BACKGROUND Smoking is one of the major risk indicators for development of coronary artery disease, and smokers develop acute myocardial infarction (AMI) approximately a decade earlier than nonsmokers. In smokers with established coronary artery disease, quitting smoking has been associated with a more favorable prognosis. However, most of these studies comprised younger patients, the majority of whom were males. HYPOTHESIS The purpose of the study was to determine mortality, mode of death, and risk indicators of death in relation to smoking habits among consecutive patients admitted to the emergency department with acute chest pain. METHODS In all, 4,553 patients admitted with acute chest pain to the emergency department at Sahlgrenska University Hospital during a period of 21 months were included in the analyses and were prospectively followed for 5 years. RESULTS Of these patients, 36% admitted current smoking. They were younger and had a lower prevalence of previous cardiovascular diseases than did nonsmokers. The 5-year mortality was 19.4% among smokers and 24.9% among non-smokers (p < 0.0001). However, when adjusting for difference in age, smoking was associated with an increased risk [relative risk (RR) 1.51; 95% confidence interval (CI) 1.32-1.74; p < 0.0001]. Among patients presenting originally with chest pain, the increased mortality for smokers was more pronounced in patients with non-acute than acute myocardial infarction (AMI). Among patients who died, death in smokers was less frequently associated with new-onset myocardial infarction (MI) and congestive heart failure. Among those who smoked at onset of symptoms and were alive 1 year later, 25% had stopped smoking. Patients with a confirmed AMI who continued smoking 1 year after onset of symptoms had a higher mortality (28.4%) during the subsequent 4 years than patients who stopped smoking (15.2%; p = 0.049). CONCLUSION In consecutive patients admitted to the emergency department with acute chest pain, current smoking was significantly associated with an increased risk of death during 5 years of follow-up. Among patients who died, death in smokers was less frequently associated with new-onset MI and congestive heart failure than was death in nonsmokers.