Stroke-related mortality trends among tobacco users in the U.S.: A 21-year retrospective analysis of national data from the CDC WONDER database

Introduction: Stroke is a leading cause of mortality, and tobacco use is a significant modifiable risk factor. This study analyzed trends in tobacco-associated stroke mortality in the United States from 1999 through 2023 using CDC WONDER data. Methods: We included adults aged ≥ 25 years with cerebrovascular disease (ICD-10 I60–I69) as the underlying cause of death and tobacco-related disorders (ICD-10 F17.0–F17.9) as contributing causes. Age-adjusted mortality rates (AAMRs) per 100,000 population were calculated based on the 2000 U.S. standard population. Rates were stratified by sex, race/ethnicity, urban-rural status, geographic region, state, and ten-year age groups. Joinpoint regression was used to estimate annual and average annual percent changes (APC and AAPC) in mortality trends over time. Results: A total of 157,916 tobacco-related stroke deaths occurred from 1999 to 2023. The AAMRs increased from 0.41 (95 % CI: 0.38–0.44) in 1999 to 3.80 (95 % CI: 3.73–3.87) in 2023 (average APC: 9.65 %, p < 0.0001). Males had higher AAMRs (3.52) than females (2.02), although females experienced a steeper increase from 1999 to 2005 (APC: 41.3 %, 95 % CI: 30.2–53.3). Non-Hispanic Blacks had the highest average AAMR (3.13), followed by Non-Hispanic Whites (2.83) and Hispanics (1.31). Rural areas (3.84) exceeded metropolitan regions (2.38). Regionally, the Midwest had the highest AAMR (3.57); state rates ranged from Oregon (8.0) to California (0.31). By age, the highest crude rates occurred in those aged 75 years and older, particularly in the 85+ group, which showed a sustained upward trend (APC: 4.29 %, 95 % CI: 3.47–5.11). Conclusion: Disparities in tobacco-associated stroke mortality are increasing across demographic and geographic subgroups, underscoring the need for targeted prevention strategies, equitable access to stroke care, and enhanced health literacy.