Tobacco-Attributable Burden of Early-Onset Ischemic Heart Disease From 1990 to 2023: A Global Analysis Using GBD 2023 and Age-Period-Cohort Modeling.

BACKGROUND: Early-onset ischemic heart disease (IHD) is a growing global threat, with tobacco exposure as a key modifiable risk factor. A global assessment of its tobacco-attributable burden is needed. METHODS: Using Global Burden of Disease Study 2023 data, we assessed tobacco-attributable deaths and disability-adjusted life years (DALYs) from early-onset IHD in 204 countries and territories during 1990-2023. Trends were evaluated using estimated and average annual percentage changes (EAPCs and AAPCs). Age-period-cohort (APC) models characterized age, period, and cohort patterns, and Bayesian APC models projected age-standardized rates to 2050. A sensitivity analysis compared the sexes aged 40-54 years. RESULTS: From 1990 to 2023, tobacco-attributable DALYs increased from 15.21 to 17.12 million and deaths from 342 900 to 386 300. Conversely, ASDR declined from 381.54 to 221.82 per 100 000 (EAPC -1.84%, 95% CI -1.94 to -1.73) and ASMR from 8.69 to 4.96 per 100 000 (EAPC -1.88%, 95% CI -1.98 to -1.77). Male rates remained higher, including when both sexes were restricted to ages 40-54 years. APC analyses showed significant favorable net drifts and lower period and cohort rate ratios in recent periods and birth cohorts. Bayesian projections suggested declining ASDRs through 2050, whereas ASMR estimates were stable or slightly increased with widening uncertainty. CONCLUSION: The age-standardized burden of tobacco-attributable early-onset IHD declined substantially between 1990 and 2023, but absolute DALYs and deaths increased and disparities by development level and sex persisted. Stronger tobacco control and integrated cardiovascular prevention are needed, particularly for high-risk males and in low- and middle-SDI settings.