Among 65,990 Spanish adults tracked across three national health surveys (2011–2017) and linked to mortality data through December 2023, 13.3% of those with prior myocardial infarction or stroke continued smoking. Current smokers with prior MI faced a relative risk of all-cause mortality of 2.26 (95% CI: 1.62–3.16) compared to never-smokers without MI history; for stroke survivors, that figure reached 2.48 (95% CI: 1.70–3.61). Even former smokers carried elevated risk — RRs of 1.36 and 1.40 respectively — confirming that cessation reduces but does not fully eliminate excess mortality.
These numbers land with force because they quantify the survival penalty of continued smoking in a population that has already experienced a sentinel cardiovascular event — precisely the group most likely to be counselled to quit. The finding that younger adults, women, and those with co-occurring alcohol use or sedentary behaviour were disproportionately likely to keep smoking identifies realistic subgroups for targeted intervention programmes.
The study's strengths include its large prospective cohort, registry-linked mortality, and a follow-up window extending over a decade. Key limitations are self-reported smoking status — susceptible to social-desirability bias — and the observational design, which cannot fully exclude residual confounding. Still, the magnitude of the effect is striking and consistent with prior literature. For clinicians and patients alike, the message is unambiguous: quitting after a cardiac event is one of the highest-yield behavioural changes available, and that opportunity is still being missed in more than one in eight survivors.