in CVH among females of childbearing age in the United States: NH Black females were found to have lower adjusted odds (OR, 0.54 [95% CI, 0.46–0.63]) of attaining ideal CVH compared with NH White females, whereas 5 spatial clusters in the Southwest, South, Midwest, and Mid-Atlantic region were identified as having significantly lower prevalence of ideal CVH.⁷¹ A systematic review and meta-analysis summarized the finding on demographic differences and socioeconomic disparities in ideal CVH in the literature through June 2020, with females having a significantly higher prevalence of ideal smoking (81% versus 60% in males), BP (41% versus 30% in males), and overall CVH (6% versus 3% in males) and people with higher education and individuals who were economically more affluent being more likely to have ideal CVH.⁷²

• Neighborhood factors and contextual relationships have been linked to health disparities in CVH, but more research is needed to better understand these complex relationships.⁷³ Recent reports on the association between better neighborhood perceptions and higher CVH score in Black communities⁷⁴ and the relationship between greater perceived social status and higher CVH score in Hispanic/Latino population in the United States⁷⁵ are some examples of effort toward identifying complex relationships between demographic and socioeconomic factors and attaining ideal CVH. A recently published narrative review⁷⁶ described knowledge gaps and outlined potential steps toward equity in CVH, which is the objective of the interim⁷⁷ and longer-term⁷⁸ Impact Goals set forth by the AHA.

• Having more ideal CVH components in middle age has been associated with lower non-CVD and CVD health care costs in later life.⁷⁹ 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.⁷⁹ 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.⁸⁰

• The 2022 AHA presidential advisory on Life’s Essential 8 also provided summaries of knowledge gained on CVH since 2010 and evidence supporting psychological health and well-being, as well as social determinants, as foundational factors for CVH.³ Additional information on the relevance of sleep to cardiometabolic health can be found in Chapter 13 (Sleep) of this Statistical Update.

CVH in the United States: Prevalence (NHANES 2013–March 2020)

(See Table 2-2)

• The national estimates of the 8 CVH components for children (2–19 years of age) and adults (≥20 years of age) are displayed in Table 2-2.⁸¹ Multiple cycles of NHANES data were combined to provide more precise estimates on all CVH components. Dietary, PA, and BMI scores were calculated for all children who were 2 to 19 years of age; blood lipid and BP scores were calculated for children who were 6 to 19 and 8 to 19 years of age, respectively; and blood glucose and nicotine exposure scores were calculated for those who were 12 to 19 years of age in the sample. The sleep health score was available only for youth 16 to 19 years of age, so the mean score of this component and the overall CVH score were derived for this age range only. Dietary estimates were available only through data up to the 2017 to 2018 NHANES cycle at the time of this report.

  –	For most components of CVH, mean scores were higher in US children (within corresponding age ranges of the components) than in US adults (≥20 years of age), except for the diet score and the sleep health score, for which mean scores in children were lower than in adults. Mean diet scores were the lowest among the 8 CVH components for both US children and adults.
  –	Among US children, BP, blood glucose, and nicotine exposure were the CVH components scoring highest compared with the rest of the CVH components, with all mean scores in the 80s and the 90s (of 100 points as the ideal score) across race and ethnicity groups. In contrast, mean PA, lipids, and sleep health scores within the corresponding age ranges were all in the 70s across race and ethnicity categories.
  –	Among US adults (Table 2-2), the lowest mean scores for CVH were observed in diet, PA, and BMI components, with mean scores ranging from the 30s to the 50s across all race and ethnicity categories. Sleep health scores were the highest among the CVH components in US adults, with mean scores in the 80s across all race and ethnicity groups except in the NH Black adult population, for whom the mean score was 75.6 (95% CI‚ 74.5–76.7). Mean scores for blood lipids, blood glucose, and BP among US adults were all in the 60s to the 70s range across race and ethnicity categories.

• From 2013 to March 2020, the overall CVH score combining health scores of all 8 components was, on average, 73.6 (95% CI, 72.4–74.7) for all US children between 16 and 19 years of age. The corresponding mean overall CVH score was 78.4 (95% CI, 75.7–81.1) for NH Asian, 74.1 (95% CI, 72.0–76.2) for NH White, 72.7 (95% CI‚ 70.6–76.3) for Mexican American‚ and 71.3 (95% CI, 68.8–73.8) for NH Black children.

• During the same period, the mean overall CVH score was 65.2 (95% CI, 64.2–66.1) for all US adults, with mean score of 69.6 (95% CI, 68.1–71.1) for NH Asian, 66.0 (95% CI, 64.8–67.2) for NH White, 63.5 (95% CI‚ 62.2–64.8) for Mexican American‚ and 59.7 (95% CI, 58.4–60.9) for NH Black adults.

• An article appeared online ahead of print on the same day as the presidential advisory on Life’s Essential 8 providing CVH score estimates by additional sociodemographic categories under this new CVH metrics using NHANES data from 2013 to 2018.⁸²

Trends in Risk Factors and Causes for YLL and YLD in the United States: 1990 to 2019

(See Tables 2-3 through 2-6)

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

  –	Smoking and high SBP remained the first and second leading YLL risk factors in both 1990 and 2019. Age-standardized rates of YLL attributable to smoking declined by 46.4%, whereas age-standardized rates attributable to high SBP declined 45.8%.
  –	From 1990 to 2019, YLLs caused by drug use rose from the 18th to 5th leading YLL risk factor with a 242.3% increase in the age-standardized YLL rate.
  –	In 2019, CVH components accounted for 13 (among which 7 were related to poor diet) of the 20 leading YLL risk factors, with 6 of the 7 diet-related risk factors rising in the risk factor rankings since 1990.

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

  –	IHD and tracheal, bronchus, and lung cancer were the first and second leading YLL causes in both 1990 and 2019. Age-standardized YLL rates attributable to IHD declined 50.9%, whereas age-standardized YLL rates resulting from tracheal, bronchus, and lung cancer declined 36.1%.
  –	From 1990 to 2019, opioid use disorders rose from the 46th to 4th leading YLL cause with a 799.2% increase in the age-standardized YLL rate. Type 2 diabetes also rose from the 12th to 6th leading YLL cause, whereas AD and other dementias also rose from the 15th to 7th leading YLL cause.
  	The leading risk factors for YLDs from 1990 to 2019 in the United States are presented in Table 2-5.
  –	High BMI, high FPG, and smoking are among the first, second, and third leading YLD risk factors in both 1990 and 2019, with high BMI and high FPG rising in ranking while smoking dropped from the first to third leading YLD risk factor during this time period. Age-standardized YLD rates attributable to smoking declined by 25.8%, and age-standardized rates attributable to high BMI and high FPG increased by 44.4% and 47.4%, respectively, between 1990 and 2019.

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

  –	Low back pain and other musculoskeletal disorders were the first and second leading causes of YLDs in both 1990 and 2019. The age-standardized rates of YLD attributable to low back pain decreased 12.5%, whereas age-standardized YLD rates for other musculoskeletal disorders increased 44.2%.
  –	From 1990 to 2019, type 2 diabetes rose from the ninth to third leading YLD cause with a 55.8% increase in the age-standardized YLD rates.
  –	Opioid use disorders rose from the 16th to 4th leading YLD cause between 1990 and 2019 with a 288.7% increase in age-standardized rates of YLD.

Trends in Global Risk Factors and Causes for YLL and YLD: 1990 to 2019

(See Tables 2-7 through 2-10)

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

  –	High SBP and smoking were the first and second leading YLL risk factors globally in 2019. Age-standardized YLL rates attributable to HBP and smoking declined 29.0% and 41.3%, respectively, between 1990 and 2019.
  –	From 1990 to 2019, high FPG rose from the 14th to 5th leading risk factor of global YLLs with a 1.5% decrease in the age-standardized YLL rates over this period.

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

  –	IHD rose from the third to first leading global YLL cause between 1990 and 2019, whereas age-standardized YLL rates declined by 29.1% during this period. This shift resulted in lower respiratory infections moving from the first to second leading cause, and age-standardized YLL rates declined 62.7%.
  –	ICH and ischemic stroke rose from the 9th to 4th and from the 13th to 8th leading cause of global YLL, respectively, between 1990 and 2019.
  –	Type 2 diabetes also rose from the 28th to 14th leading global YLL cause, showing a 9.1% increase in age-standardized YLL rate.

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

  –

  High FPG and high BMI were the first and second leading YLD risk factors globally in 2019, replacing iron deficiency and smoking, which ranked fourth and third, respectively, in 2019. Age-standardized YLD rates attributable to high FPG and high BMI increased 44.1.% and 60.2%, respectively, whereas age-standardized global YLD rates attributable to smoking and iron deficiency deceased 22.9% and 16.7%, respectively.

  –

  Ambient particulate matter pollution rose from the 17th to 8th leading global risk factor for YLD, resulting in a 64.9% increase in the age-standardized global YLD rates.

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

  –	Low back pain and migraine were the first and second leading global causes of YLDs in both 1990 and 2019. The age-standardized rates of YLD attributable to low back pain decreased 16.3%, whereas rates for migraine increased 1.5% across the same time period.
  –	From 1990 to 2019, type 2 diabetes rose from the 10th to 6th leading global cause of YLD during this time period, with a 50.2% increase in the age-standardized global YLD rate.

COVID-19 Mortality in the United States

• 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 of July 1, 2022, the cumulative number of COVID-19 deaths in the United States was 1 014 620, which equates to ≈306 deaths per 100 000 people.83 In metropolitan areas in the United States, the cumulative COVID-19 death rate was ≈292 deaths per 100 000 compared with ≈392 deaths per 100 000 in nonmetropolitan areas.83
  –	In US counties with a high percentage (>37%) of the population that is NH Black individuals, the COVID-19 death rate was ≈354 deaths per 100 000 compared with ≈297 deaths per 100 000 in counties with a low percentage (<2.5%) of the population that is NH Black individuals.83
  –	In US counties with a high percentage (>45.5%) of the population that is Hispanic individuals, the cumulative COVID-19 death rate was ≈348 deaths per 100 000 compared with ≈307 deaths per 100 000 in counties with a low percentage (≤18.3%) of the population that is Hispanic individuals.83
  –	In US counties with a high percentage (>17.3%) of the population in poverty, the cumulative COVID-19 death rate was ≈394 deaths per 100 000 compared with ≈248 deaths per 100 000 in counties with a low percentage (≤12.3%) of the population that is living in poverty.83

Impact of COVID-19 on Life Expectancy in the United States

• 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.

• US life expectancy estimates released in December 2021^84,85 indicate that life expectancy (at birth) decreased from 78.8 years in 2019 to 77.0 years in 2020 (−1.8 years) overall; corresponding life expectancy decreased from 76.3 to 74.2 years (−2.1 years) in males and from 81.4 to 79.9 years (−1.5 years) in females. Provisional estimates released in December 2021 indicated that life expectancy decreased from 74.7 to 71.8 years (−2.9 years) for NH Black individuals, from 81.8 to 78.8 years (−3.0 years) for Hispanic individuals, and from 78.8 to 77.6 years (−1.2 years) for NH White individuals.⁸⁴

Furthering the AHA’s Impact Through Continued Efforts to Improve CVH

(See Tables 2-3 through 2-6)

• 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,²⁵ AD,⁸⁶ stroke,^87,88 CKD,⁸⁹ diabetes,^90,91 and breast cancer^92,93 (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, AD, 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.⁹⁴

Global Efforts to Improve CVH

(See Tables 2-7 through 2-10)

• 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.

3. SMOKING/TOBACCO USE

See Table 3-1 and Charts 3-1 through 3-5

Tobacco use is one of the leading preventable causes of death in the United States and globally. Cigarette smoking, the most common form of tobacco use, is a major risk factor for CVD, including stroke.¹ The AHA has identified combustible tobacco use or inhaled nicotine delivery system use (e-cigarettes or vaping) and secondhand smoke exposure to have adverse effects on CVH in Life’s Essential 8.² Unless otherwise stated, throughout the rest of this chapter, we report tobacco use and smoking estimates from the NYTS³ for adolescents and from the NHIS⁴ for adults (≥18 years of age) because these data sources have more recent data. As a survey of middle and high school students, the NYTS may not be generalizable to youth who are not enrolled in school; however, in 2016, 97% of youth 10 to 17 years of age were enrolled in school, which indicates that the results of the NYTS are likely broadly applicable to US youth.³

Other forms of tobacco use are becoming increasingly common. E-cigarette use, which involves inhalation of a vaporized liquid that includes nicotine, solvents, and flavoring (vaping), has risen dramatically, particularly among young adults and high school–aged children. The variety of e-cigarette–related and nicotine products has increased exponentially, giving rise to the more general term electronic nicotine delivery systems.⁵ A notable evolution in electronic nicotine delivery systems technology and marketing has occurred recently with the advent of pod mods, small rechargeable devices that deliver high levels of nicotine from nicotine salts in loose-leaf tobacco.⁶ Use of cigars, cigarillos, filtered cigars, and hookah (ie, water pipe) also has become increasingly common in recent years. Thus, each section here addresses the most recent statistical estimates for combustible cigarettes, electronic nicotine delivery systems, and other forms of tobacco use if such estimates are available.

Prevalence

Youth

(See Chart 3-1)

• Prevalence of cigarette use in the past 30 days for middle and high school students by sex and race and ethnicity in 2021 is shown in Chart 3-1.

• In 2021⁷:

  –	34.0% (95% CI, 31.6%–36.5%) of high school students (corresponding to 5.2 million users) and 11.3% (95% CI, 9.8%–13.0%) of middle school students (corresponding to 1.3 million users) reported ever use of any tobacco product; 13.4% (95% CI, 11.8%–15.2%) of high school students (corresponding to 2.1 million users) and 4.0% (95% CI, 3.3%–4.8%) of middle school students (corresponding to 470 000 users) reported current (past 30-day) tobacco product use. Of all high school students, 1.9% (95% CI, 1.5%–2.4%; corresponding to 280 000 users), and of all middle school students, 1.0% (95% CI, 0.8%–1.4%; corresponding to 120 000 users), smoked cigarettes in the past 30 days.
  –	2.1% (95% CI, 1.7%–2.6%) of high school students (310 000 users) and 0.6% (95% CI, 0.4%–0.8%) of middle school students (60 000 users) used cigars in the past 30 days.
  –	1.2% (95% CI, 0.8%–1.6%) of high school students (170 000 users) and 0.6% (95% CI, 0.4%–0.9%) of middle school students (60 000) used smokeless tobacco in the past 30 days.
  –	1.2% (95% CI, 0.9%–1.6%) of high school students (180 000 users) and 0.4% (95% CI, 0.2%–0.6%) of middle school students (40 000 users) used hookah in the past 30 days.

• Of youth who smoked cigarettes in the past 30 days in 2021, 18.9% (95% CI, 13.6%–25.7%) of middle and high school students (corresponding to 70 000 users) reported smoking cigarettes on 20 to 30 days of the past 30 days.⁸

• In 2021, 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 1.8% (95% CI, 1.4%–2.2%) in NH White youth compared with 1.0% (95% CI, 0.6%–1.6%) in NH Black youth and 1.5% (95% CI, 1.1%–2.0%) in Hispanic youth. For cigars, the respective percentages were 1.4% (95% CI, 1.1%–1.8%), 3.1% (95% CI, 2.4%–4.1%), and 0.9% (95% CI, 0.7%–1.2%). For hookah use, the prevalence among NH Black youth was 2.2% (95% CI, 1.4%–3.4%) compared with 0.5% (95% CI, 0.4%–0.7%) in NH White youth and 1.0% (95% CI, 0.6%–1.5%) in Hispanic youth.⁹

• The percentage of high school (11.3% or 1 720 000 users) and middle school (2.8% or 320 000 users) students who used e-cigarettes in the past 30 days exceeded the proportion using cigarettes in the past 30 days in 2021 (Chart 3-1).

Adults

(See Charts 3-2 and 3-3)

• According to the NHIS 2020 data, among adults ≥18 years of age¹⁰:

  –	12.5% (95% CI, 11.9%–13.0%) of adults reported cigarette use every day or some days.
  –	14.1% (95% CI, 13.3%–14.9%) of males and 11.0% (95% CI, 10.3%–11.6%) of females reported cigarette use every day or some days.
  –	7.4% of those 18 to 24 years of age, 14.1% of those 25 to 44 years of age, 14.9% of those 45 to 64 years of age, and 9.0% of those ≥65 years of age reported cigarette use every day or some days.
  –	27.1% of NH American Indian or Alaska Native adults, 14.4% of NH Black adults, 8.0% of NH Asian adults, 8.0% of Hispanic adults, and 13.3% of NH White adults reported cigarette use every day or some days.
  –	By annual household income, reported cigarette use every day or some days was 20.2% of people with <$35 000 income compared with 14.1% of those with an income of $35 000 to $74 999, 10.5% of those with an income of $75 000 to $99 999, and 6.2% of those with an income ≥$100 000.
  –	In adults ≥25 years of age, the percentage reporting current cigarette use was 21.5% for those with <12 years of education, 32.0% in those with a General Educational Development high school equivalency, 17.6% among those with a high school diploma, 14.4% among those with some college, 12.7% among those with an associate’s degree, and 5.6% among those with an undergraduate degree compared with 3.5% among those with a graduate degree.
  –	16.1% of lesbian/gay/bisexual individuals were current smokers compared with 12.3% of heterosexual/straight individuals.
  –	By region, the prevalence of current cigarette smokers was highest in the Midwest (15.2%) and South (14.1%) and lowest in the Northeast (10.4%) and West (9.0%).

• According to data from BRFSS 2020, the state with the highest age-adjusted percentage of current cigarette smokers was West Virginia (23.6%). The state with the lowest age-adjusted percentage of current cigarette smokers was Utah (8.2%; Chart 3-2).¹¹

• In 2020, smoking prevalence was higher among adults ≥18 years of age who reported having a disability or activity limitation (19.8%) than among those reporting no disability or limitation (11.8%).¹⁰

• Among individuals who reported cigarette use every day or some days, 21.4% reported having regular feelings of anxiety compared with 11.3% who reported no regular feelings of anxiety; 26.9% reported having regular feeling of depression compared with 11.8% who reported having no regular feelings of depression.¹⁰

• 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%).¹² 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.¹¹

Incidence

• 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).¹³ 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).¹³

• Overall, for individuals 12 to 17 years of age, use of tobacco products in the past month declined from 21.1% to 18.7% between 2019 and 2020, and tobacco product use in the past year declined from 26.2% to 23.3% during the same time period (2020 NSDUH; Tables 6.19B and 6.18B‚ respectively).¹³

• 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.¹⁴

Lifetime Risk

Youth

• Per NSDUH data for individuals 12 to 17 years of age, overall, the lifetime use of tobacco products has changed 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).¹³

  –

  The lifetime use of tobacco products among adolescents 12 to 17 years of age varied by the following: ° Sex: Lifetime use was higher among males (14.5%) than females (11.0%; 2019 NSDUH; Table 2.8B).13 ° Race and ethnicity: Lifetime use was highest among American Indian and Alaska Native adolescents (21.6%), followed by NH White adolescents (14.8%), Hispanic or Latino adolescents (12%), NH Black adolescents (8.8%), and NH Asian adolescents (3.5%; 2019 NSDUH; Table 2.8B).13

Adults

• 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 during the same years was 60.3% and 59.5%, respectively (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)¹³:

  –	Sex: Lifetime use was higher in males (74.4%) than females (57.7%).
  –	Race and ethnicity: Lifetime use was highest in American Indian or Alaska Native adults (70.4%) and NH White adults (74.4%), followed by Native Hawaiian or other Pacific Islander adults (48.9%), Hispanic or Latino adults (51.7%), NH Black adults (53.0%), and NH Asian adults (36.9%).

• In 2019, the lifetime use of smokeless tobacco for adults ≥18 years of age was 16.6% (2019 NSDUH; Table 2.4B).¹³

Secular Trends

Youth

(See Chart 3-4)

• According to data from NSDUH (12–17 years of age) and MTF (8th and 10th grades combined), the percentage of adolescents who reported smoking cigarettes in the past month declined from 13.0% and 14.2% in 2002 to 2.3% and 2.9% in 2019, respectively (Chart 3-4).^13,15 The percentages for daily cigarette use among those with past-month cigarette smoking in individuals 12 to 17 years of age were 31.5% in 2002 and 13.2% in 2019.^13,16

Adults

• Since the US Surgeon General’s first report on the health dangers of smoking, age-adjusted rates of smoking among adults have declined, from 51% of males smoking in 1965 to 15.6% in 2018 and from 34% of females in 1965 to 12.0% in 2018, according to NHIS data.⁴ The decline in smoking, along with other factors (including improved treatment and reductions in the prevalence of risk factors such as uncontrolled hypertension and high cholesterol), is a contributing factor to secular declines in the CHD death rate.¹⁷

• On the basis of weighted NHIS 2019 data, 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.¹⁸

• According to data from the BRFSS, the overall prevalence of e-cigarette use nonsignificantly increased from 4.3% to 4.8% (P=0.18) between 2016 and 2018 in US adults. Increases in e-cigarette use over this period were significant for middle-aged adults 45 to 54 years of age (from 3.9% in 2016 to 5.2% in 2018; P=0.004), females (from 3.3% in 2016 to 4.3% in 2018; P<0.001), and former smokers (from 5.2% in 2016 to 7.9% in 2018; P=0.02).¹⁹

CVH Impact

• 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.²⁰ 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.²¹

• 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.²⁰

• Among the US Black population, cigarette use is associated with elevated measures of subclinical PAD in a dose-dependent manner whereby those who self-reported smoking ≥20 cigarettes per day and higher pack-years had higher odds of subclinical PAD compared with those who self-reported smoking 1 to 19 cigarettes per day. Current smokers had an increased adjusted odds of ABI <1 (OR, 2.2 [95% CI, 1.5–3.3]) compared with never-smokers.²²

• 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]).²³

• 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.²⁴

• 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.²⁵

• Current smokers have a 2 to 4 times increased risk of stroke compared with nonsmokers or those who have quit for >10 years.^24,26 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]).²⁷

• 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 an increased risk of HF.²⁸ 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).²⁹

• 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.³⁰ 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.³¹ 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.³² 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.³³

• The long-term CVD risks associated with e-cigarette use are not known because of a lack of longitudinal data.^34,35 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.³⁶ In addition, daily and some-day use of e-cigarettes may be associated with MI and CHD.^37,38

• 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.³⁸ 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.³⁹

• In a 2-sample mendelian randomization study that examined the causal effect of 12 lifestyle risk factors on the risk of stroke, genetically predicted lifetime smoking was associated with ischemic (OR, 1.23 [95% CI, 1.10-1.39]) and large artery (OR, 1.72 [95% CI, 1.26-2.36]) stroke.⁴⁰ In another mendelian randomization study, genetic liability to smoking was associated with 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).⁴¹

Family History and Genetics

• Genetic variation contributes to smoking initiation, smoking regularity, nicotine dependence, and smoking cessation, among other smoking traits. Twin studies have estimated heritability as large as 70% for the transition from regular smoking to nicotine dependence⁴² and ≈50% for other smoking measures.^43,44 A much smaller fraction (8.6%) of variation in nicotine dependence is explained by genetic variation in commonly occurring SNPs,⁴⁵ although genetic variation explains higher proportions of phenotypic variance for smoking initiation (18%) and smoking cessation (12%).⁴⁶

• GWASs have identified loci associated with smoking initiation, heaviness of smoking, smoking regularity, and smoking cessation. In analyses of up to 1.2 million participants, common and rare variants in 298 independent loci were identified.⁴⁷ Highlights of this study include identification of novel associations between ≥1 smoking phenotypes with central nervous system–expressed nicotinic receptor genes. Loci underlying reward-related learning and memory systems, particularly the neurotransmitter glutamate, also were identified for smoking initiation phenotypes.

• Genetic loci underlying nicotine dependence also have been identified; a GWAS of >58 000 smokers of European and African ancestry identified 5 genome-wide significant loci, including 2 loci unique to nicotine dependence at NAGI2/GNAI1 and TENM2.⁴⁵

• GRSs for age at smoking initiation, number of cigarettes per day, smoking cessation, and smoking initiation explain ≈1% to 4% of phenotypic variation.⁴⁷

• The genetic architecture of smoking shares similarities with alcohol dependence⁴⁸ and CAD.⁴⁹

Smoking Prevention

Tobacco 21 legislation was signed into law on December 20, 2019, increasing the federal minimum age for sale of tobacco products from 18 to 21 years.⁵⁰

• 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.

  –	For instance, investigators used repeated cross-sectional, statewide surveys of adolescents in Minnesota in 2016 and 2019 across a range of tobacco products (including any tobacco, cigarettes, cigars, e-cigarettes, hookah, chewing tobacco, flavored tobacco, and multiple products).51 Eighth and ninth grade students exposed to Tobacco 21 laws had significantly lower odds of tobacco use than unexposed students in using the following: any tobacco (aOR, 0.80 [95% CI, 0.74–0.87]), cigarettes (aOR, 0.81 [95% CI, 0.67–0.99]), e-cigarettes (aOR, 0.78 [95% CI, 0.71–0.85]), flavored tobacco (aOR, 0.79 [95% CI, 0.70–0.89]), and dual/polytobacco (aOR, 0.77 [95% CI, 0.65–0.92]).
  –	In Massachusetts, investigators examined the associations between county-level Tobacco 21 laws and adolescent cigarette and e-cigarette use. Increasing Tobacco 21 laws were significantly (P=0.01) associated with decreases in cigarette use only among adolescents 18 years of age.52
  –	Another study using BRFSS 2011 to 2016 data before the federal legislation found that metropolitan and micropolitan statistical areas with local Tobacco 21 policies yielded significant reductions in smoking among youth 18 to 20 years of age.53

• In addition, in several towns in which Tobacco 21 laws were enacted before federal legislation, reductions of up to 47% in smoking prevalence among high school students have been reported.⁵⁴ 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 2019.⁵⁴

• 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 City‚ KS‚ and Kansas City‚ MO) passed legislation setting the minimum age for the purchase of tobacco to 21 years.⁵⁵

Awareness, Treatment, and Control

Smoking Cessation

• 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%).⁵⁶

  –

  Between 2011 and 2017, according to BRFSS surveys, quit attempts varied by state, with quit attempts increasing in 4 states (Kansas, Louisiana, Virginia, and West Virginia), declining in 2 states (New York and Tennessee), and not changing significantly in 44 states. In 2017, the quit attempts over the past year were highest in Guam (72.3%) and lowest in Wisconsin (58.6%), with a median of 65.4%.57

  –

  According to NHIS 2015 data, among all smokers, the majority (68.0%) of adult smokers wanted to quit smoking; 55.4% had tried in the past year, 7.4% had stopped recently, and 57.2% had received health care professional advice to quit.58 Receiving advice to quit smoking was lower among uninsured smokers (44.1%) than among those with health insurance coverage through Medicaid or those who were dual eligible for coverage (both Medicaid and Medicare; 59.9%).

• 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.⁵⁹

• 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]).⁶⁰ 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%]).

  –	The period from 2000 to 2015 revealed significant increases in the prevalence of smokers who had tried to quit in the past year, had stopped recently, had a health professional recommend quitting, or had used cessation counseling or medication.58
  –	In 2015, fewer than one-third of smokers attempting to quit used evidence-based therapies: 4.7% used both counseling and medication; 6.8% used counseling; and 29.0% used medication (16.6% nicotine patch, 12.5% gum/lozenges, 2.4% nicotine spray/inhaler, 2.7% bupropion, and 7.9% varenicline).58

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

  –	In several studies, a dose-response relationship has been seen among current smokers between the number of cigarettes smoked per day and CVD incidence.61,62
  –	Quitting smoking at any age significantly lowers mortality from smoking-related diseases, and the risk declines with the time since quitting smoking.1 Cessation appears to have both short-term (weeks to months) and long-term (years) benefits for lowering CVD risk.63
  –	Smokers who quit smoking at 25 to 34 years of age gained 10 years of life compared with those who continued to smoke. Those 35 to 44 years of age gained 9 years, those 45 to 54 years of age gained 6 years, and those 55 to 64 years of age gained 4 years of life, on average, compared with those who continued to smoke.61
  –	Among those with a cumulative smoking history of at least 20 pack-years, individuals who quit smoking had a significantly lower risk of CVD within 5 years of smoking cessation compared with current smokers (HR, 0.61 [95% CI, 0.49–0.76]). However, former smokers’ CVD risks remained significantly higher than risks for never-smokers beyond 5 years, and possibly for 25 years, after smoking cessation.64

• Among 726 smokers included in the Wisconsin Smokers Health Study, smoking cessation was associated with less progression of carotid plaque (mean change, 0.093 mm [SD, 0.0094]) but not IMT.⁶⁵

• Cessation medications (including sustained-release bupropion, varenicline, nicotine gum, lozenge, nasal spray, and patch) are effective for helping smokers quit.^66,67

• 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.⁶⁸

• The EAGLES trial⁶⁹ 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.⁶⁹

• Extended use of a nicotine patch (24 compared with 8 weeks) has been demonstrated to be safe and efficacious for abstinence (OR, 1.70 [95% CI, 1.03–2.81]; P=0.04) in randomized clinical trials.⁷⁰

• An RCT demonstrated the effectiveness of individual- and group-oriented financial incentives for tobacco abstinence (abstinence rate range, 9.4%–16.0% with different incentive group versus 6.0% for usual care; P<0.05 for all comparisons) through at least 12 months of follow-up.⁷¹

• In addition to medications, smoke-free policies, increases in tobacco prices, cessation advice from health care professionals, quit lines, and other counseling have contributed to smoking cessation.^58,72

• 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.⁷³

• 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.⁷⁴

• 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.⁷⁵

• 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.⁷⁶

• In a double-blind, 2×2 factorial randomized clinical trial, patients were randomized to 1 of 4 medication groups: varenicline monotherapy for 12 weeks, varenicline plus nicotine patch for 12 weeks, varenicline monotherapy for 24 weeks, or varenicline plus nicotine patch for 24 weeks.⁷⁷ Results demonstrated that there were no significant differences in 7-day point prevalence abstinence at 52 weeks among those treated with combined varenicline plus nicotine patch therapy versus varenicline monotherapy or among those treated for 24 weeks versus 12 weeks.

• An RCT comparing combined treatment with varenicline and nicotine patch against placebo and nicotine patch for smoking cessation among smokers who drink heavily showed that combination treatment led to higher smoking cessation rates (44% versus 27.9%; P=0.04) and lower likelihood of relapse (HR, 0.62 [95% CI, 0.40-0.96]; P=0.03).⁷⁸

Mortality

• 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 2016.⁷⁹ Overall mortality among US smokers is 3 times higher than that for never-smokers.⁶¹

• 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.^17,80

• Recent analyses from multiple cycles of the Tobacco Use Supplements to the Current Population Survey (1992–1993, 1995–1996, 1998–1999, 2000, 2001–2002, 2003, 2006–2007, or 2010–2011) show that current daily (HR, 2.32 [95% CI, 2.25–2.38]) and lifelong nondaily (HR, 1.82 [95% CI, 1.65–2.01]) cigarette smokers had higher all-cause mortality risks compared with never-smokers.⁸¹

• Harmonized tobacco use data from adult participants in the 1991, 1992, 1998, 2000, 2005, and 2010 NHIS show that daily smokeless tobacco use (HR, 1.41 [95% CI, 1.20–1.66]) and daily cigar smoking (HR, 1.52 [95% CI, 1.12–2.08]) were associated with a higher mortality risk compared with no tobacco use.⁸²

• Increased CVD mortality risks exist among daily (HR, 1.47 [95% CI, 1.40–1.54]) and nondaily (HR, 1.24 [95% CI, 1.11–1.39]) cigarette smokers compared with never tobacco smokers⁸³ and 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.⁸⁴

• 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.⁸⁵

• 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.⁸⁶

• If current smoking trends continue, 5.6 million US children will die of smoking prematurely during adulthood.²⁰

E-Cigarettes and Vaping Products

(See Charts 3-1 and 3-3)

• 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 in the United States only around 2007, there are currently >450 e-cigarette brands and vaping products on the market, with sales in the United States showing dramatic increases from 2015 ($304 million) through 2018 ($2 billion).^87–89 Juul came on the market in 2015 and has rapidly became one of the most popular vaping products sold in the United States.⁹⁰ The popularity of 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.⁹¹ Besides e-cigarettes and Juul, electronic hookahs (ie, electronic water pipes) are a new category of vaping devices patented by Philip Morris in 2019.^92,93 Unlike e-cigarettes and Juul, electronic hookahs are used through traditional water pipes, allowing the flavored aerosol to pass through the water-filled bowl before being inhaled.⁹⁴ The popularity of electronic hookahs is driven in part by unsubstantiated claims that the presence of water “filters out toxins,” rendering electronic hookahs as healthier tobacco alternatives.^95,96

• 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.⁹⁷

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

• The 2021 NYTS was fully conducted amid the unprecedented COVID-19 pandemic. Because participants were allowed to participate in classrooms, at home, or at some other place, because of potential underreporting of tobacco and nicotine product use behaviors by location, estimates from the 2021 NYTS are not to be compared with previous years in which surveys were conducted primarily on school campuses. According to the 2021 NYTS data⁷:

  –	E-cigarettes were the most commonly used tobacco products in youth: Ever use of e-cigarettes was reported by 7.3% (860 000) of middle school and 28.9% (4.4 million) of high school students. In the past 30 days, 2.8% (320 000) of middle school and 11.3% (1.7 million) of high school students reported current e-cigarette use (Chart 3-1).
  –	Daily use was 27.6% among current high school e-cigarette users and 8.3% among current middle school e-cigarette users.98 Among high school students, rates of current use were slightly higher among females (11.9%) than males (10.7%) and most pronounced among NH White students (14.5%).7 In middle school students, current use rates among females were 3.2% compared with 2.3% among males, with higher rates among Hispanic (3.9%) compared with NH White (2.6 %) students.
  –	Among current e-cigarette users, 85.8% of high school users and 79.2% of middle school users used flavored e-cigarettes, with fruit being the most common flavor type used.
  –	Among both middle and high school current e-cigarette users, the most commonly used e-cigarette device type was disposables, followed by prefilled or refillable pods or cartridges and tanks or mod systems.

• According to the NYTS, current exclusive e-cigarette use among US youth who have never used combustibles, including cigarettes, increased exponentially from 2014 to 2019.⁹⁹ Among high school students, current exclusive e-cigarette use increased from 1.4% (95% CI, 1.0%–2.1%) in 2014 to 9.2% (95% CI, 8.2%–10.2%) in 2019 and from 0.9% (95% CI, 0.6%–1.3%) in 2014 to 4.5% (95% CI, 3.7%–5.2%) in 2019 among middle school students.

• Frequent use of e-cigarettes among high school students who were current e-cigarette users increased from 27.7% in 2018 to 34.2% in 2019. In middle school students, the percentage frequently using e-cigarettes among current users increased from 16.2% in 2018 to 18.0% in 2019.^3,8

• In 2021, 70.3% of US middle and high school students were exposed to e-cigarette marketing (advertisements or promotions).⁷ Among adolescents and young adults, a systematic review suggested an association between exposure to e-cigarette advertisement and lower harm perceptions of e-cigarettes, intention to use e-cigarettes, and e-cigarettes trial.¹⁰⁰

• In 2020, the prevalence of current e-cigarette use in adults, defined as use every day or on some days, was 3.7% according to data from the NHIS. The prevalence of current e-cigarette use was highest among males (4.6%), individuals 18 to 24 years of age (9.4%), and those reporting severe generalized anxiety disorder (10.1%).¹⁰

• According to data from BRFSS 2016 to 2018, current use of e-cigarettes in adults ≥18 years of age was higher in sexual and gender underrepresented individuals.^101,102 Data from 2017 and 2018 data sets show that the prevalence of current e-cigarette use among sexual and gender underrepresented adults was 13.0% (95% CI, 12.0%–14.2%) versus 4.8% (95% CI, 4.6%–4.9%) among heterosexuals.¹⁰¹ In 2016, with respect to sexual orientation, 9.0% of bisexual and 7.0% of lesbian/gay individuals were current e-cigarette users compared with 4.6% of heterosexual people. Individuals who were transgender (8.7%) were current e-cigarette users at a higher rate than cisgender individuals (4.7%). Across US states, the highest prevalence of current e-cigarette use was observed in Oklahoma (7.0%) and the lowest in South Dakota (3.1%).¹⁰²

• Limited data exist on the prevalence of other electronic nicotine delivery devices besides e-cigarettes. According to nationally representative data from the PATH study, in 2014 to 2015, 7.7% of youth 12 to 17 years of age reported ever electronic hookah use.¹⁰³ Among adults >18 years of age, 4.6% reported ever electronic hookah use, and 26.8% of them reported current use.

• E-cigarettes contain lower levels of most tobacco-related toxic constituents compared with traditional cigarettes,¹⁰⁴ including volatile organic compounds.^105,106 However, nicotine levels have been found to be consistent across long-term cigarette and long-term e-cigarette users.^36,107

• E-cigarette use has a significant cross-sectional association with a less favorable perception of physical and mental health and with depression.^108,109

• According to the BRFSS 2016 and 2017, e-cigarettes are associated with a 39% increased odds of self-reported asthma (OR, 1.39 [95% CI, 1.15–1.68]) and self-reported chronic obstructive pulmonary disease (OR, 1.75 [95% CI, 1.25–2.45]) among never users of combustible cigarette.^110,111 There is a dose-response relationship such that higher frequency of e-cigarette use was associated with more asthma or chronic obstructive pulmonary disease.

• An outbreak of e-cigarette or vaping product use–associated lung injury peaked in September 2019 after increasing rapidly between June and August 2019. Surveillance data and product testing indicate that tetrahydrocannabinol-containing e-cigarettes or vaping products are linked to most e-cigarette or vaping product use–associated lung injury cases. In particular, vitamin E acetate, an additive in some tetrahydrocannabinol-containing e-cigarettes or vaping, has been identified as the primary source of risk, although exposure to other e-cigarette– or vaping-related toxicants may also play a role. As of February 18, 2020, a total of 2807 hospitalized e-cigarette or vaping product use–associated lung injury cases or deaths have occurred in the United States.¹¹²

• Effective August 8, 2016, the FDA’s Deeming Rule prohibited sale of e-cigarettes to individuals <18 years of age.¹¹³

• In January 2020, the FDA issued a policy prioritizing enforcement against the development and distribution of certain unauthorized flavored e-cigarette products such as fruit and mint flavors (ie, any flavors other than tobacco and menthol).¹¹⁴ This policy, however, applies only to cartridge- or pod-based e-cigarette products, defined as “any small, enclosed unit (sealed or unsealed) designed to fit within or operate as part of an electronic nicotine delivery system.”¹¹⁵ Products that would be exempted from this prohibition include self-contained, customizable, or disposable products.

• According to data from the BRFSS 2016 and 2017, e-cigarette use among adults is associated with state-level regulations and policies on e-cigarettes: OR of 0.90 (95% CI, 0.83–0.98) for laws prohibiting e-cigarette use in indoor areas; OR of 0.90 (95% CI, 0.85–0.95) for laws requiring retailers to purchase a license to sell e-cigarettes; OR of 1.04 (95% CI, 0.99–1.09) for laws prohibiting self-service displays of e-cigarettes; OR of 0.86 (95% CI, 0.74–0.99) for laws prohibiting sales of tobacco products, including e-cigarettes, to people <21 years of age; and OR of 0.89 (95% CI, 0.83–0.96) for laws applying taxes to e-cigarettes.¹¹⁶