Myocardial infarction is a major public health burden in France: it is one of the main cardiovascular diseases, which together account for the second leading cause of death in France. Myocardial infarction accounts for more than 70,000 hospitalizations per year in France. Tobacco is one of the main risk factors for this disease, and what distinguishes the cardiovascular impact in smokers is that it is immediate, whereas cancers may take several years of exposure to develop. In addition, cardiovascular risk is reduced as soon as the individual stops smoking. These two factors make myocardial infarction a good model for studying the impact of smoking reduction scenarios in France.

In this study, we modeled four smoking reduction scenarios based on the proportion of smokers aged 18–75 in the French population between 2024 and 2035. The first scenario, known as the baseline scenario, uses the current trend of smoking reduction in France, which is a 1% annual decline in the proportion of smokers. The second scenario simulates a reduction in smokers twice the current rate, i.e., 2% per year. The third scenario applies one of the preliminary objectives of the National Tobacco Control Plan (PNLT), which aims for 22% of the population to be smokers by 2027, equating to a 10% reduction per year. Finally, the fourth scenario simulates a complete cessation of tobacco use starting in 2024, i.e., the proportion of smokers being 0% from that year onward. The data supporting these different scenarios are drawn from the French National Health Data System (SNDS), the 2021 Santé publique France Health Barometer, and INSEE.

Implementing scenario 3 would mean that 45,000 myocardial infarctions could be prevented by 2035, more than 60% of which would be in the under-65 age group, as well as 4,500 deaths due to myocardial infarction and 265,000 deaths from all causes. The second scenario, which is less ambitious in terms of reducing smoking prevalence, would yield significant gains compared to maintaining the current trend, but the impact would be smaller than in scenario 3: 6,800 fewer myocardial infarctions, 640 fewer deaths from myocardial infarction, and 40,000 fewer deaths from all causes.

Finally, a theoretical scenario of complete cessation of smoking in France by 2024, used to estimate the maximum benefit, would mean that 103,000 myocardial infarctions, 12,800 deaths from myocardial infarction, and 653,000 deaths from all causes could be prevented by 2035. Beyond the impact on the number of cases and deaths, a reduction in the prevalence of smoking in the population would result in the average age of disease onset being delayed by between 2.8 and 4.1 years in men and between 1.1 and 2.0 years in women. These results confirm the relevance of ambitious quantitative targets for reducing smoking.

Our research has shown that, without any preventive measures, the prevalence of myocardial infarction in France will increase significantly by 2035. This projected increase is linked to several factors, both demographic—due to the inevitable aging of the population—and epidemiological, as the prevalence of cardiovascular risk factors remains high in France.

It is estimated that nearly half of the increase in the prevalence of myocardial infarction by 2035 is attributable to population aging alone. INSEE data show that by 2050 in France, people aged 60 and older will account for one-third of the population, compared to one-fifth in 2005.

Prevention takes on major importance in this context, as it does for chronic diseases more broadly. The risk factors responsible for the highest proportion of cardiovascular events are smoking, high cholesterol, diabetes, and hypertension. These four risk factors can be modified through behavioral changes. While smoking is currently the focus of active and regular prevention campaigns that have proven effective, the other three risk factors remain at very high levels in the population (30% of adults have hypertension, 7.4% of adults have diabetes, and 23.3% of adults have high LDL cholesterol), and a significant proportion of people have not been screened (45% for hypertension, 23% for diabetes, and 43% for high LDL cholesterol) (3–5). Improving screening for hypertension, diabetes, and hypercholesterolemia, as well as running nutrition campaigns, are of greater priority than ever if we are to reverse these trends.

The multiple-state model used for myocardial infarction can be applied to other cardiovascular or chronic diseases, provided that appropriate hypotheses are formulated for each targeted disease.

Applying the model to all tobacco-related diseases would quantify the overall benefit that could be expected from smoking prevention.

It is also possible to consider using these models for other risk factors or combining several risk factors. However, we must bear in mind that these models are complex and require the formulation of many hypotheses to function effectively. They are also very computationally intensive.

In addition to simulating prevention scenarios, the advantage of these models is that they demonstrate the significant impact of aging on the prevalence of cardiovascular diseases by incorporating INSEE’s population age structure projections into the modeling. Given the significant influence of demographics on the projected prevalence trend, our results highlight the need to adapt the healthcare system to anticipate treating rising patient numbers. These adaptations would be required not only during the acute hospital admission phase, but also in the management of the chronic phase. This includes cardiac rehabilitation followed by the provision of secondary and tertiary prevention and therapeutic patient education upon discharge.

Beyond cardiovascular diseases, population aging has an impact on all age-related chronic diseases. Our findings regarding the need for more active prevention and adaptation of the healthcare system apply to all chronic diseases.