Amyocardial infarction – or heart attack – occurs when a disruption in blood supply causes the myocardial cells or heart muscle to die (Thygesen et al, 2018). Around 100 000 patients are admitted to hospital with myocardial infarction in the UK each year, of whom around 70% survive (British Heart Foundation, 2025).
Smoking tobacco has consistently been shown to increase the risk of myocardial infarction in the general population (Oliveira et al, 2007; Pedersen et al, 2016). The risk of death for people who continue to smoke after a myocardial infarction is nearly double that of those who quit (Critchley and Capewell, 2003; Yudi et al, 2017). Following smoking cessation, this risk rapidly declines; 5 years after quitting, people with a lighter smoking history can see their risk reduced to that of someone who has never smoked (Cho et al, 2024).
There is some evidence suggesting that patients with a tobacco-related illness, such as myocardial infarction, may be more receptive to smoking cessation interventions (McBride et al, 2003). Therefore, it is important that primary care nurses are able to support patients who have recently experienced a cardiac event to quit smoking.
Healthcare professionals often perceive barriers to the delivery of smoking cessation interventions, such as lack of time, insufficient skills and lack of knowledge regarding which interventions are most effective (National Institute for Health and Care Excellence, 2012). Factors such as poor mental health, social isolation and multiple comorbidities can reduce the likelihood of the patient quitting smoking after a myocardial infarction (Lovatt et al, 2021), and smoking rates are generally higher among these groups (Action on Smoking and Health, 2019). It is important for general practice nurses to be aware of these potential barriers so that interventions can be tailored accordingly.
The authors conducted a literature review, published in March 2025, to explore perceived barriers to, and facilitators of, smoking cessation among patients who have experienced a myocardial infarction, to inform the development of effective interventions (Lovatt et al, 2025). The authors also aimed to identify perceived barriers and facilitators for healthcare professionals delivering these interventions. This article summarises the main findings of this review, highlighting the key implications for primary care nurses.
Study search and characteristics
This mixed-methods systematic review was conducted in accordance with the Joanna Briggs Institute guidance, following the convergent integrated approach (Stern et al, 2020). Six databases were searched (MEDLINE, EMBASE, CINAHL, PsycINFO, The Cochrane Library and Web of Science) in April 2023. The National Grey Literature database was also searched and citation tracking was used as a supplementary search method (Cooper et al, 2017). Searches were limited to papers published on or after 1 January 1990, as smoking cessation services developed substantially after this date (Owen and Youdan, 2006).
The review included primary research with adult patients who had undergone percutaneous coronary intervention – a minimally invasive procedure whereby a stent is inserted to open up narrowed blood vessels in the heart and restore blood flow. Studies with patients who had acute coronary syndrome, ischaemic heart disease or coronary artery disease were included if the participants had a history of myocardial infarction. Studies were excluded from the review if they involved patients undergoing angiography and those with angina pectoris or coronary artery disease without a diagnosis of myocardial infarction. Study settings were limited to high- or middle-income countries and, as translation resources were limited, only studies published in English were eligible for the review.
The final review included 15 studies, with a combined total of 386 patients and 28 healthcare professionals. Most patients were men (n=236, 61.1%) and the age range was 34–83 years. The studies were conducted at various points in the patient's recovery after myocardial infarction, from 1 week to 3 years following hospitalisation. All studies were conducted between 1998 and 2023, with over half (n=9) published after 2010.
Thirteen studies focused on patients with cardiovascular disease; all of these included patients diagnosed with myocardial infarction and seven also included patients with acute coronary syndrome and those undergoing percutaneous coronary interventions. The remaining two studies explored healthcare professionals' experiences of delivering smoking cessation through interviews with nurses, physicians and cardiothoracic surgeons. All studies were conducted in high-income countries: four in the UK, three in Australia, three in the US, two in Norway, two in Germany and one in Denmark.
Barriers and facilitators to smoking cessation
Synthesising the findings from the 15 studies resulted in the development of 14 categories relating to facilitators of and barriers to smoking cessation in patients who had experienced a myocardial infarction. These categories were grouped into five overarching descriptors: motivation for change; support; smoking as an identity; lack of knowledge of and confidence in smoking cessation interventions; and impact of healthcare professionals. These barriers and facilitators are presented in Table 1, with their related studies. Each overarching descriptor is discussed, with recommendations for practice.
| Descriptor | Categories | Studies |
|---|---|---|
| Motivation for change | Taking control | Fålun et al (2016); Hansen and Nelson (2011; 2017); Dullaghan et al (2014); McAnirn et al (2015); Riley et al (2019); Getz et al (2023) |
| The power of the teachable moment | Gregory et al (2006); May et al (2008); Hansen and Nelson (2011; 2017) | |
| Further incentive to change | Getz et al (2023) | |
| Understanding smoking as a risk factor for myocardial infarction | Gulanick et al (1998); Darr et al (2008); Dullaghan et al (2014); Fålun et al (2016); Hansen and Nelson (2017); Nicolai et al (2018); Riley et al (2019) | |
| Support | Fellowship | Getz et al (2023) |
| Family support | Gulanick et al (1998); McAnirn et al (2015); Nissen et al (2018); Getz et al (2023) | |
| Smoking as an identity | Addiction and habit | Hansen and Nelson (2017); Riley et al (2019); Getz et al (2023) |
| Challenging circumstances | Gulanick et al (1998); Crane and McSweeney (2003); Hansen and Nelson (2017); Getz et al (2023) | |
| Lack of knowledge and confidence in smoking cessation interventions | Nurses' role in the provision of smoking cessation support | May et al (2008); Raupach et al (2014) |
| Physicians' role in the provision of smoking cessation support | May et al (2008); Raupach et al (2014) | |
| Institutional barriers | May et al (2008); Raupach et al (2014) | |
| Patients' limited understanding of support for smoking cessation | Hansen and Nelson (2011); Riley et al (2019); Getz et al (2023) | |
| Impact of healthcare professionals | Stigmatisation | Hansen and Nelson (2011; 2017); Getz et al (2023) |
| Patients' sense of healthcare professionals being ‘on their side’ | Gregory et al (2006); Hansen and Nelson (2011); Getz et al (2023) |
Motivation for change
Motivation for change relates to the patient's experience of myocardial infarction as a major life event, providing the impetus for smoking cessation. This motivation could stem from the power of the ‘teachable moment’, as many patients will see smoking as a causative factor for myocardial infarction. However, the impact of this teachable moment is likely to diminish over time and may not be sufficient to motivate patients towards continued change. Awareness of this is particularly important for primary care nurses, who may see the patient some time after their discharge from hospital.
Patients are more likely to make changes if they believe that there will be benefits. Continuation of smoking after myocardial infarction may result from a lack of understanding about smoking as a risk factor for future cardiac events, or of the strong preventive effects that lifestyle changes can have. This can lead the patient to believe that nothing can reduce their risk of future myocardial infarctions. Lack of understanding may be more common in patients with less severe presentations, such as non-ST segment elevation myocardial infarction, potentially because they see this as a less severe event.
Recommendations
Well-timed, brief interventions and patient education are essential to help patients identify smoking as a causative factor of myocardial infarction. However, this teachable moment should not be the sole agent to promote behavioural change, as its power may diminish over time. Primary care nurses should thus consider other interventions to support patients to quit smoking and reinforce this message, especially if a longer period of time has passed since discharge from hospital.
Support
The location of an individual within their social support network can act as both a facilitator and barrier to quitting smoking. Many participants described how their immediate family were influential in their decision to quit smoking and maintain their abstinence, indicating that family members can provide the motivation to quit and be a source of support through the process. However, close family relationships could also be barrier to cessation, such as if the patient's partner did not wish to quit smoking themselves.
Recommendations
The right support is crucial to initiate and maintain behavioural change, so giving patients information on smoking cessation is crucial. However, further support is needed from those close to the individual, so primary care nurses may consider involving the patient's wider social networks, including family members and partners, in smoking cessation interventions.
Smoking as an identity
Smoking can be a strong part of a person's identity and their environment, representing a barrier to quitting. It is likely that the more strongly a patient identifies as a smoker, the harder it will be for them to quit. Addiction also results in use of reasoning to justify the behaviour, with some patients making other positive lifestyle changes to justify continued smoking.
For many individuals, their identity as a smoker will not be questioned outside of a healthcare setting; when they are alone or with friends who also smoke, it is accepted as part of daily life. Many patients in the included studies also faced additional barriers to smoking cessation, such as comorbidities. These challenges may create a fatalistic attitude, reducing motivation to quit. However, the studies also suggested that patients who surround themselves with non-smokers who do not share the smoker identity may find it easier to change their habits.
Recommendations
Smoking is a highly addictive behaviour and difficulties quitting often arise from the person's strong identity as a smoker, especially for those facing additional challenges, such as comorbidities and stress. Smoking cessation interventions should focus on strategies to manage stress, form new habits and develop self-awareness. Primary care practitioners should also aim to identify any additional challenges that may hinder cessation.
Lack of knowledge of smoking cessation interventions
Physicians are often responsible for prescribing smoking cessation therapies, but the review found a sense of reluctance to do so, caused by misconceptions or lack of knowledge. This may result in therapies not being initiated in secondary care, leading to delays or barriers to access. This lack of knowledge may also extend to patients, especially if healthcare professionals do not have the skills to provide education.
Recommendations
All healthcare professionals involved in the care of patients with myocardial infarction should recognise the importance of smoking cessation and be knowledgeable of evidence-based interventions and therapies. However, primary care nurses should be aware that patients may not have received in-depth smoking cessation education or interventions before leaving secondary care.
Impact of healthcare professionals
This synthesised finding highlighted the impact that healthcare professionals can have on smoking cessation. Many patients who had experienced a myocardial infarction reported feeling stigmatised for smoking, with some finding interactions with healthcare professionals patronising, believing that smoking was the only thing that clinicians noticed about them. This perception may come from the delivery of brief interventions and the use of the teachable moment of hospitalisation; although these strategies could have a positive impact, they could also make patients feel stigmatised or discredited. This could result in patients not seeking support for smoking cessation or lying about quitting. Making the patient feel that the clinician is ‘on their side’ by acknowledging the difficulties they face in a non-judgemental manner can help to avoid stigmatisation. This may include other aspects of advice and counselling, rather than focusing solely on smoking.
Recommendations
It is important to recognise the highly addictive nature of smoking and respect the immense challenge that patients face in quitting. Healthcare professionals should reflect on their impact on patients, aiming to treat the individual, develop good relationships and work with patients to support them to quit.
Discussion
This review highlighted that the teachable moment of a myocardial infarction may be closely related to the patient's understanding or experience of their condition (Dullaghan et al, 2014), but that the impact of this can diminish over time (Gregory et al, 2006). Healthcare professionals may believe that an initial brief intervention is sufficient to facilitate and maintain behavioural change (May et al, 2008). Consequently, other interventions, such as medications, may not be provided, despite strong evidence that quitting smoking without assistance is the least effective method (Public Health England, 2018). Long-term support for smoking cessation, using evidence-based interventions, should be considered for patients who have a history of myocardial infarction.
In the reviewed studies, participants with multiple comorbidities, such as depression and other physical health problems, described how these challenges created barriers to quitting smoking. For example, quitting smoking was perceived as a low priority among the other challenging aspects of patients' lives, while some felt that there was little to gain from quitting, as smoking provided one of their few pleasures (Hansen and Nelson, 2017). While it is crucial to maintain respect for autonomy, it is also important that people facing additional challenges can access adequate levels of support to quit smoking. Primary care professionals must not assume that these individuals will never change their behaviour, as this could lead to discrimination (Huddlestone et al, 2022). Equally, it is important to refute the perception that smoking is a lifestyle choice that patients can easily change (Ekezie et al, 2020). Instead, nurses should acknowledge that smoking is an addiction and a deeply ingrained habitual activity (Benowitz, 2008; 2010), with significant challenges associated with quitting.
The stigmatisation of people who smoke has been described in the wider literature, with some attributing this to the reduced prevalence and negative perceptions of smoking created by public health campaigns (Graham, 2012). The impact of stigmatisation may have a ‘transient’ effect during the act of smoking, disappearing at other times (Ritchie et al, 2010). However, following a myocardial infarction, a person labelled as ‘a smoker’ may perceive this as a permanent part of their identity. This could lead to dishonesty about their smoking behaviours or difficulties in quitting, coming from a desire to avoid a sense of personal failure (Hansen and Nelson, 2017). General practice nurses can mitigate this challenge by making patients feel that they are ‘on their side’. Some patients described good relationships with clinicians, from whom they received well-delivered support without condescending or judgemental attitudes (Getz et al, 2023). It important to act in a supportive, non-judgemental manner to foster good relationships and provide better smoking cessation support.
Conclusions
This review highlighted key recommendations for practice, including the need to acknowledge myocardial infarction as a potential turning point in patients' lives, recognise the difficulties that patients can face in quitting smoking and involve wider support networks in smoking cessation interventions. Avoiding stigmatisation and offering non-judgemental support are also crucial. Nurses must have up-to-date knowledge of the best interventions for smoking cessation and implement these where appropriate.