HIV and smoking: associated risks and prevention strategies

Figures & data

Table 1 Smoking cessation intervention studies with PLWH

Author (N)	Design	Setting	Participant characteristics	Interventions	Outcomes
Behavioral-only interventions
Manuel et al, 2013^Citation49 N=30	Randomized controlled trial Follow-up: 1 month	Hospital-based HIV primary care clinic, San Francisco, California	100% female, 13% Hispanic ethnicity, 46.7% Black, 30% White, and 23% other, mean age of 49 years, mean number cigarettes per day was 15.5 for intervention and 16.7 for comparison	Intervention: a single motivational interview (Ml) session plus referral to NRT (n=15) Comparison: prescribed advice (PA) plus referral to NRT (n=15)	Biochemical verification abstinence: 1/15 (7%) Ml participants vs no PA participants at 1-month follow-up (no significant differences). Self-reported 7-day-point prevalence (7D-PP) abstinence: 3/15 (20%) MI participants vs no PA participants at 1-month follow-up (no significant differences). Cigarettes per day: significantly fewer cigarettes per day in the Ml condition, with an average of seven cigarettes among Ml participants vs 15.79 cigarettes among PA participants. Other: no significant group differences in nicotine dependence, desire to quit, abstinence self-efficacy, and perceived difficulty of quitting.
Lazev et al, 2004^Citation50 N=19	Non-experimental, single group design Follow-up: 1 and 2 weeks post-quit date	Comprehensive HIV/ AIDS outpatient clinic, Houston, Texas	80% male, 80% Black, mean age of 41 years, mean number of cigarettes smoked per day was 19.5	Six brief cell phone counseling sessions	Self-reported abstinence: 75% (n=15) abstinent at 1 and 2 weeks post-quit date. Quit attempts: 100% of intervention participants made at least one quit attempt. Relapse: 7 participants relapsed, of whom 71% (n=5) made a second quit attempt.
Pharmacological-only interventions
Tornero and Mafe, 2009^Citation51 N=22	Non-experimental, single group design Follow-up: 3 and 6 months	HIV clinic in Gandia, Spain	HIV+ smokers currently on varenicline, 95% male	Participants prescribed varenicline for 2 months, after receiving free samples of varenicline in preceding 15 days	Biochemical verification abstinence: 6/18 (33.3%) at 3 months and 5/18 (27.8%) at 6 months. Other: 1 individual discontinued cessation treatment due to intolerable side effects, including vomiting, headaches, and discomfort. Eighteen participants reported nausea, sleep disturbances and restlessness, but these did not disrupt treatment.
Combined interventions
Ingersoll et al, 2009^Citation68 N=40	Randomized controlled trial Follow-up: 3 months	Hospital-based Infectious Disease clinic, USA	55% male, 95% Black, 5% White, 43% had greater than a high school diploma, mean age of 42 years, 93% were employed; mean number cigarettes per day was 17.3. The mean carbon monoxide level expired by participant at baseline was 15.05 indicating current daily smoking	Intervention: Ml plus nicotine patch. Throughout the interview participants received personalized feedback drawn from the baseline measures regarding the participant’s current health status, consequences of smoking and readiness to change (n=22) Control: self-guided reading plus nicotine patch – participants received a reading packet developed by the National Cancer Institute which includes self-assessment of smoking habits and other tips. Minimal guidance and no feedback from counselor (n=18)	No significant group differences found in any outcomes. Biochemical verification of abstinence: change from baseline to follow-up not significant, with 1/40 (2.5%) at baseline and 9/40 (22.5%) at 3 months. Cigarettes per day: decreased from 17.3 at baseline to 6.2 at 3 months. Other: Fagerstrom scores suggested that nicotine dependence declined from 5.0 to 3.8, and percent of smoking days decreased from 39/40 (98%) at baseline to 23/40 (58%) at 3 months. Confidence to avoid smoking in positive effect situations was the only significant predictor of achieving smoking abstinence.
Lloyd-Richardson et al, 2009^Citation8 N=445	Randomized controlled trial Follow-up: 2, 4, and 6 months	Eight immunology clinics – six outpatient HIV clinics and two primary care medical offices in southeastern New England, USA	63.6% male, 18.56% Black, 51.80% White, 21% had greater than a high school diploma, mean age of 42.06 years, 21% were employed; mean number cigarettes per day was 18.27	Intervention: motivational enhancement (ME) – smoking materials were tailored to the needs of HIV individuals (eg, emphasis on improved immune functioning, prevention of infection based upon feedback provided in qualitative interviews, and four 30-minute intervention sessions and quit-day counseling call and NRT patches (n=233) Control: standard care (SC) – participants received two brief sessions, consisting largely of baseline assessments and assessment of quit plans; nicotine patches; and self-help materials. Participants came to the clinic biweekly to pick up additional patches, allowing the health educator to briefly reinforce quit efforts, check on patch side effects, and answer questions (n=212)	Biochemical verification of 7D-PP abstinence: at 2, 4, and 6 months, 12%, 9%, and 9%, quit smoking in the ME condition, respectively, and 13%, 10% and 10% at 2, 4, and 6 months, respectively. Other: few African Americans were able to quit smoking, whereas Hispanic participants achieved abstinence at higher rates than all other racial/ethnic groups.
Moadel et al, 2012^Citation69 N=145	Randomized controlled trial Follow-up: 3 months	HIV care center in the Bronx, New York	77.9% male, 71.6% Black, 18.9% White, 8.4% Hispanic, mean age of 49.2 years for intervention and 47.9 years for comparison, mean number cigarettes per day was 12.8 for intervention and 11.1 for comparison	Intervention: positively smoke free (PSF) – an intensive group-therapy intervention targeting HIV-infected smokers. PSF is an 8-session intervention modeled on the program described in the Tobacco Dependence Treatment Handbook and based on the Social Cognitive Theory Principles and 3-month supply of NRT (n=73) Comparison: SC – subjects were given a quit smoking brochure, brief advice to quit smoking (ie, <5 minutes), and 3-month supply of NRT (n=72)	Biochemical verification of abstinence: 14/73 (19.2%) in the PSF group and 7/72 (9.7%) in the SC group at 6 months from the intent-to-treat analysis. In the complete case analysis, assignment to PSF was associated with an increase odd of quitting (OR=3.55, 95% confidence interval 1.04–12.0). Other: a significant decrease in daily cigarette smoking was observed among subjects in the PSF condition. PSF participants attended an average of four sessions, and a higher rate of quitting was observed in PSF group with ≥7 sessions. African American PLWH smokers were significantly less likely to achieve abstinence, whereas Latino participants and those who scored lower on the loneliness scale were more likely to achieve abstinence.
Vidrine et al, 2006^Citation70 N=95	Randomized controlled trial Follow-up: 3 months	Comprehensive HIV/AIDS outpatient clinic, Texas	49% male, 85.8% Black, 11.0% White, 3.1% American Indians/Alaska Natives, mean age of 42.8 years, mean number cigarettes per day was 19.5 for intervention and 20.6 for comparison	Intervention: 8 brief cell phone intervention (CPI) sessions based on cognitive-behavioral techniques, access to hotline number for additional support, and recommended standard of care services (n=48) Comparison: recommended standard of care, which involved a single session with physician advice, assistance in setting quit date, 10-week supply of NRT, and self-help resources (n=47)	Biochemical verification of 24-hour abstinence: 14/38 (36.8%) in the CPI group compared to 4/39 (10.3%) in the UC group at 3 months; group differences significant Biochemical verification of 7D-PP abstinence: 8/38 (21.1%) in the CPI group compared to 3/39 (7.7%) in the UC group; group differences not significant Other: 37/38 (97.4%) in the CPI group attempted to quit compared to 29/39 (74.4%) in the UC group; CPI participants had longer period of abstinence than UC group (30.8 days vs 12.3 days, respectively).
Vidrine et al, 2012^Citation71 N=474	Randomized controlled trial Follow-up: 3 months (6- and 12-month data collection ongoing)	Comprehensive HIV/AIDS outpatient clinic, Houston, Texas	70% male, 76.6% Black, mean age of 44.8 years, mean number cigarettes per day was 18.6 for intervention and 19.7 for comparison	Intervention: 11 brief CPI sessions based on cognitive-behavioral techniques, access to hotline number for additional support, and usual care (UC) services (n=236) Comparison: UC, which involved a single session with physician advice, assistance in setting quit date, information on NRT, and self-help resources (n=238)	Self-reported 24-hour abstinence: 14/38 (36.8%) in the CPI group compared to 4/39 (10.3%) in the UC group at 3 months. Self-reported 7D-PP abstinence: 40/236 (16.9%) in the CPI group compared to 12/238 (5%) in the UC group at 3 months. Self-reported 30D-PP abstinence: 21/236 (8.9%) in the CPI group compared to 7/238 (2.9%) in the UC group at 3 months. Self-reported continuous abstinence: 21/236 (8.9%) in the CPI group compared to 5/238 (2.1%) in the UC group at 3 months. Other: at 3 months, CPI participants had longer period of abstinence than UC group (14.7 days vs 6.6 days, respectively); no significant group differences in quit attempts.
Humfleet et al, 2013^Citation72 N=209	Randomized controlled trial Follow-up: 3, 6, 9, and 12 months	Three clinics serving HIV+ individuals in San Francisco, California	81.7% male, 26.6% Black, 52.7% White, 20.6% had less than a high school diploma, mean age of 45 years, 14% were employed; mean number cigarettes per day was 19.8	Interventions: 6 individual counseling sessions based on cognitive-behavioral principles plus NRT (n=69) Computer-based Internet smoking treatment, a web version of the IC sessions, plus NRT (n=58) Self-help plus NRT (n=82)	Biochemical verification of abstinence: 25.6% in the computer-based Internet group vs 20.4% in the individual counseling group vs 19.7% in the self-help group; no significant group differences were observed at anytime point. Cigarettes per day: the number of cigarettes used in the last 24 hours and 7-day period among participants in both conditions significantly declined over time (P<0.001); no significant group differences were observed. Other: participants with higher levels of active coping, a positive outlook regarding HIV, and employment were significantly more likely to quit smoking. Perceived health control did not significantly predict smoking status.
Ferketich et al, 2013^Citation65 N=228	Non-randomized comparison control design Follow-up: 3 months	One site of the Lung HIV study	84,6% male in NRT and 85.6% in varenicline, 50% White in NRT and 60.7% in varenicline, 60% had greater than a high school diploma, mean age of 42.7 years in NRT and 42.8 years in varenicline, 14.5% were employed in NRT and 39.0 were employed in varenicline	12 weeks of pharmacotherapy (either NRT or varenicline) and telephone counseling provided by an advanced practice nurse Pharmacotherapy included NRT (n=110) or varenicline (n=118) Behavioral intervention consisted of one face-to-face session, followed by 11 weekly telephone sessions for all participants	Biochemical verification of abstinence: 13/110 (11.8%) in the NRT group vs 30/118 (25.6%) in the varenicline group at 3 months. Other: the most frequently reported adverse effects (AEs) that were similar for both NRT and varenicline were nausea, sleep-related problems, and abnormal dreams.Approximately 14% of participants taking varenicline had to stop taking the agent or switch to NRT due to AEs, whereas less than 2% of subjects on NRT stopped the drug for the same reason. No adverse cardiovascular events were noted among participants taking varenicline, whereas one patient in the NRT group developed a myocardial infarction with subsequent coronary stent placement. One out of 35 patients who took varenicline, but not on HAART developed suicidal ideation, which resolved following cessation of the drug.
Elzi et al, 2006^Citation73 N=417	Non-randomized comparison control design Follow-up: 3 and 12 months	Swiss University Hospital infectious disease outpatient clinics, hospitals, and private physicians caring for HIV+ patients	82% were male, the median age was 43 years, mean number cigarettes per day was 28 for intervention and 21 for comparison	Intervention: weekly nurse-delivered smoking cessation counseling sessions based on a cognitive-behavioral approach and NRT (smoking cessation program [SCP]; n=34) Control: control group of smokers not participating in the SCP but followed as part of the cohort study (n=383)	Self-reported abstinence: 13/34 (38%) for intervention group compared to 27/283 (7%) among controls at 12 months. Relapse: at 6 months, one intervention participant relapsed. Other: at follow-up, six participants experienced a myocardial infarction, specifically 2 out of 34 SCP participants vs 4 out of 383 controls. Percutaneous transluminal coronary angioplasty was performed on 2 SCP and 3 control participants, but no one required coronary artery bypass graft surgery. One patient died of existing lung cancer in the SCP group. Three patients in the control group developed lung cancer. Due to small sample size, no meaningful conclusions could be drawn regarding the overall impact of smoking cessation on cardiovascular outcomes.
Wewers et al, 2000^Citation74 N=15	Non-randomized comparison control design Follow-up: 8 months	Infectious disease clinic at Ohio State University, Ohio	All male, mean age of 42 years; mean number cigarettes per day was 27 in the intervention group and 28 in the control group	Intervention: nurse-managed peer-led intervention – 21 mg NRT for 6 weeks, weekly face-to-face or telephone counseling and skills training (n=8) Control: received same written materials as participants in the intervention group, NRT but no counseling (n=7)	Biochemical verification of 7D-PP abstinence: 5/8 (62.5%) in the intervention, and 0% in the control group at 8 weeks; identical abstinence rates were observed at 8 months.
Fuster et al, 2009^Citation75 N=33	Non-experimental, single group design Follow-up: 12 months	Outpatient clinic at Hospital Clinico San Carlos, Madrid, Spain	79.9% male, mean age of 44.9 years, 21% were employed; mean number of cigarettes per day was 20	The SCP included three phases: 1) an assessment of participants’ motivational level, nicotine dependence, and cardiovascular risk; 2) assessment and use of pharmacological treatment, including bupropion, varenicline, and/or NRT; and 3) six 1-hour medical and psychological visits over a 2-month period	Biochemical verification of abstinence: 13/33 (39.4%) at 3 months, 10/33 (30.3%) at 6 months, and 8/32 (25%) at 12 months. Other: at the 12-month follow-up, participants who quit smoking were more motivated. Both participants who stopped smoking and those who continued smoking had significant reductions in their risk of cardiovascular disease. Outcomes not significant were: diastolic blood pressure, cholesterol, triglycerides, glucose, and body mass index.
Cuietal, 2012^Citation76 N=36	Non-experimental, single group design Follow-up: 9, 12, and 24 weeks	HIV clinics in Hamilton and Windsor, Ontario, Canada	All but one were male, 33 (92%) were White, mean age of 46 years, mean number cigarettes per day was 19	Varenicline 1.0mg was used twice daily for 12 weeks with dose titration in the 1st week, educational materials, and brief counseling	Biochemical verification of abstinence: 15/36 (42%) through week 12, and 10/36 (28%) at 24 weeks; 17/36 (47%) never quit. Self-reported 7D-PP abstinence: 18/36 (50%) at week 12, and 15/36 (42%) at week 24. Cigarettes per day: average decrease of 11, 7, and 5 at 4, 12, and 24 weeks, respectively. Other: eight (22%) participants had elevated diastolic blood pressure resulting in hypertension. Six (17%) subjects discontinued varenicline due to AEs, including nausea, anger, and insomnia. Overall, subjects gained a significant amount of weight over the course of the study. Varenicline side effects were common but generally tolerable, and there were no AEs in HIV control group. There were small but statistically significant changes in diastolic blood pressure, which were not due to weight change. Significant improvement was found in CD4 T-lymphocyte counts by 24-week follow-up.
Chew et al, 2014^Citation77 N=123	Non-experimental, single group design Follow-up: 6 months	HIV Care Clinic, New Jersey	52.8% male, 85.4% Black, mean age of 50 years, mean number cigarettes per day was 11.	At least one face-to-face counseling session and pharmacotherapy (96% NRT, 5% varenicline, 16% bupropion, and 54% combination treatment)	Self-reported 7D-PP abstinence: 20/123 (16%) at 6 months. Other: participants with a history of illicit cocaine or heroin use were significantly less likely to be abstinent than those without a history of drug use. Participants in the preparation stage of change were significantly more likely to be abstinent than those in pre-contemplation and contemplation stages.
Cummins et al, 2005^Citation78 N=27	Non-experimental, single group design Follow-up: 5 months	Hospital Immunology Clinic, Australia	98% male, ages range from 20 to over 60 years, half of participants smoked 11 to 20 cigarettes per day and a third smoked more than 21 cigarettes per day	A motivational counseling session, Quit Kit, and NRT for 8-12 weeks	Self-reported abstinence: 12/27 (44%) following NRT completion, and 6/27 (22%) at 5 months. Other: participants who stopped smoking had higher scores for readiness and desire and were confident in their ability to stop smoking. Nineteen participants were prescribed HAART, of which seven had a protease inhibitor as part of their treatment. Individuals with a protease inhibitor had elevated cholesterol and triglyceride levels.
Matthews et al, 2013^Citation79 N=31	Non-experimental, single group design Follow-up: I and 3 months	Community-based health center, Chicago, Illinois	All African American, MSM HIV+ smokers with a mean education years 12.8, mean age of 45.7 years, 78% were employed; mean number cigarettes per day were 8.5	6-session group-based treatment that incorporated ME, relaxation techniques, and cognitive-behavioral skills training combined with nicotine patch	Biochemical verification of 7D-PP abstinence: 3/23 (16.1%) at 1 month, and 1/27 (6.4%) at 3 months. Cigarettes per day: reduced from an average of 8.7 per day at baseline to 2.1 at 1 month and then increased to 3.5 at 3 months. Other: 80% of the participants made a quit attempt during the study. At 1 month follow-up, participants’ readiness to quit scores improved and there were significant reductions in urges, nicotine dependency scores, withdrawal symptoms, and depression scores. Improvements were sustained for urges and depression scores at 3 months. Quit rates were somewhat higher for those who attended three or more sessions. Program acceptability was high however adherence to patch was 39%.

Abbreviations: PLWH, persons living with HIV; OR, odds ratio; NRT, nicotine replacement therapy; HAART, highly active anti-retroviral therapy; MSM, men who have sex with men.

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