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Special Report: HIV Smoking and Drinking
A striking majority in HIV cohort smoke
Five A plan: Ask, Advise, Assess, Assist, Arrange
Public health officials and researchers are focusing more attention on helping HIV patients quit smoking because it's any extremely common behavior that has deleterious impact on their long-term health.
Recent studies have shown an increased risk of cardiovascular and pulmonary disease among HIV-infected people who smoke cigarettes. For example, one study concluded that HIV-infected individuals who smoked more than one pack a day had double the lung cancer risk and four-times the risk of death.1
This type of evidence is alarming because cigarette smoking is very common among HIV populations, reaching as high as 70% having a lifetime history of smoking in some studies, says Hilary A. Tindle, MD, MPH, an assistant professor of medicine at the University of Pittsburgh (PA). Tindle is involved in a study, funded by the National Cancer Institute, that provides a smoking cessation intervention for low-income smokers.
In the Veterans Aging Cohort Study (VACS), about 60% of HIV-positive individuals currently smoke, compared with 40% of non-HIV-infected individuals smoking, she adds.
The prevalence of smoking is much higher than the general population in both groups, but the HIV group is highest, Tindle says.
"An increased awareness of this important risk factor has emerged," says Kristina Crothers, MD, an assistant professor at the University of Washington School of Medicine and Harborview Medical Center in Seattle, WA.
"We don't have definitive data in an HIV population, but based on data from uninfected populations, if you quit smoking you slow your decline in lung function," she adds.
The problem is that changing these behaviors is challenging and requires HIV clinicians' time when there already are multiple competing issues to be covered at every patient visit.
Tindle sees hospitalized HIV-positive patients who often have a high prevalence of mental illness, low socioeconomic status, and substance use problems – all of which make it more challenging to deal with their smoking habit.
For instance, low-income patients often have more trouble quitting smoking, Tindle says.
"They make fewer attempts, and if they do attempt to quit they relapse more often," she adds.
Add several other barriers and smoking cessation is no longer a simple process.
A `quadruple whammy'
"Each of these things alonelow income, mental illness, cocaine/heroin/alcohol abusewould make it difficult to treat their smoking problem," Tindle says. "And these HIV-positive individuals often have all of these problems – making it a quadruple whammy."
This is why an eight-week smoking cessation program is unlikely to achieve success.
"It seems HIV-positive individuals represent a particularly difficult case and may need more coordination in their care," Tindle says. "It's not a one-shot or two-or-three-shot deal."
HIV clinicians should view smoking cessation programs as long-term interventions. It may take patients five or more attempts to quit smoking, she adds.
From the HIV practitioner's perspective, this is a daunting task.
"There's limited time to achieve all the things we want to achieve," Crothers says. "How do you balance all the clinical needs you might have in caring for a patient in a short encounter?"
One strategy is to start with the Five A's, as listed by the National Institutes of Health (NIH) in the "Quick Reference Guide for Clinicians: Treating Tobacco Use and Dependence."
The Five A's are as follows:
HIV patients often have mental health, substance use, and other problems that make smoking a difficult behavior to change.
"Tobacco dependence is a chronic disease, and patients will need repeated assistance to be smoke-free," Crothers adds.
It might help HIV clinicians to view smoking as a chronic health condition that requires a multi-pronged approach, including the use of medications, such as topiramate (Topamax®), nicotine patches, nicotine gum, varenicline (Chantix®), and bupropion (Zyban®). They could refer patients to behavioral programs, including phone counseling, a quit line, group classes, web-based programs, and more formal behavioral therapy, Tindle suggests.
"And when they relapse, and most people will relapse, we get them back for another quit attempt," Tindle says. "If we treat people over the long haul, they eventually will quit smoking."