Challenges associated with delivering smoking cessation counseling in cardiac rehabilitation

Introduction: Smoking is associated with an increased risk of cardiovascular disease and mortality and lower rates of enrollment and attendance in Cardiac Rehabilitation (CR). Tobacco cessation can reduce cardiovascular and all-cause mortality, making it an important aspect of secondary prevention. Purpose: Analyze the effect of brief tobacco cessation and subsequent referrals for intensive smoking cessation counseling. Design: Prospective observational Methods: Data was systematically gathered on consecutive patients entering CR from 4/2018 to 12/2020. Measures obtained at CR entry included self-reported smoking status and directly- measured expired air carbon monoxide (CO). Current smokers were actively smoking at CR entry. Recent smokers were defined as those who quit during hospital admission. Smoking status was determined through review of the electronic medical record and self-report. Patients classified as current or recent smokers were provided with brief tobacco cessation counseling at CR and encouraged to participate in formal cessation interventions delivered by the Community Health Team. Formal cessation included group counseling, phone or online support with access to free nicotine replacement therapy. Participation in the cessation program was determined through review of the electronic medical record. Statistical tests included Chi-squared and t-tests. Results are presented as mean±SD and proportions. Results: 1102 patients attended CR with 12% (133/1102) classified as current or recent smokers. Additionally, 11 patients endorsed cannabis use, 5 used smokeless tobacco and 3 reported vaping without recent tobacco use. At baseline, there were 73 current and 60 recent smokers with CO levels unavailable for 17 patients due to COVID-19 restrictions. CO levels were ≥5ppm in 84% (52/62) of current and 20% (11/54) of recent smokers. Following completion of CR, 65% (11/17) of current and 17% (3/18) of recent smokers had CO levels ≥5ppm. Completion of CR was 38% (50/133), which was similar between current (25/73) and recent (25/60) smokers (p=NS). Mean number of sessions attended was 26±11 (current) and 27±11 sessions (recent) for those patients completing CR (p=NS). All patients were given brief tobacco interventions with 23% (17/73) of current and 7% (4/60) of recent smokers accepting referrals to formal cessation programs (p=0.02, between groups). Of those accepting referrals, 4 patients (3 current, 1 recent;p=NS) completed the intervention. Conclusions: Only 12% of patients attending CR were current or recent smokers despite smoking being a major contributor to the development of cardiovascular disease. Smokers attending CR may be more likely to implement behavioral changes. Despite regular support in CR, few patients accepted referrals to formal cessation programs (16%, 21/133) and even fewer completed the intervention (3%, 4/133) though all were receptive to brief counseling. Low participation in the intervention highlights the challenges associated with changing addictive behaviors in these patients.