Smoking has long been a major risk factor for coronary artery disease (CAD). The last 4 decades have seen significant changes to population health and CAD risk factors, including a decline in smoking prevalence, an increase in diabetes and obesity, and the widespread use of potent preventative medications, including statins, which have led to a decline in average cholesterol levels. We sought to investigate if these changes to risk factors and preventative care has altered the magnitude of the risk of developing CAD in smokers compared to non-smokers. To accomplish this, we analyzed over 5,000 participants in the Framingham Heart Study, focusing on three separate 12-year periods from 1971 to 2006. We found that despite recent improvements in preventative cardiac care and the changing prevalence of CAD risk factors, smoking cigarettes continues to confer a 2-fold increase in the risk of developing CAD for men, and a 1.5-fold increase in the risk for women. Our findings point to the continued importance of smoking cessation programs to prevent CAD.