What We Know About HIV+ Smokers

Implications for Treatment

Jack Burkhalter, Ph.D.Smoking Cessation Program

Memorial Sloan-Kettering Cancer Center

HIV

Acknowledgments

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.

HIV

Approach to this talk

Evidence-based, with the state of current knowledge

Clinical researcher’s perspective

Cancer prevention perspective

HIV

HIV and Smoking: Why now?

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

HIV

Comparisons of Smoking Rates

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

HIV

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)

What we don’t 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

Two Published Studies

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

HIV

Sample characteristicsCharacteristics 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% < high school 87% < 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

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 > 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

Texas Findings

Current smokers vs. nonsmokers (former + never) more likely to be:– White non-Hispanic– Older (vs. 20-29 years)– Have lower education (< high school)– Heavy drinkers of alcohol

Quitters (vs. current smokers) more likely to:– Be White (vs. Black, p<.06)– Have higher education– Not be heavy drinkers of alcohol

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 (p<.10)

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

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%

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*

*p<.001

What health risks do you believe smoking exposes you to?

Smokers’ responses and % endorsing this risk Percent

Respiratory problems, e.g., “breathing problems”1 38

Cancer of any type 20

Impact on immune system, e.g. “lowers T-cells”1 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 < .05) and immune system functioning (28% vs. 12%; p < .05).

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*

*p<.001

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

Summary

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

HIV

What do research findings mean for designing treatment programs?

Enhancing Motivation to Quit: The “5 R’s”

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)

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

•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

“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

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 person’s 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.”

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

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

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

Treating depression, anxiety, alcohol or substance abuse, nonadherence to HIV meds—where 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

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.

Let’s 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

For more HIV-related resources, please visit www.hivguidelines.org