Published research shows that cigarette smoking rates among people living with HIV/AIDS are substantially higher than those of the general public. “The prevalence of smoking adults in the United States is about 18%, but that figure increases to approximately 50% for people with HIV/AIDS,” says Damon J. Vidrine, DrPH, MS. “Furthermore, people with HIV/AIDS are at higher risk from the adverse health consequences of smoking, including heart disease, cancer, pulmonary disease, and overall mortality.” A recent study found that more than 60% of deaths among people living with HIV/AIDS can be attributed to smoking. “Smoking can also interfere with the efficacy of medications used to keep HIV/AIDS under control,” adds Ellen R. Gritz, PhD.
Despite compelling evidence suggesting that people with HIV/AIDS could benefit considerably from smoking cessation treatment, large-scale trials conducted exclusively in these patients are scarce. “Few studies have looked at interventions that have been effective for long-term smoking abstinence in these patients,” says Dr. Gritz. “We need more studies that focus on the unique needs of people with HIV/AIDS in the context of this patient group being economically disadvantaged.”
A Unique Smoking Cessation Intervention
Dr. Gritz, Dr. Vidrine, and colleagues had a study published in Clinical Infectious Diseases that compared a usual care (UC) approach with an innovative cell phone counseling-based smoking cessation intervention in low-income, multiethnic people with HIV/AIDS who smoked. “We wanted to develop and implement a smoking cessation intervention that addressed the complex medical and social needs encountered by these patients,” says Dr. Vidrine. “This is one of the largest studies to look at a smoking cessation intervention that exclusively targets people living with HIV/AIDS.”
Participants received smoking cessation treatment either through UC or were assigned to counseling that was delivered by a cell phone intervention (CPI). The CPI group received the UC components plus counseling over 3 months and access to a supportive hotline. The CPI was designed to reduce access to care barriers, provide an intensive level of support, and meet the special needs of the target population. CPI participants were provided with a prepaid cell phone, and those who provided counseling were trained and supervised by a licensed clinical psychologist. The study team designed cognitive and behavioral components to help modify thoughts and behaviors that often serve as barriers to quitting smoking and remaining abstinent. A motivational component was designed to address fluctuations in quit motivation and promote greater self-efficacy for quitting smoking during the treatment delivery phase.
According to results, participants in the CPI group were 2.41 times more likely to be abstinent from smoking when compared with the UC group (Table) when evaluating the overall 7-day abstinence outcomes at 3, 6, and 12 months follow-up. “The treatment effect was strongest at 3-months follow-up but diminished at 6 and 12 months,” notes Dr. Vidrine (Figure). “This finding indicates that, while efficacious, the CPI effect may not be well sustained beyond the 3-month treatment period. This suggests that an extended intervention approach may be beneficial.”
Tailoring Approaches Among Patients with HIV/AIDS
Despite the study team’s best efforts, the absolute smoking quit rates were low in both CPI and UC groups and diminished over time. “This finding illustrates that we still have substantial work ahead of us in order to assist this underserved patient population in smoking cessation,” Dr. Vidrine says. “Targeting and personalizing interventions may be critical for long-term smoking cessation among patients with HIV/AIDS.”
High levels of depressive symptoms and poor mental health status are also important to consider, according to Dr. Gritz. “There is a substantial burden of mental illness among smokers and those with HIV/AIDS,” she says. It has been well documented that people suffering from depression have lower quit rates than non-depressed people.
Although the CPI featured personalized counseling to address barriers to cessation, Dr. Vidrine says the study team did not directly connect participants to social services, mental health counselors, drug abuse counselors, or other specialties to address their real-world problems. “To address this issue, we’re developing an intervention that incorporates such features into future research,” he says. “We need to examine the best ways to make pharmacologic and behavioral support readily available and tailor interventions to address the specific needs of this patient population. In addition, an extended intervention of our program may help patients in their efforts to sustaining smoking abstinence. These efforts may also raise quit rates and could potentially reduce real-life barriers to smoking cessation.”
Gritz ER, Danysh HE, Fletcher FE, et al. Long-term outcomes of a cell phone–delivered intervention for smokers living with HIV/AIDS. Clin Infect Dis. 2013;57:608-615. Available at: http://cid.oxfordjournals.org/content/57/4/608.abstract.
Vidrine DJ, Marks RM, Arduino RC, Gritz ER. Efficacy of cell phone-delivered smoking cessation counseling for persons living with HIV/AIDS: 3-month outcomes. Nicotine Tob Res. 2012;14:106-110.
Vidrine DJ, Arduino RC, Gritz ER. The effects of smoking abstinence on symptom burden and quality of life among persons living with HIV/AIDS. AIDS Patient Care STDS. 2007;21:659-666.
Vidrine DJ. Cigarette smoking and HIV/AIDS: health implications, smoker characteristics and cessation strategies. AIDS Educ Prev. 2009;21(suppl):3-13.
Nahvi S, Cooperman NA. Review: the need for smoking cessation among HIV-positive smokers. AIDS Educ Prev. 2009;21(suppl):14-27.
Helleberg M, Afzal S, Kronborg G, et al. Mortality attributable to smoking among HIV-1-infected individuals: a nationwide, population-based cohort study. Clin Infect Dis. 2013;56:727-734.