Nicotine dependence is highly prevalent among patients with stroke, yet trends of stroke mortality in nicotine-dependent populations are underexplored.

We analyzed the Centers for Disease Control and Prevention’s Wide-ranging Online Data for Epidemiologic Research (CDC WONDER) for death certificates (2001-2022) of adults 45 years and older, with stroke (ICD-10 code: I60-I69) and nicotine dependence (ICD-10 code: F17). Age-adjusted mortality rates (AAMR) per 1,000,000 and annual percent change (APC) with a 95% confidence interval (CI) were calculated through Jointpoint regression.

Between 2001 and 2022, a total of 335,446 stroke-related deaths were reported in nicotine-dependent adults. Overall, the AAMR increased from 20.2 in 2001 to 176.5 in 2022, an 8.7-fold increase, with APC rising sharply from 2001 to 2004 [73.03* 95% CI: 46.4 to 92.9], followed by a gradual rise until 2022 [4.11* 95% CI: 3.6 to 4.6]. Although men had almost double the AAMR than women (160.2 vs 86.2), women had higher APC in AAMR from 2004 to 2022 than men (4.18* vs 3.85*). AAMR peaked during the COVID-19 period (2020-2021= 178.2). AAMR varied by race, with Non-Hispanic (NH) American Indians having the highest (179), followed by NH African Americans (136.3), NH Whites (127.4), Hispanics (55.1), and NH Asians/Pacific Islanders (35.1). Geographically, the Midwest had the highest AAMR (156.4), followed by the South (122.1), Northeast (96.9), and West (95.7). States above the 90th percentile were Oregon, Vermont, North Dakota, Montana, and Idaho.

Stroke-related mortality in nicotine-dependent adults spiked over two decades, especially among NH American Indians, NH African Americans, men, and the Midwestern US. Targeted strategies aimed at smoking reduction and cessation, especially among at-risk populations are needed for smoking-related stroke burden reduction.