Myocardial infarction poses a significant burden on public health in France: it is one of the leading cardiovascular diseases, which are the second leading cause of death in France. Myocardial infarction accounts for more than 70,000 hospitalizations per year in France.
Tobacco use is one of the main risk factors for this disease, with the distinct feature of having an immediate cardiovascular impact on smokers, unlike cancers, which can develop after several years of exposure. Furthermore, the reduction in cardiovascular risk takes effect as soon as smoking is stopped. These two observations make myocardial infarction a suitable model for studying the impact of smoking reduction scenarios in France.

In this study, we modeled four smoking reduction scenarios regarding the proportion of smokers aged 18–75 in the French population between 2024 and 2035. The first scenario, known as the standard scenario, replicates the current trend of smoking reduction in France, namely a 1% annual decrease in the proportion of smokers. The second scenario simulates a doubling of the reduction in smokers compared to the previous scenario, i.e., 2% per year. The third scenario applies one of the preliminary objectives of the PNLT (National Tobacco Control Plan), targeting a proportion of smokers at 22% by 2027, i.e., a reduction of 10% per year. Finally, the fourth scenario simulates a complete cessation of tobacco use starting in 2024, resulting in a smoking rate of 0% by that year. The data used in these various scenarios are sourced from the National Health Data System, the 2021 France Public Health Barometer, and INSEE.

Implementing Scenario 3 would prevent, by 2035, 45,000 cases of myocardial infarction—more than 60% of which would occur in people under 65—4,500 deaths from myocardial infarction, and 265,000 deaths from all causes. The second scenario, which is less ambitious in terms of reducing smoking prevalence, would yield a significant benefit compared to maintaining the current trend, though less than Scenario 3: 6,800 fewer cases of myocardial infarction, 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—allowing for an estimate of the maximum benefit—would prevent 103,000 cases of myocardial infarction, 12,800 deaths from myocardial infarction, and 653,000 all-cause deaths by 2035. Beyond the impact on the number of cases and deaths, a reduction in smoking prevalence in the population would lead to a decrease in the average age of onset of the disease by 2.8 to 4.1 years among men and by 1.1 to 2.0 years among women. These results confirm the relevance of ambitious, quantified targets for reducing smoking.

Our study has shown that, even without any preventive measures, the prevalence of myocardial infarction will rise sharply by 2035. The projected increase in the prevalence of myocardial infarction in France by 2035 is linked to several factors: demographic factors, including the inevitable aging of the population, and epidemiological factors, including the prevalence of cardiovascular risk factors, which remains high in France.

It is estimated that nearly half of the increase in the prevalence of myocardial infarction by 2035 will be due solely to population aging. Indeed, 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.

In this context—and more broadly for chronic diseases—prevention is of paramount importance. The risk factors with the highest attributable share of cardiovascular events are smoking, high cholesterol, diabetes, and high blood pressure. These four risk factors can be modified through behavioral changes. While tobacco is now the focus of active and regular prevention campaigns with proven effectiveness, the other three risk factors remain at very high levels in the population (30% of adults with high blood pressure, 7.4% of adults with diabetes, and 23.3% of adults with high LDL cholesterol), with a significant proportion of undiagnosed cases (45% for high blood pressure, 23% for diabetes, and 43% for high LDL cholesterol) (3–5). Improving screening for high blood pressure, diabetes, and high cholesterol, along with nutritional prevention campaigns, remain more critical than ever to reverse these trends.

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

Applying this to all diseases attributable to tobacco use would allow us to quantify the overall benefit that could be expected from tobacco prevention.
It is also possible to consider using these models for other risk factors or by combining multiple risk factors. Nevertheless, it is important to keep in mind that these models are complex and require the formulation of numerous assumptions. They are also very computationally intensive.
Beyond prevention scenario simulations, these models have the advantage of demonstrating the major impact of aging on the prevalence of cardiovascular diseases by incorporating population age structure projections provided by INSEE into the modeling. Given the significant role of demographic factors in the projected changes in prevalence, our results highlight the need to adapt the healthcare system to anticipate the management of an increased number of patients. These adaptations concern not only the acute, hospital-based phase but also the management of the chronic phase, namely cardiac rehabilitation followed, at home, by the implementation of secondary and tertiary prevention measures and therapeutic education.

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