What We Know About HIV Smokers Implications for Treatment

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What We Know About HIV SmokersImplications for
Treatment
HIV

• Jack Burkhalter, Ph.D.
• Smoking Cessation Program
• Memorial Sloan-Kettering Cancer Center

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Acknowledgments
HIV

• Support NYS HRI 656-03-FED awarded to The AIDS
  Institute, NYS Dept. of Health Resources and
  Services Administration under the Special
  Projects of National Significance Program
• Colleagues
• Carolyn Springer, Ph.D., Adelphi University
  Rosy Chhabra, Psy.D., Yeshiva
  University Jamie Ostroff,
  Ph.D., Memorial Sloan-Kettering Cancer Ctr.
  Bruce Rapkin,
  Ph.D., Memorial Sloan-Kettering Cancer Ctr.

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Approach to this talk
HIV

• Evidence-based, with the state of current
  knowledge
• Clinical researchers perspective
• Cancer prevention perspective

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HIV and Smoking Why now?
HIV

• Improved life expectancy in HIV disease
• Increasing interest in health behaviors that
  affect length and quality of life
• Growing research that links smoking to increased
  health risks for PLWHIV
• Recent studies indicating very high rates of
  tobacco use among PLWHIV

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Comparisons of Smoking Rates
HIV
Population Smoking Rate
U.S. General Females Males 22.1 20.3 24.8
U.S. Medicaid patients 36.0
HIV National samples 45-51
HIV Outpatient clinics 47-72
Sources CDC, 2001 2004 Collins et al., 2001
Turner et al., 2001 Gritz, et al., 2004 Mamary,
et al., 2002 Niaura et al., 1999
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What are the health risks of smoking for HIV
persons?

• Risk of oral thrush and oral hairy leukoplakia
• Risk of community-acquired pneumonia, emphysema,
  spontaneous pneumothorax, and bronchial hyper-
  responsiveness (indicator of asthma)
• Risk of cryptococcosis
• Incidence of periodontal disease and oral lesions
• Lung, lip, and anal cancer, in addition to
  AIDS-defining cancers (Kaposi Sarcoma,
  non-Hodgkin lymphoma, and invasive cervical
  cancer)

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What we dont know for sure--

• Cannot conclude that smoking promotes progression
  in HIV disease
• Although smoking negatively affects SOME aspects
  of immune system, this has not been linked with
  AIDS onset or mortality
• More research needed

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Two Published Studies
HIV

• Gritz et al. (2004). Smoking behavior in a
  low-income multiethnic HIV/AIDS population.
  Nicotine Tobacco Research, 6 (1), 71-77.
• N 348 HIV, medically indigent persons
  receiving outpatient services at Thomas St.
  Clinic in Houston
• Burkhalter et al. (2005). Tobacco use and
  readiness to quit smoking in low-income
  HIV-infected persons. Nicotine Tobacco
  Research, 7 (4), 511-522.
• N 428 HIV persons on Medicaid in New York State

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Sample characteristics
Characteristics Texas New York
N 348 (one clinic) 428 (statewide)
Response rate 62 92
Age 40 years 40 years
Gender 78 male 59 male
Sexual behavior identity 46 MSM 40 LGB
Ethnicity 44 Black 29 Hispanic 53 Black 30 Hispanic
Education 58 lt high school 87 lt high school
with AIDS 52 38
Smoking status TX daily/some days NY within past 3 mos. 47 current 17 former 36 never 66 current 19 former 16 never
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Smoker characteristics
Measures Texas New York
Mean cigarettes/day 15.4 15.7
Nicotine dependence1 62 67
Readiness to quit Precontemplator Contemplator Preparation 38 29 34 42 40 18
Excessive alcohol use2 66 16
Current illicit drug use3 64 31
1Percent smoking within 5 minutes of
waking 2Texas assessed by asking if drank gt 5
drinks at one time in past 30 days. NY assessed
by asking if they had used too much alcohol in
past 3 months 3Texas assessed for any illicit
drug use in last 30 days NY assessed for any
illicit drug use in past 3 months
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Texas Findings

• Current smokers vs. nonsmokers (former never)
  more likely to be
• White non-Hispanic
• Older (vs. 20-29 years)
• Have lower education (lt high school)
• Heavy drinkers of alcohol
• Quitters (vs. current smokers) more likely to
• Be White (vs. Black, plt.06)
• Have higher education
• Not be heavy drinkers of alcohol

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New York Findings

• Current smokers vs. nonsmokers (vs. former
  never) more likely to report
• Greater lifetime illicit drug use
• Greater current illicit drug use
• Less bodily pain
• Quitters (vs. current smokers) more likely to
• Perceive greater health risks of smoking
• Not currently use illicit drugs
• Report more bodily pain (plt.10)

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NY Study What affects readiness to quit smoking?

• Lower readiness to quit smoking associated with
• Greater current illicit drug use
• Greater emotional distress
• Lower number of quit attempts since HIV diagnosis

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Other Indicators of Readiness to Quit Smoking
Advised by a healthcare provider to quit smoking 81
Would use a low cost or free smoking cessation program 46
Smokers who had not attempted to quit since HIV diagnosis 35
Former smokers who quit after HIV diagnosis 77
Former smokers who quit within 1 year of diagnosis 14
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Perceived risks of smoking

• How much do you believe that there are health
  risks associated with quitting smoking?

Not at all A little bit Somewhat Quite a bit Very much
1 2 3 4 5
Current smokers 3.8
Former smokers 4.5
plt.001
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What health risks do you believe smoking exposes
you to?
Smokers responses and endorsing this risk Percent
Respiratory problems, e.g., breathing problems1 38
Cancer of any type 20
Impact on immune system, e.g. lowers T-cells1 8
Non-specific health risks, e.g., definitely no good 8
Cardiovascular diseases, e.g., heart attack 6
1Former smokers, compared to current smokers,
more frequently endorsed risks to respiratory
(84 vs. 71 p lt .05) and immune system
functioning (28 vs. 12 p lt .05).
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Perceived benefits of quitting
How much do you believe that there are health
benefits associated with quitting smoking?
Not at all A little bit Somewhat Quite a bit Very much
1 2 3 4 5
Current smokers 3.8
Former smokers 4.5
plt.001
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What health benefits do you believe quitting
smoking provides?
Smokers responses and endorsing this risk Percent
Improved respiration, e.g. better sense of breathing 32
Non-specific health benefits, e.g. feel better 14
Improved energy level, e.g., would not have fatigue 9
Better immune function, e.g., healthy immune system 5
Do not know or unsure 5
NOTE No differences between current and former
smokers in percent endorsement of benefit
categories
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Summary
HIV

• High prevalence of smoking and low readiness to
  quit
• HIV diagnosis a weak teachable moment for
  quitting
• Continued smoking despite medical advice to quit
• Lower readiness to quit Emotional distress,
  illicit substance use, fewer quit attempts
• Barriers to quitting Alcohol abuse, illicit
  substance use
• Motivational boosters Perceived risks of smoking
  for lung health, cancer, and immune system
• Motivational boosters Perceived benefits of
  quitting need more emphasis

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What do research findings mean for designing
treatment programs?
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Enhancing Motivation to Quit The 5 Rs

• Relevance Why quitting is personally relevant.
  Be specific.
• Risks Identify acute (shortness of breath),
  long-term (emphysema), and environmental risks
  (increased heart disease for family)

• Rewards Identify benefits (e.g., lower risk of
  oral thrush, improved breathing)
• Roadblocks Identify barriers to quitting
  (e.g.,substance use)
• Repetition Repeat motivational intervention
  every time client visits

Source USDHHS Clinical Practice Guidelines
Treating Tobacco Use and Dependence, 2000
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Teachable Moments

• HIV diagnosis
• Respiratory events, symptoms, diagnoses
• PCP or bacterial pneumonia
• Symptoms such as shortness of breath, chronic
  cough
• Bronchitis

• Oral conditions, such as thrush, OHL
• Any concerns about health or well-being

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Personalizing Risks Benefits

• Intrinsic motivation (health concerns) is related
  to quitting success
• Extrinsic motivation (social pressure to quit) is
  not as powerful as intrinsic motivation
• Identify each persons specific benefits in
  cessation and educate them about benefits unknown
  to them
• You complain of shortness of breath giving up
  cigarettes will improve your breathing and
  stamina.
• Do the same for risks of continued smoking
• Your risk for oral thrush and bacterial
  pneumonia are higher.

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Systems Level Interventions

• Regular contact with healthcare providers offers
  many opportunities to
• Ask
• Advise
• Assess willingness to quit
• Assist
• Arrange for follow-up
• Discuss NYS Medicaid coverage for treatment of
  tobacco dependence, cost

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Comprehensive Care

• Comprehensive treatment needed for prevalence of
  substance abuse, depression, and smoking among
  PLWHIV
• Integrate services for maximum uptake,
  reinforcement of adherence, and continuity of
  care
• Tobacco use should be treated seriously as a
  significant health threat

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What to treat first?So many problems, so few
resources

• Treating depression, anxiety, alcohol or
  substance abuse, nonadherence to HIV medswhere
  to begin?
• Can PLWHIV change more than one health behavior
  at a time?
• What about motivation to change?
• Tobacco use assessment and treatment may be an
  opening to address other problems as well

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Queens Quits!

• Our mission is to promote tobacco prevention and
  cessation among the residents of Queens County.
• To provide training and technical assistance to
  enhance readiness and capacity of Queens-based
  physicians, dentists and other health care
  providers to deliver brief tobacco cessation
  interventions in clinical practice.
• To increase the number of Queens residents who
  are referred for intensive cessation counseling,
  cessation pharmacotherapy and use the services of
  the NYS QuitLine.
• Funded by a Tobacco Cessation Center Grant from
  the NYS DOH Tobacco Control Program.

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Lets work together!

• Health care clinicians, advocates, service
  providers, researchers, policy makers
• Reduce smoking prevalence among HIV persons
  through education, research, and HIV care that
  targets tobacco use
• Improve the quality and length of life of those
  living with HIV

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