HIV treatment has improved and patients can expect life expectancy close to that of HIV negatives. Smoking cessation is therefore an intervention that must be adequately addressed in this population

1. TOBACCO USE AND HIV
Leonard Sowah, MBChB, MPH
1

2. Epidemiology of Tobacco Use
• Prevalence of Tobacco use in USA 20.6%1
• Prevalence among HIV positives 45 – 74%2,3,4
• Prevalence in Swiss Cohort – 76%5
• Among HIV patients who used IV drugs – 96%5
• A comparative analysis within the NHIS Survey
suggests that MSMs are 2.3X more likely to smoke
compared to general male population6
1. Vital Signs: Current Cigarette Smoking Among Adults Aged ≥18 Years - United States, 2009 - Morbidity and
• Tobacco use 2010;59(35):1135–40 20102011 Aug. 11].
Mortality Weekly Report data CDC [accessed
2. Burkhalter, JE et al, 2005; Nicotine and Tobacco Research, 7(4), 511–522
3. Gritz, ER et al, 2004; Nicotine and Tobacco Research, 6(1), 71–77
4. Webb, MS et al, Journal of Behavior Medicine, 30(5), 371–383
2
5. Clifford GM , Polesel J, Rickenbach M, et al, JNCI J Natl Cancer Inst (2005) 97 (6): 425-432
6. McKirnan D et al, 2006, Substance Use & Misuse, 41:1197–1208

3. Tobacco use and HIV patient
• Tobacco use reduces effectiveness of HAART therapy 1
• High rates of lung and bronchial cancers in HIV patients is associated with
high prevalence of smoking among HIV patients2,3
• HIV patients who smoke have an increased risk of bacterial pneumonia 3
• HIV positive smokers have 56% increased risk of PCP compared to non-
smokers4
• Long term Tobacco use is associated with increased risk of Pulmonary
Tuberculosis about 3x among HIV patients 4
• HIV patients with COPD who smoke progress faster. 5
1. Feldman JG, Minkoff H, Schneider MF et al, Am J Public Health 2006, 96: 1060 – 1065
2. Clifford GM , Polesel J, Rickenbach M, et al, JNCI J Natl Cancer Inst (2005) 97 (6): 425-432
3. Frisch M, Biggar RJ, Engels EA, Goedert JJ. JAMA 2001;285:1736 –1745
4. Miguez-Burbano MJ et al, Addiction Biology 2003: 8 , 39 - 42
5. Diaz PT, King MA, Pacht ER, et al. Ann Intern Med 2000;132:369–372..
3

4. Health Effects of Smoking in HIV Patients (I)
• In the Monica database in France risk of MI is 1.52
per 1000 person years1
• Among HIV patients MI incidence was 5.0 – 5.5 per
1000 person years suggestive of at least 3-3.5 fold
increase1
• HIV infected smokers have a 2.8 times increased risk
of lung cancer2
• The risk of lung cancer in HIV positive IV drug users is
12.6 times according to data from the Swiss Cohort2
1. AIDS 2003; 17 (suppl. 1): S70 – S76
4
2. J. Natl Cancer Inst 2005; 97: 425 -432

5. Health Effects of Smoking in HIV Patients
(II)
• Smoking is associated with a 33% increased risk of
HPV infection in women1
• HIV positive smokers are 33% more likely to have
persistence of HPV infection2
• Analysis of data from the MACS Cohort shows a R.R.
of 3.9 for Anal Squamous cell cancers in HIV positive
smokers vrs non-smokers3
1. Minkoff, H. et al, 2004, J Infect Dis. 189 (10): 1821-1828.
2. Rowhani-Rabar, A et al, 2007, J Infect Dis. 196:887–94
5
3. D’Souza, G. et al, 2008, J Acquir Immune Defic Syndr;48:491–499

6. Tobacco use and incidence of PCP
6
Miguez-Burbano MJ et al, Addiction Biology 2003: 8 (1) 39 - 42

7. Relationship between Smoking and other Cardiovascular Risk Factors and the
Rate of Myocardial Infarction
Cardiovascular Risk Relative Risk of Heart p-value
Factor Attack
Protease Inhibitor use per 1.10 (1.04 – 1.18) 0.002
additional year
Age per additional 5 yrs 1.32 ( 1.23 – 1.41) < 0.001
BMI > 30 1.34 (0.86 – 2.09) 0.19
Family History of Heart Dx 1.40 (0.92 – 1.91) 0.08
Current Smoker 2.92 (2.04 – 4.18) < 0.001
Former Smoker 1.63 (1.07 – 2.48) 0.02
Previous CVS event 4.64 (3.22 – 6.69) < 0.001
Diabetes 1.86 (1.31 – 2.65) < 0.001
Hypertension 1.30 (0.99 – 1.72) 0.06
Total Cholesterol per mmol 1.26 (1.19 – 1.35) < 0.001
HDL per mmol 0.65 (0.48 -0.88) 0.05
The DAD Study Group. N Engl J Med 2007;356:1723-1735

8. CARDIOVASCULAR DISEASE IN HIV
HIV Viral
Replication
Anti-retroviral
Immune Therapy
activation
Insulin
Inflammation
Resistance &
Diabetes
Macrophage Dyslipidemia
Recruitment
Atherosclerosis
Endothelial
Dysfunction
Hypertensio Genetics
Smoking
n
Modified from: Currier J.S., Topics in HIV Medicine, 2009, 17(3); 98-103

9. Estimated Relative Risk of Myocardial Infarction after Quitting Smoking .
9
Rosenberg L et al. N Engl J Med 1985;313:1511-1514.

10. Cardiovascular disease risk factors in HIV patients - association
with antiretroviral therapy. Results from the DAD study. Cardiovascular disease risk factors in HIV patients -
association with antiretroviral therapy. Results from the
DAD study.
Friis-Moller, Nina; Weber, Rainer; Reiss, Peter; Thiebaut,
Rodolphe; Kirk, Ole; Monforte, Antonella; Pradier,
Christian; Morfeldt, Linda; Mateu, Silvia; Law, Matthew;
El-Sadr, Wafaa; De Wit, Stephan; Sabin, Caroline; Phillips,
Andrew; Lundgren, Jens
AIDS. 17(8):1179-1193, May 23, 2003.
Fig. 1. Prevalence of elevated total cholesterol (>= 6.2
mmol/l) according to current antiretroviral therapy (ART),
CD4 cell count (a) and HIV RNA (b) at baseline. The six
ART categories are: naive (ART naive), no ART
(treatment-experienced, but not currently receiving
antiretroviral therapy), NRTI (currently receiving only
NRTI), NNRTI (currently receiving NNRTI and NRTI but not
PI), PI (currently receiving PI and NRTI but not NNRTI),
and PI/NNRTI (currently receiving PI, NNRTI and NRTI).
10
© 2003 Lippincott Williams & Wilkins, Inc. Published by Lippincott Williams & Wilkins, Inc. 6

11. Psychosocial Aspects of Smoking and HIV
• HIV positive patients are 3x more likely to be smokers1
• MSMs are more likely to be smokers compared with
heterosexuals2
• In the US HIV patients tend to be socio-economically
disadvantaged and are more likely to have social networks
with more smokers3,4
• High rates of depression and drug use among HIV patients5
• Individual self efficacy is one of the strongest predictors of
successful quit attempt6
1. Gritz, ER et al, 2004; Nicotine and Tobacco Research, 6(1), 71–77
2. Eur. J, Med Res. 2003; (8) 229 – 235
3. Sheahan, S. L. & Garity, T, E 1992 J. Amer. Acad. Nur. Pract. 4 (3), 111 -116
4. Ryan, H et al, 2001 Amer. Jour. Prev. Med. 21(1), 142 – 149
5. Reynolds, N. 2009, AIDS Educ. Prev. 21, Suppl. A, 106 – 121
11
6. Lloyd-Richardson, E. E. et al, 2008; Amer. Jour. Health Beh, J2(1). 3 -15

12. SMOKING CESSATION
• 70% of the 45million smokers in the US report
they wish to quit1
• 44% of all smokers attempt to quit each year1
• HIV positive smokers are just as willing to quit as
other smokers2
12
1. Morbidity and Mortality Weekly Report 2002;51(29):642–5 [accessed 2011 Aug 11].
2. Mamary EM, Bahrs D, Martnez S, AIDS PATIENT CARE and STDs, 2002 16 (1) 39 - 42

13. Tobacco Use History
• Introduction to Healthy Tobacco Free Life
• Onset of habit
• Longest periods of abstinence and circumstance
• Current smoking habits – Intensity and Frequency
• Determination of Nicotine dependence
• Living situation and smokers and non-smokers in the home
• Prior quit attempts and results
13

14. The Financial Costs of Smoking
Potential Gains of Quitting
For a 1 pack per day smoker
Cost • Save enough for a full tank of
$6.65 per pack gas in a week
At 1 pack per day,
• In one month one could buy a
Weekly cost = $46.55
Nintendo Wii or similar high
Monthly cost = $205 end video game
Annual cost = $2,427 • In two months you could buy
a 40inch flat screen TV
Half a pack per day
Weekly cost = $23.27 • In a year enough money for a
Monthly Cost = $102 vacation package for two
• In 5yrs enough money to pay
Annual cost = $1,213
for a fairly nice car
6 cigarettes a day • In 15 yrs enough for a down
Weekly cost = $13.30 payment on a house
Monthly cost = $60.00
Annual cost = $720
14
Source: www.marketplace.org

15. Individualized Motivational
Speech
5 A’s
1.Ask- Ask about Tobacco
use at every visit
2.Advise – Strongly urge
all smokers to quit
3.Assess– Determine
willingness to make a quit
attempt
4.Assist – Aid client in
quitting
5.Arrange – Schedule
follow-up contact
15

16. Behavior Therapy
16
Can Fam Physician 2008;54:994-999

17. What Happens When People Quit Smoking
Nicotine withdrawal symptoms How to Handle Withdrawal Symptoms
• Irritability
• Anxiety
The Five D's
• Difficulty concentrating Delay until the urge passes - usually
•
•
Increased appetite
Cravings to smoke
within 3 to 5 minutes.
• Insomnia Distract yourself. Call a friend or go for
• Fatigue a walk.
• Headache
• Cough Drink water to fight off cravings.
• Sore throat Deep Breaths - Relax! Close your eyes
• Constipation, gas, stomach pain
• Dry mouth
and take 10 slow, deep breaths.
• Sore tongue and/or gums Discuss your feelings with someone
•
•
Postnasal drip
close to you or at the support group
Tightness in the chest
17

18. Drug Therapy
Nicotine patches • What if I am unable to quit after
• What is it? completing a full course of
• Why must I use a patch if I am treatment ?
trying to quit nicotine in
cigarettes?
• How long I am going to use this
medication for?
• What if I want to smoke whilst
having the patch on?
• How must I apply the patch?
• Does the patch have side- • What if the patch falls off?
effects? • Can I take a bath with the patch?
• Can I add a second patch if I • What if I get redness at the site
have cravings with a single of application of the patch?
patch? 18

19. Zyban
• What is zyban?
• How does it work to help me quit?
• When must I start this medication?
• How long will I need to take this
medication?
• Are there any side-effects of this
medication?
• What if I forget to take my
medication in the morning?
• Would this medication interact with
my HIV medications?
• Would this medication interact with
other medications that I take?
19

20. Chantix
• What is Chantix?
• How does it work to help me quit?
• When must I start this medication?
• How long will I need to take this
medication?
• Are there any side-effects of this
medication?
• Will this medication change my behavior
• I have heard that you can get a heart
attack if you take Chantix, is this true?
• What if I forget to take my medication in
the morning?
• Would this medication interact with my
HIV medications?
• Would this medication interact with other
medications that I take?
20

21. Pharmacotherapy
21
Can Fam Physician 2008;54:994-999

22. Summary
• Health Impact of Tobacco use appears to be accelerated in HIV patients
• HIV patients by virtue of certain socio-cultural characteristics are more
likely to be smokers
• Smoking cessation interventions have proven more challenging in HIV
patients
• HIV patients are however just as willing to quit as all other smokers
• Use of combined behavioral intervention and pharmacotherapy has
shown some success in this population
22

23. Online Resources
• http://mdquit.org/quitline
• http://www.smokefree.gov/
• http://www.lungusa.org/stop-smoking/
• http://www.cancer.org/Healthy/StayAwayfromTobacco/index
• 1-800-QUIT-NOW OR 1-800-784-8669
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