Background-The extent to which differences in cardiovascular risk between smokers with similar daily tobacco consumption may be related to plasma levels of inflammation-sensitive proteins (ISP) and whether these proteins are associated with levels of carboxyhemoglobin (COHb%) have not been clarified. Methods and Results-In a population-based cohort of 1489 never smokers, 1685 former smokers, and 2901 current smokers, aged 28 to 61 years, plasma levels of orosomucoid (␣ 1 -acid glycoprotein), ␣ 1 -antitrypsin, haptoglobin, fibrinogen, and ceruloplasmin were measured. COHb% levels were available for 2098 of them. Incidence of myocardial infarction, stroke, and death were monitored over 18.7Ϯ4.7 years. The proportion with high ISP levels (ie, Ն2 ISP in the top quartile) increased progressively with daily tobacco consumption (PϽ0.01) and COHb% (PϽ0.01). In all smoking categories, the incidence of stroke, cardiac events, and death was related to ISP. In heavy smokers, high ISP levels were associated with adjusted relative risks of 1.57 (1.05 to 2.35) and 1.50 (1.11 to 2.03) for cardiac events and death, respectively. Corresponding figures for moderate and light smokers were 1.59 (1.13 to 2.24) and 1.14 (0.87 to 1.49), respectively, and 1.32 (0.95 to 1.85) and 1.48 (1.10 to 1.98), respectively. Key Words: stroke Ⅲ myocardial infarction Ⅲ smoking Ⅲ inflammation Ⅲ plasma proteins Ⅲ epidemiology S moking is one of the major risk factors for arteriosclerosis and its complications. [1][2][3] Yet how smoking harms the vessel wall remains controversial. The biological mechanism linking smoking and atherothrombosis is complex and not fully understood 4 and include vascular endothelial dysfunction, 5 systemic coagulation disturbances, 6 and lipid disorders. 7 It has been demonstrated in several cohort studies that the incidence of myocardial infarction and stroke are associated with plasma level of interleukin-6 (IL-6), 8 tumor necrosis factor-␣ (TNF-␣), 9 soluble intracellular adhesion molecule type 1 (ICAM-1), 10 E-selectin, 11 P-selectin, 12 high sensitive C-reactive protein (CRP), 13,14 and other inflammatory-sensitive proteins (ISP), eg, fibrinogen, orosomucoid (␣ 1 -acid glycoprotein), ␣ 1 -antitrypsin, haptoglobin, and ceruloplasmin. 15,16 Plasma levels of inflammatory markers are generally higher in smokers compared with nonsmokers. 17,18 Between smokers with equal tobacco consumption there are, however, great variations of the cardiovascular risk. This may be related to the amount of harmful components in the tobacco smoke that is absorbed into the blood. Carboxyhemoglobin (COHb%), which in prospective studies has been identified as a predictor of cardiovascular disease in smokers, 19 may vary substantially within categories defined in terms of daily consumption. Whether and how the cardiovascular risk in smokers is related to the plasma levels of ISP and whether the amount of these proteins has any relationship with the level of COHb% is largely unknown. 20 The objectives in this prospective cohort study have been to...