Joel W. Hughes, PhD, FAACVPR
Question: What does it take to graduate from being a “current” or “recent” smoker to a “former” or “one-time smoker?”
The Answer: It requires recognizing smoking as a tenacious addiction and accepting the past while consistently moving forward.
I recently facilitated a smoking cessation support group at a local cardiac rehabilitation site. The attendees were positive, encouraging each other with no hint of judgment.
Their attitude dovetails with two new tobacco cessation frameworks released this year by the U.S. Department of Health and Human Services (HHS)1 and the World Health Organization (WHO).2 Smoking remains the leading cause of preventable deaths, but accessing effective treatment and support is challenging.
The HHS framework addresses this challenge by providing a comprehensive approach to “support and accelerate” smoking cessation. It takes a health equity approach, given the persistent disparities in both smoking and smoking cessation. Key themes are coordination and collaboration, as well as community-engaged approaches.
The WHO framework focuses on behavioral support, pharmacological treatments, and the potential of digital interventions. It aims to “support the use of evidence-based behavioral interventions and pharmacological treatments for tobacco cessation” by integrating cessation efforts into clinical and community settings.
Interpretation
Both frameworks cover much material and are worth reading. Together, they gave me the impression that they are calling for a cultural change — one in which everyone knows what works, has ready access to the right tools, and cooperates at every level to support smoking cessation efforts. For me, the implications of these new frameworks for cardiopulmonary rehabilitation (CR/PR) include the emphasis on enhancing health outcomes, the need for evidence-based interventions, the push for integrated approaches, and the need for community participation.
When patients arrive at CR/PR, the connection between tobacco cessation and improved health is immediate and stark, which makes CR/PR the perfect time to bolster motivation and action. In the 2024 update of the Core Components of Cardiac Rehabilitation,3 tobacco cessation is one of four cardiovascular disease and risk factor management components. This core component emphasizes the need for care-coordinated pathways to provide medications and behavioral interventions consistent with the most recent guidelines.4,5 The core components and these new frameworks encourage us to redouble our efforts to ensure that tobacco cessation provided in CR/PR is part of a comprehensive, integrated approach consistent throughout the health care system, particularly concerning the availability of pharmacological interventions (e.g., nicotine replacement therapy and medications).
None of this is surprising. However, I also wondered if we could consider CR/PR to be a part of each patient’s community. Whereas many health care contacts involve brief, infrequent encounters, patients can attend CR/PR for 12 weeks, with three visits per week. If we foster a sense of community and belonging, which has long been part of the culture of CR/PR, are we providing tobacco cessation in a community-engaged manner? Yes, and no. On the one hand, patients come from their respective communities to attend CR/PR or they participate in their community (e.g., virtual or remote rehab). In this sense, CR/PR is not their community.
On the other hand, the patients attending the smoking cessation support group mentioned earlier had certainly formed a community of sorts. Could we incorporate critical points from these new frameworks in simple, direct messages to our “community” of CR/PR program participants? This approach might “frame” tobacco cessation as a community-supported goal. Perhaps we can convey the value that tobacco cessation is an issue of fundamental fairness because it wasn’t right for some people to have been lured into smoking while other people were spared. For example, historically, smoking took off in America among veterans who were issued cigarettes in their rations. Smoking rates are higher among people who have less access to resources, education, and health care. Tobacco marketing has often targeted economically disadvantaged communities. None of this was fair, or the fault of the people who became smokers.
Each CR/PR community can support smokers while remaining nonjudgmental to promote health equity. Current, former, and never smokers can all benefit from learning what works, helping with access to treatment, and cooperating to support tobacco cessation. For CR/PR programs, this may be the culture change these frameworks are calling for.
Joel Hughes, PhD, FAACVPR, is a Professor of Psychology at Kent State University and maintains non-employee medical staff privileges at University Hospitals, Portage Medical Center, so he can volunteer at cardiopulmonary rehabilitation. He also sits on AACVPR's Board of Directors.
REFERENCES
1 U.S. Department of Health and Human Services. (2024). HHS Framework to Support and Accelerate Smoking Cessation 2024. Retrieved from https://www.hhs.gov/sites/default/files/hhs-framework-support-accelerate-smoking-cessation-2024.pdf
2 WHO clinical treatment guideline for tobacco cessation in adults. Geneva: World Health Organization; 2024. Licence: CC BY-NC-SA 3.0 IGO.
3 Brown, Todd M., Quinn R. Pack, Ellen Aberegg, LaPrincess C. Brewer, Yvonne R. Ford, Daniel E. Forman, Emily C. Gathright, Sherrie Khadanga, Cemal Ozemek, and Randal J. Thomas. "Core Components of Cardiac Rehabilitation Programs: 2024 Update: A Scientific Statement From the American Heart Association and the American Association of Cardiovascular and Pulmonary Rehabilitation." Circulation (2024).
4 Leone FT, Zhang Y, Evers-Casey S, Evins AE, Eakin MN, Fathi J, Fennig K, Folan P, Galiatsatos P, Gogineni H, et al. Initiating pharmacologic treatment in tobacco-dependent adults: an official American Thoracic Society clinical practice guideline. Am J Resp Crit Care Med. 2020;202:e5–e31. doi: 10.1164/rccm.202005-1982ST
5 Coleman, S.R., Menson, K.E., Kaminsky, D.A. and Gaalema, D.E., 2023. Smoking cessation interventions for patients with chronic obstructive pulmonary disease: a narrative review with implications for pulmonary rehabilitation. Journal of Cardiopulmonary Rehabilitation and Prevention, 43(4), pp.259-269.