Conquering the HIV+ Patient's Special Challenges With Smoking Cessation

An estimated 50-70% of HIV-positive individuals smoke, far higher than the 20% rate in the general population.¹ In addition to the classic health-related effects of smoking such as respiratory symptoms, chronic obstructive pulmonary disease, and lung cancer, people with HIV who smoke also increase their risk of thrush, oral hair leukoplakia, bacterial pneumonia, pneumocystis pneumonia, and heart disease, among other conditions.² One study found that regular tobacco use also reduced the immune and virological response to anti-retroviral therapies (ART) up to 40%,  while another study suggested that smoking reduced effectiveness of ART among women.^3,4

There are numerous reasons for the high rates of smoking in this population, said Jonathan Shuter MD, who directs clinical research at Montefiore Medical Center’s AIDS Center in New York City. These include low socioeconomic status, prevalence of African Americans with HIV, the gay or transgender status of many of those infected, and the presence of comorbid substance abuse and mental health conditions. People in these categories-with or without HIV-are more likely to smoke.⁵

A French study found that intellectual/emotional support, stress relief, weight control (to counteract fat accumulation from ART), and pleasure were the top four reasons HIV-infected individuals gave for smoking.⁶

Yet people with HIV are as interested in quitting as anyone else. One survey of 1,094 HIV-positive adults in New York state, 59% of whom were smokers, found that about three fourths wanted to quit and 64% had tried to quit at least once in the past year.² Although it isn’t clear whether quitting is more difficult for people with HIV, said Dr. Shuter, “I think there’s a lot of suspicion out there that it is because these are ‘complicated smokers’ given their comorbidities and substance use. It’s not easy to quit when you’re addicted to cocaine and marijuana and other things.”

The Role of the Primary Care Physician in Smoking Cessation

Numerous studies find that primary care physicians and other clinicians have an important role to play in smoking cessation. Indeed, just a few minutes of counseling can double the likelihood of successful quitting.⁷

Unfortunately, studies find too little emphasis on smoking cessation among providers who treat HIV-infected patients. The New York study, for instance, which also questioned 173 HIV/AIDS service providers in the state, found that only about half regularly assessed their patient’s tobacco use and history, with just 39% discussing dependency and 36% asking about the patient’s interest in quitting. Twenty-five percent didn’t offer any smoking cessation services.²

Indeed, there is evidence that HIV providers are less likely to recognize smoking in their patients than non-HIV providers, regardless of comorbid illness, cough, or dyspnea. ⁸ A major barrier to such counseling is lack of knowledge and comfort with smoking cessation counseling.⁸

One way to improve quit rates in this population, experts suggest, is with customized programs that address the unique issues people with HIV face, including codependency, depression, and low motivation.²

A pilot study at Montefiore of just such a program found  quit rates in those participating in an HIV-focused program were twice as high as those who received just brief physician counseling.

Group Counseling; Focus on HIV

Montefiore’s Positively Smoke Free (PSF) program is designed specifically for HIV-infected smokers. Participants attend eight 90-minute group sessions of six to eight people led by a psychologist and a specially trained HIV-infected ex-smoker.

The program “targets the unique concerns and issues that pertain to smoking in the setting of a life with HIV,” said Dr. Shuter. Those include highlighting adverse effects of smoking that are unique to people with HIV; dispelling myths about the "benefits" of smoking for people living with HIV; comparing smoking to high-risk situations pertaining to HIV; and contrasting smoking cessation “relapses” with ART adherence.

The presence of a peer counselor is particularly important to the program’s success, Dr. Shuter said. The counselor “can identify with many of the issues that come up around the table and participants can identify with him or her."

The group aspect also helps. “Patients with HIV are accustomed to support groups, so the idea of them supporting each other to quit smoking isn’t such a novel idea.”

“One thing we do that I’m proud of is that we don’t harp on all the negatives of smoking,” said Dr. Shuter. “We try to introduce the idea that living with HIV can be a real positive in one’s attempt to get off this addiction and emphasize the fact that people in the HIV-infected community are champions at beating addiction and improving their health. We tell them that you’re great at taking measures to improve your health and this is one more activity that fits with that theme.”

Counselors must have been smoke-free for at least a year and have experience participating in support groups. To date, two peer counselors, both patients at the Montefiore clinic, have undergone the intensive, five-day training course.

Given the success of the pilot, Montefiore recently received a five-year, $3.7 million grant from the National Institute on Drug Abuse to investigate the program. The trial will compare the PFS approach to the current standard of care. All participants will also be offered pharmacotherapy in the form of nicotine replacement products and medication.

Since the PFS curriculum is not publically available yet, Dr. Shuter has his own recommendations to increase quit rates in this population. “I’ve gotten more than one patient to quit by dialing the quit line and handing him the phone while I type up my notes,” he said. “Busy clinicians don’t have time or expertise to counsel patients about quitting but we have quit lines in all 50 states.”

He also recommends that clinicians make a specific appointment to discuss smoking cessation with the patient, rather than making it just one item in a long list of issues during a typical office visit. “That’s a completely legitimate medical visit,” he said.