Among 3,268 US adults aged 40 and older with ankle-brachial index testing (NHANES 1999-2004, 235 with peripheral artery disease), smoking showed the strongest association with PAD (odds ratio 3.37), followed by renal failure (1.78) and diabetes (1.68). PAD roughly 2.65-fold raised cardiovascular death risk. In 390,174 PAD deaths from 1999-2024, the share mentioning tobacco climbed from 2.20% to 18.50% and diabetes rose after 2014, while renal failure stayed flat near 14.5%.
The design is the interesting part: pairing individual-level risk estimates with national death-certificate trends guards against each stream's blind spots, and agreement on smoking and diabetes strengthens an already well-established story. The rising tobacco share likely reflects improved death-certificate coding and fewer deaths from competing causes as much as true risk change, so it should not be read as smoking becoming more dangerous. The kidney disagreement is best explained by differing estimands, not contradiction, and the study cannot resolve it. Only 235 PAD cases limits precision, the ankle-brachial index was measured two decades ago, and ecological trends cannot be attributed to individuals. This is a preprint awaiting peer review, so results may shift. For readers, the practical takeaway is confirmatory: quitting smoking and controlling glucose remain the most actionable levers against PAD, and anyone with diabetes, kidney disease or a smoking history can ask about ankle-brachial index screening. Editorially, this is incremental, with methodological novelty more than new clinical insight.