Substance use (SU) affects a significant number of individuals globally. More recently, national statistics showed that 13.3% of the U.S. population recently initiated or increased SU to cope with stress during the COVID-19 pandemic, with young adults being at higher risk (24.7% and 19.5% of those aged 18-24 and 25-44 years, respectively.).1 The association of SU and atherosclerotic cardiovascular disease (ASCVD) is well-described in the literature.2 Given the prevalence of SU in the young population, we examined the association of SU and premature ASCVD.
We used data from the Behavioral Risk Factor Surveillance System survey (2016 to 2019), a nationwide telephone-based survey of a random sample of U.S. adults. Variables were self-reported and weighted based on sampling methodology. Premature ASCVD was defined as that occurring in individuals <55 years. SU was defined as current use of e-cigarettes or cigarettes, or use of smokeless tobacco (ST), heavy alcohol (>14 drinks in men and >7 drinks in women per week), or marijuana; high-risk behavior was defined as intravenous drug use or high-risk sexual behavior. Analyses were performed via Stata version 16.1 (Stata Corp, College Station, Texas).
The study population consisted of 1,122,765 individuals younger than 55 years, 50% of whom were women, 59% white, 13% black, 19% Hispanic, and 5% with ASCVD (n = 72,233). Those with premature ASCVD (Table 1 ) had higher prevalence of e-cigarette, cigarette, and ST use (p < 0.001 for all). In multivariable analysis, e-cigarette (Odds Ratio 1.45; 95% Confidence Interval 1.15,1.81), cigarette (1.44; 1.34,1.54), ST (1.23; 1.07,1.41), marijuana use (1.25; 1.01,1.55), and high-risk behavior (1.26; 1.09,1.44) were independently associated with premature ASCVD. There was a significant interaction between gender and ST: among those with ST use, prevalence of ASCVD was 7.7% among men vs. 2.0% among women (p for interaction <0.05). There was no significant interaction between race and any SU.
Table 1.
Prevalence and odds ratios (95% confidence interval) of substance use and premature ASCVD
| Presence of Atherosclerotic Cardiovascular Disease |
Odds Ratio (95% Confidence Interval) |
|||
|---|---|---|---|---|
| No | Yes | Unadjusted | Adjusted* | |
| E-cigarette Smoking | 6.90% | 8.30% | 1.21 (1.11,1.33) | 1.45 (1.15,1.81) |
| Cigarette Smoking | 16.90% | 30.60% | 2.16 (2.09,2.24) | 1.44 (1.34,1.54) |
| Smokeless Tobacco | 4.00% | 5.30% | 1.33 (1.23,1.43) | 1.23 (1.07,1.41) |
| Heavy Alcohol | 6.90% | 5.90% | 0.84 (0.77,0.91) | 0.95 (0.79,1.14) |
| Marijuana | 12.50% | 11.90% | 0.95 (0.84,1.06) | 1.25 (1.01,1.55) |
| High-Risk Behavior† | 8.00% | 5.90% | 0.73 (0.68,0.78) | 1.26 (1.09,1.44) |
Results adjusted for age, gender, race/ethnicity, education, employment, incomes, presence of comorbidities (hypertension, hyperlipidemia, diabetes mellitus, chronic kidney disease, chronic obstructive pulmonary disorder, and cancer).
High-risk behavior was defined as intravenous drug use or high-risk sexual behavior.
Our results highlight the significance of addressing SU as a risk factor for premature ASCVD in young individuals, especially given increased SU noted during the COVID-19 pandemic. Importantly, the association between SU and premature ASCVD in our study was independent of other cardiovascular risk factors. The decline in rates of cigarette use has been partially attributed to the increased use of alternative products, such as e-cigarettes and ST. Data from the National Health Interview Survey showed that e-cigarette users had higher rates of myocardial infarction and stroke compared to non-users.3 Although there is mixed data on ST and ASCVD, ST may be associated with increased rates of fatal MI.4 Marijuana use has been shown to be associated with myocardial infarction in meta-analyses, with a temporal association.5 Data from the VITAL (Veterans Affairs Healthcare database and theVeterans wIth premaTure AtheroscLerosis) registry showed the use of alcohol, cocaine, and amphetamine were each independently associated with premature ASCVD (OR 1.50, 2.44, and 2.74, respectively).2 Interestingly in our results, high-risk behavior was only significant after adjusting for multiple variables, indicating the importance of further examination of the role of gender, education, income, and other factors that may drive this association.
Our results should be interpreted in the context of potential limitations, including the self-reporting of SU, which can generate recall bias. Furthermore, we did not assess the association between the frequency of SU and premature ASCVD.
In conclusion, the use of e-cigarette, cigarette, ST, marijuana, and high-risk behavior are associated with higher rates of premature ASCVD and need to be specifically addressed alongside traditional metabolic risk factors in order to mitigate the rates of ASCVD in this patient population.
Disclosures
The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Salim S. Virani reports a relationship with Department of Veterans Affairs, World Heart Federation, Tahir and Jooma Family that includes: funding grants.
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