After a heart attack or other serious cardiac event, many Galveston County residents are referred to cardiac rehabilitation. These supervised programs help patients rebuild strength, improve mental well-being, and reduce the risk of future heart problems. For many families, cardiac rehab represents hope and a fresh start.
But research led by Diann Gaalema, PhD, associate director of research in the Department of Cardiovascular Medicine, suggests that for patients who continue to smoke, that fresh start may be harder to achieve.
The nine-year study, which examined nearly 450,000 cardiac rehabilitation patients across the United States, found that people who smoke when they begin rehab benefit significantly less from these programs than nonsmokers.
At the start of cardiac rehabilitation, about 8% of patients reported that they were current smokers. Compared with nonsmokers, these patients were younger and more likely to come from lower socioeconomic backgrounds, as reflected by higher Medicaid enrollment. They were also more likely to be entering rehabilitation after a heart attack compared to the nonsmokers who were more likely to have had bypass surgery or surgery on the valves in their heart.
From the outset, smokers faced added challenges. They reported higher levels of anxiety and depression, had lower physical fitness, and attended fewer rehabilitation sessions than nonsmokers. Cardiac rehab is designed to strengthen both the body and the mind, but tobacco use appeared to blunt progress on both fronts.
“What is most striking to me is how continued smoking not only has these patients starting at a disadvantage but also impacts how much they improve,” Gaalema said. “You might think, since these patients are coming in weaker and have more symptoms of depression and anxiety, that they would have more room to improve. Instead, they start worse off and improve less.”
These disparities remained even after researchers accounted for age, diagnosis, and other health and socioeconomic factors, Gaalema added. In other words, smoking itself played a major role in limiting recovery.
“Heart disease remains a leading cause of illness and death in Galveston County, and we have a substantial portion of the county that still smoke,” Gaalema said. “Cardiac rehabilitation is one of the most effective tools we have to prevent repeat heart attacks, reduce hospitalizations, and help people return to active lives. Smoking represents a one-two punch to cardiovascular health. Not only is it a significant driver of heart attacks, but it is also impeding recovery.”
The findings point to a clear conclusion: Smoking cessation must be a central part of heart health and recovery — not a secondary goal. For patients, quitting smoking is not only about preventing future disease. It directly affects how well the heart heals.
For health care providers and rehabilitation programs, this means making smoking cessation support a routine part of care. Counseling, medications, and follow-up support should be embedded into cardiac rehabilitation, not offered as an optional add-on.
“Quitting smoking is undeniably difficult,” Gaalema said. “But cardiac rehab offers a rare window when patients are already motivated, supported, and focused on recovery. Using that moment to help people quit could mean stronger hearts and healthier families.”
Co-authors on this study are Bashar Al Hemyari, MD, assistant professor of Cardiovascular Medicine at UTMB; Melissa Morrow, PhD, director of the Sealy Center on Aging at UTMB; Blair Yant and Katherine Menson, DO, University of Vermont Medical Center; and Yu Zhang, University of Alabama at Birmingham.