Clinical challenges facing patient participation in cardiac rehabilitation: cigarette smoking

ABSTRACT

Introduction

Cardiac rehabilitation (CR) is highly effective at reducing morbidity and mortality. However, CR is underutilized, and adherence remains challenging. In no group is CR attendance more challenging than among patients who smoke. Despite being more likely to be referred to CR, they are less likely to enroll, and much more likely to drop out. CR programs generally do not optimally engage and treat those who smoke, but this population is critical to engage given the high-risk nature of continued smoking in those with cardiovascular disease.

Areas covered

This review covers four areas relating to CR in those who smoke. First, we review the evidence of the association between smoking and lack of participation in CR. Second, we examine how smoking has historically been identified in this population and propose objective screening measures for all patients. Third, we discuss the optimal treatment of smoking within CR. Fourth, we review select populations within those who smoke (those with lower-socioeconomic status, females) that require additional research and attention.

Expert opinion

Smoking poses a challenge on multiple fronts, being a significant predictor of future morbidity and mortality, as well as being strongly associated with not completing the secondary prevention program (CR) that could benefit those who smoke the most.

KEYWORDS:

• Adherence
• Cardiac rehabilitation
• participation
• smoking
• tobacco
• treatment

Article highlights

• Participation in cardiac rehabilitation continues to be a challenge as less than half of eligible patients attend.

• Certain groups, such as those who smoke, are much less likely to enroll in and complete cardiac rehabilitation despite higher referral rates.

• Those who smoke are also more likely to have recurrent events and should be retained in cardiac rehabilitation.

• Better identification of those who smoke and treatment for smoking could improve cardiac rehabilitation participation and health outcomes.

• Programs should consider targeting those who smoke for interventions to improve retention in cardiac rehabilitation.

Declaration of interests

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial relationships or otherwise to disclose.

Additional information

Funding

This paper is supported by the National Institutes of Health National Heart, Lung, and Blood Institute (R33HL143305; R01HL156851) and the National Institutes of Health National Institute of General Medical Sciences (P20GM103644).