Poor adherence to lipid lowering therapy (LLT) is a major barrier in the prevention of cardiovascular disease (CVD) worldwide. The burden of CVD can be significantly reduced by LLT, particularly in populations with high cardiovascular (CV) risk. Despite established benefits from LLT, efforts to improve adherence have had varying degrees of success in primary prevention. Adherence is a multifactorial process and requires tailored strategies to address an individual's specific needs. Despite numerous studies exploring strategies to improve medication adherence, empirical evidence indicates that adherence to LLT remains a persistent challenge. Strategies used to improve long-term LLT adherence in primary prevention can be grouped into four themes: (1) individualized CV education; (2) emotional engagement with CV prevention; (3) mobile health prompts and (4) approaches to improve patient acceptability of LLT. This review will revisit the strategies used to improve LLT adherence in the primary prevention of CVD and evaluate their effectiveness in promoting long-term adherence. Future perspectives for enhancing LLT adherence will explore the application of behavioural economic principles to facilitate shared decision making, the development of novel communication strategies and implementation of targeted interventions.