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AIDS Educ Prev. Author manuscript; available in PMC Dec 29, 2011.
Published in final edited form as:
PMCID: PMC3248054
NIHMSID: NIHMS342725

CIGARETTE SMOKING AND HIV: MORE EVIDENCE FOR ACTION

Abstract

As many as 50–70% of persons infected with HIV are current smokers. Compelling evidence concerning the risks of cigarette smoking to persons living with HIV urges the inclusion of smoking treatment protocols in contemporary models of HIV care. Yet in spite of growing awareness of this problem, persons living with HIV are not being effectively treated for tobacco use. To further an understanding of contributing factors and define directions for evidenced-based intervention, factors associated with smoking behavior among persons living with HIV are examined.

Cigarette smoking is highly prevalent among persons living with the HIV. In contrast to the prevalence rate among the general U.S. population which has gradually declined to 19.8% (“Cigarette Smoking Among Adults,” 2008), disproportionately high rates of cigarette smoking persist among HIV-positive individuals. Estimates indicate that as many as 50–70% of persons infected with HIV are current smokers (Shuter & Bernstein, 2008; Tesoriero, Gieryic, Carrascal, & Lavigne, 2008). The high rates of smoking have particularly detrimental health implications for this population. HIV treatment with potent combination antiretroviral therapy has produced rapid and remarkable improvement in mortality and morbidity outcomes, yet persons living with HIV still face substantial health risks. Of note, a growing body of research shows that in addition to accelerating the development of well known adverse health consequences of tobacco use, cigarette smoking places HIV-positive persons at risk for a host of serious HIV-related comorbidities and premature death (Centers for Disease Control and Prevention [CDC], 2004; Cohen et al., 2002; Crothers et al., 2005; Feldman et al., 2006; Fiore et al., 2008; Lewden et al., 2005). Intervening to improve the rate of successful smoking cessation has potential to significantly improve the health and longevity of HIV-positive smokers and related individual and public health costs.

Many innovative and effective smoking-cessation treatments, both behavioral and pharmacologic, have been developed over the past several decades (Fiore et al., 2008). However, smoking cessation efforts have largely been aimed at healthy people in the general population as a form of primary prevention (Gritz, Vidrine, & Fingeret, 2007). While effective, empirically validated treatments for smoking cessation are available in the general population, it is not clear whether these treatment strategies are suitable or effective for cohorts with population-specific concerns and clinical issues such as persons living with HIV (Fiore et al., 2008).

There is little research that explains the unusually high rates of smoking among HIV-positive persons and there are few published reports of controlled clinical research studies that have evaluated the efficacy of smoking-cessation treatments in HIV-positive cohorts. In order to better define future directions for evidence-based intervention, this review examines prominent health risks followed by an examination of factors associated with cigarette smoking among persons living with HIV. Lastly, indications for intervention are considered.

RATES OF TOBACCO CONSUMPTION AND CLINICAL IMPLICATIONS AMONG HIV-POSITIVE ADULTS

Although the prevalence of cigarette smoking among adults in the United States has declined to approximately 19.8% (“Cigarette Smoking Among Adults, 2008), the prevalence of smoking among persons with HIV is as much as two to three times higher. In an early population-based study (N = 998), Royce and Winkelstein (1990) reported a smoking prevalence of 45.6% among HIV-positive men. Other clinic and population-based studies further substantiated the high rate of smoking in this population (Mamary, Bahrs, & Martinez, 2002; Niaura et al., 2000; Stall, Greenwood, Acree, Paul, & Coates, 1999; Wallace et al., 1993) with recent studies continuing to report rates in diverse samples of HIV-positive adults between 50% and 70% (Benard et al., 2007; Burkhalter, Springer, Chhabra, Ostroff, & Rapkin, 2005; Crothers et al., 2007; Feldman et al., 2006; Gritz et al., 2007; Tesoriero et al., 2008).

HIV remains a major public health problem in America. Over 1.1 million persons are now living with HIV in the United States and the CDC recently released a report that revealed that 56,000 people are being infected with HIV annually in the United States, a figure 40% higher than previously estimated (Hall et al., 2008). The high prevalence of cigarette smoking among persons infected with HIV has profound health implications. Although advances in the treatment of HIV have improved overall rates of morbidity and mortality, it appears that some of the benefits afforded by combination antiretroviral therapy are negated in cigarette smokers. In 2005, researchers looking at more than 800 HIV-positive U.S. veterans taking combination antiretroviral therapy found that the mortality rate for smokers was twice that of nonsmokers after adjusting for other factors such as age, CD4 cell count, and viral load (Crothers et al., 2005). Similarly, an analysis involving more than 900 HIV-positive women taking antiretroviral therapy in the Women’s Interagency HIV Study cohort, showed poorer viral and immunologic response and greater risk of disease progression. After controlling for other factors, smokers had a 36% greater likelihood of developing an AIDS-defining condition and a 53% higher risk of dying during the 5-year follow-up period (Feldman et al., 2006).

Both HIV and smoking are risk factors for suppression of local lung defenses and pulmonary diseases including a variety of bacterial pneumonias, acute bronchitis, and tuberculosis (Burns et al., 1996; Conley et al., 1996; Gordin et al., 2008; Hajjeh et al., 1999; Marrie, 1999; Miguez-Burbano et al., 2005; Nuorti et al., 2000; Tumbarello et al., 1998). Evidence exists that the lungs of HIV-positive individuals are especially susceptible to the damaging effects of cigarette smoke with reduction in pulmonary diffusing capacity and increased susceptibility to early development of emphysema (Crothers et al., 2006; Diaz, King, Wewers, et al., 2000; Diaz, King, Pacht, et al., 2000; Diaz et al., 1999; Diaz et al., 2003; Petrache et al., 2008).

The incidence of cancers, especially lung and cervical cancers, are higher among HIV-infected smokers than nonsmokers and develop at a younger age in persons with HIV in contrast to the general population (Engels, Brock, Gillison, Hooker, & Moore, 2005; Heard, Potard, Costagliola, & Kazatchkine, 2005; Kirk et al., 2007; Phelps et al., 2001; Tirelli, 2000; Vyzula & Remick, 1996). Additionally, cigarette smoking significantly increases the likelihood of persons with HIV to develop periodontal disease, oral candidiasis, and oral hairy leukoplakia (Chattopadhyay et al., 2005; Conley et al., 1996; Slavinsky, 2002; Shiboski, Neuhaus, Greenspan, & Greenspan, 1999) and overall poorer quality of life. Turner et al. (2001) found cigarette smoking to be independently associated with lower scores for general health perception, physical functioning, bodily pain, energy, role and cognitive functioning.

Cigarette smoking has also been identified as a significant cofactor in the inordinately high rates and premature development of HIV-related peripheral artery disease as well as cardiometabolic syndrome and renal disease which have emerged as major causes of morbidity and mortality in individuals infected with HIV (Bozzette, Ake, Tam, Chang, & Louis, 2003; The Data Collection on Adverse Events of Anti-HIV Drugs (DAD) Study Group, 2003; De Silva, Post, Griffin, & Dockrell, 2007; Law et al., 2006; Mutimura, 2008; Periard et al., 2008).

Although it is clear that smoking cessation is an important modifiable risk factor, it is less clear why the rates of smoking continue to be so high among persons living with HIV in comparison with the general population.

FACTORS INFLUENCING PATTERNS OF CIGARETTE SMOKING

Several highly interactive factors prominently associated with tobacco use can be observed among individuals living with HIV including certain social conditions, polysubstance use, psychiatric comorbidities, physical/mental distress, supporting beliefs, access and treatment adherence.

SOCIAL CONDITIONS

Many persons living with HIV face difficult psychological, physical, and social conditions. Socioeconomic disadvantage is a well-recognized predictor of smoking in the general population (Fiore et al., 2008; Krueger & Chang, 2008). Economically and socially marginalized persons continue to represent a large proportion of persons infected with HIV. Thus, well established social situational factors associated with persistent tobacco use in the general population will be seen commonly among persons living with HIV-positive including a disproportionate amount of daily stress and discrimination, less education, social environments comprising a higher prevalence of smokers than nonsmokers, and less social support and network members supportive of smoking cessation (Ryan, Wortley, Easton, Pederson, & Greenwood, 2001; Sheahan & Garrity, 1992; Wiltshire, Bancroft, Parry, & Amos, 2003).

Further, although the HIV epidemic has shifted steadily toward a growing proportion of cases among socioeconomically disadvantaged non-Hispanic Blacks and women, smoking is also highly prevalent among other subgroups, particularly men who have sex with men (MSM). MSM remain the largest single exposure group in the United States with recent data showing that 53% of new HIV cases in the United States are MSM (Hall et al., 2008). Rates of smoking are higher among MSM than the general population and a large population-based study showed that rates of smoking are even higher among MSM who are HIV-infected (Stall et al., 1999).

MSM are also at risk for socioeconomic factors associated with tobacco dependence observed in other exposure groups. Higher rates of smoking among MSM may also be associated with other cultural and gender-related social-situational factors. Places where smoking is prevalent, such as gay-identified bars or clubs, have historically been an important social focus for MSM, possibly because of a history of exclusion or discrimination in other social settings. These venues continue to play an important role for segments of this population. Numerous subgroups operate as unique social and cultural entities with codes of conduct that may not only expose the individual to and reinforce cigarette smoking but are also aligned with participation in activities that reduce inhibition and promote other high risk behavior such as alcohol, club drug use, and unprotected sex (Adam, 2008; Kipke et al., 2007).

POLYSUBSTANCE USE

Tobacco use not only commonly cooccurs with other substance use, but the rate of smoking when used with other substances (e.g., alcohol, cannabis, psilocybin, MDMA, cocaine, amphetamine, LSD, or methylphenidate) is significantly increased relative to “sober” smoking rates (Barrett, Darredeau, & Pihl, 2006). Both recreational substance use and substance use disorders are well-known risk factors for acquiring HIV. Since 1989, approximately one third of all AIDS cases in the United States have been among active or former injection drug users (CDC, 2006; Hall et al., 2008), and increasing prevalence of HIV among sectors of MSM is associated with pervasiveness of club drug use (e.g., Kipke et al., 2007). The prevalence of nicotine dependence among HIV-positive persons who abuse alcohol and other substances is as high as 75% and drug use is a key risk factor for smoking cessation failure.

A considerable body of research indicates that the cooccurrence of abuse of tobacco and all various types of illicit drugs reflects a common vulnerability that is influenced by both genetic and environmental factors. It is well established that cigarettes and other tobacco products induce dependence (Niaura & Abrams, 2002). The physiologic basis for tobacco dependence is an addiction to nicotine, a critical constituent of tobacco smoke (Dani & Heinemann, 1996). The mechanism of nicotine addiction in the brain is also the region of the brain at which other substance additions are reinforced. Substance abusers are thought to be more addicted to nicotine than nonabusers as evidenced by studies that have documented that abusers smoke higher nicotine cigarettes, more cigarettes per day, have higher Fagerstrom scores and/or have increased carbon monoxide, nicotine, and cotinine levels than nonabusers (Hurt & Patten, 2003). Substance abusers usually initiate smoking at a younger age, become regular smokers earlier, and smoke more cigarettes per day than nonabusers (DiFranza & Guerrera, 1990). Further, relapse is common following treatment for both smoking and other addictive drugs. Thus, polysubstance use can be expected to be a common and difficult barrier to smoking cessation treatment in subgroups of HIV-positive individuals.

Interestingly, in contrast to common practice in many drug treatment settings, ongoing research examining the neurobiology of addiction indicates that treatment may be more effective if cosubstance dependencies are treated concurrently. Research advances in the understanding of genetics and the neurobiological basis of addiction also indicate that more personalized, effective treatment for drug dependencies may be possible in the future with use of genetic markers to guide selection of the treatment approach that will have the greatest potential for success in a given individual (Durazzo et al., 2007; Wong, 2008).

PSYCHIATRIC COMORBIDITY

Higher rates of cigarette smoking, greater nicotine addiction, and abuse of other substances are also associated with collateral mental disorders, especially anxiety disorders, depression, and schizophrenia (Niaura & Abrams, 2002; Ziedonis et al., 2008). As many as half of persons living with HIV have mental disorders, particularly depression (Bing et al., 2001; Catalan, Meadows, & Douzenis, 2000).

The relationship between depression and nicotine use is well established. Several studies have shown that smokers among the general population of U.S. adults are less likely to quit if they have a history of a major depressive disorder, compared to nondepressed smokers (O’Brien et al., 2004). Smokers with a history of depression are more likely to experience more severe withdrawal symptoms and abstinent smokers are at greater risk of recurrent depression than nonabstinent smokers (Covey et al., 1990; Glassman et al., 2001; O’Brien et al., 2004). Rates of current despression among HIV-patients range from 22% to 32%, which is two to three times higher than the prevalence of depression in the general population (Bing et al., 2001; Ferrando & Freyberg, 2008; Rabkin et al., 1997).

Depressive symptoms are thus a probable, common contributing factor to cigarette smoking among persons living with HIV. Further, depressive symptoms among HIV-positive smokers have been associated with lower mental functioning and quality of well-being and are known to negatively influence other health behaviors that are essential to the longevity of persons living with HIV, notably adherence to antiretroviral therapy (Kowal et al., 2008).

Clinical depression in HIV-positive persons can be treated effectively (Bing et al., 2001; Ferrando & Freyberg, 2008; Wagner, Rabkin, & Rabkin, 1996, 1997), but symptoms are sometimes overlooked, mistaken for HIV-related or other illness related symptoms and treatment choices may be complicated by the treatment of other common comorbid illnesses (e.g., hepatitis C) and the potential for drug interactions with medications used in the treatment of HIV (Ferrando & Freyberg, 2008).

PHYSICAL-MENTAL DISTRESS

A host of physical discomforts related to the illness and side effects of treatment may be suffered by persons living with HIV. HIV-related symptoms and physical distress have been linked to higher rates of tobacco use. Webb, Vanable, Carey, and Blair (2007), for example, found that heavier tobacco use among HIV-positive smokers was associated with greater frequency and degree of physical symptoms compared to nonsmokers. This may suggest that smoking exacerbates HIV-related symptoms (Webb et al., 2007), or it may indicate that persons who smoke more frequently do so to obtain relief from uncomfortable symptoms.

Burkhalter et al. (2005) found that HIV-positive smokers currently using tobacco were more likely to report less pain. In another large diverse sample HIV-positive adults, cigarette smoking was identified as one of the primary behaviors used to self-manage symptoms, particularly by those with high levels of HIV-related peripheral nerve pain (neuropathy) (Nicholas et al., 2007). Use of cigarette smoking to self-manage HIV-related suffering was also reported in a small focus group study (Reynolds, Neidig, & Wewers, 2004). HIV-positive participants described using cigarette smoking to cope with the daily stress of living with a difficult illness and as an effective method of distraction and reprieve from illness-related symptoms and fear not available or as easily obtained through other available measures. These findings are consistent with a self-regulation framework and the observation long noted in the general tobacco literature that cigarette smoking may be used as a form of “self-medication” to mange physical and emotional discomfort.

SUPPORTING BELIEFS

Beliefs held by persons living with HIV may also be important in sustaining smoking behavior and influence smoking cessation efforts. For example, persons living with HIV have been found to believe that they will not live long enough to suffer the health risks of tobacco use or think that they are at a lower health risk for continued smoking and thus less likely to be concerned about smoking cessation (Burkhalter et al., 2005; Reynolds et al., 2004).

Contrary to what might be expected given the high rates of tobacco use, several researchers have found that many HIV-positive smokers are interested in quitting. In sample of current smokers, as many as 63–75% reported an interest in quitting or having made at least one quit attempt during the past year (Mamary et al., 2002; Tesoriero et al., 2008). However, as observed in other populations, belief that one will not be able to quit successfully (low-self-efficacy) may be a significant barrier to both initiation and maintenance of smoking cessation treatment.

In a preliminary smoking cessation trial targeting HIV-positive smokers, self-efficacy was found to mediate the efficacy of treatment (Vidrine, Arduino, & Gritz, 2006). Low self-efficacy to resist social and emotional triggers and temptations to smoke was also the strongest indicator of nicotine dependence in another large sample of HIV-positive adults (Lloyd-Richardson et al., 2008).

ACCESS AND TREATMENT ADHERENCE

The large majority of smokers who try to quit without treatment fail, most relapsing within 2 weeks (Allen, Bade, Hatsukami, & Center, 2008). Therefore, the odds of HIV-positive smokers quitting without smoking cessation treatment are slim. There would appear to be good opportunity to provide smoking cessation treatment to persons living with HIV. Many HIV-infected persons, particularly those taking antiretroviral medication, use medical services regularly because repeated visits are necessary for monitoring disease progression and antiretroviral medication regimens.

Health care providers can improve smoking cessation outcomes, but HIV-positive smokers who present at ambulatory care settings are not routinely offered effective assistance in quitting.

Lack of attention to smoking cessation may be related to several factors. First, HIV providers may not identify smoking as a problem. Crothers et al. (2007) found that HIV providers enrolled in the Veterans Aging Cohort 5 Site Study were significantly less likely to recognize current smoking compared to non-HIV providers. Even if recognized, clinicians may give smoking treatment low priority. There may be concern that it imposes additional, undue burden on already highly burdened individuals living with a complex, stigmatized illness, unstable social circumstances, and other comorbidities (Mamary et al., 2002). Smoking cessation may be regarded by providers as less important in comparison with competing priorities or because of economic barriers and limited time for health promotion activities in clinic-based settings. The resource limitations of HIV patients (e.g., transportation) may further complicate identification of viable alternatives (Gritz et al., 2007). Clinician’s reluctance to intervene may also occur because of limited familiarity and skills with available conventional smoking cessation treatments or because of the limited evidence base specific to persons living with HIV. Providers may be uncertain how to manage smoking cessation treatment in the context of HIV and its many treatment demands and complexities.

Even if smoking cessation treatment is accessed by HIV-positive individuals, success may be short lived. Relapse to smoking following escalations in symptoms of withdrawal, nicotine craving, and negative affect is seen commonly in other populations, despite treatment efforts. Inadequate adherence to treatment may be a contributing factor. Adherence to prescribed regimens is increasingly recognized as a critical but often under appreciated factor that may significantly influence treatment outcomes (World Health Organization [WHO], 2003). Like many conditions that require treatment over a period of time, a positive linear correlation between adherence to smoking cessation treatment and cessation rates has been demonstrated. Adherence to smoking cessation treatment for tobacco dependence is generally low (<40%) across different populations (WHO, 2003). Available, albeit limited, data indicate that rates of adherence to smoking cessation treatment among persons living with HIV are similarly poor and decline over time (Ingersoll, Cropsey, & Heckman, 2007).

Adherence to other treatments, importantly antiretroviral therapy, has also been found to be suboptimal among many persons living with HIV, with overall rates generally estimated between 50% and 70% (Chesney, 2000; WHO Report, 2003). Interestingly, a recent study of HIV-infected individuals being treated with antiretroviral medication, found current cigarette smoking to be an important and significant marker of inferior adherence to antiretroviral medication (Shuter & Bernstein, 2008). Current smokers took 63.5% (SD = 22.1) of prescribed doses, compared to 84.8% (SD = 15.8%) in nonsmokers (p < .001).

Factors associated with cigarette smoking among persons living with HIV have also been associated with lower rates of antiretroviral adherence including active substance use, depression, low social support, low literacy, cognitive impairment, side effects, and beliefs (Malta, 2008; Waldrop-Valverde, Jones, Weiss, Kumar, & Metsch, 2008). Smoking behavior and rate of adherence to smoking cessation treatment are therefore not only predictive of tobacco-related health outcomes, but may be indicative of unfavorable performance of other critically important health behaviors that may jointly accelerate and seriously compromise health outcomes among persons living with HIV.

SUMMARY AND UNIFYING, SELF-REGULATION FRAMEWORK

Taken together, the available evidence establishes the significance of several factors (social conditions, polysubstance use, psychiatric comorbidities, physical-mental distress, supporting beliefs, and access and treatment adherence) associated with the high rates of smoking among persons living with HIV as summarized above. The process by which the factors interact to perpetuate smoking as well as other detrimental health behaviors among persons living with HIV can be understood within a self-regulatory model (Figure1) that provides a dynamic, unifying framework.

FIGURE 1
Self-Regulatory Model

Within a self-regulatory framework, individuals are thought to be motivated to regulate or minimize threats to their well-being and act to reduce these threats in ways consistent with their perceptions of them (e.g., Cameron & Leventhal, 2003; Leventhal et al., 1997; Reynolds, 2003). The individual interprets stimuli and acts to maintain or enhance an acceptable or desirable status or avert or reduce a stimulus that is interpreted as unacceptable or undesirable. The stimulus may be psychological, physical, or anticipatory and fluctuate from moment to moment. The individual considers his/her options and selects an action based upon his/her perception of viable options and past successes and failures under similar circumstances. Once the action is taken the individual appraises the effectiveness of the action taken (outcome appraisal) and makes modifications as considered necessary (e.g., “I still feel bad, I need to try something else.”). When a particular self-regulating action is repeatedly selected, the selection becomes so routine that it is enacted virtually automatically with little consideration of alternate actions.

Cigarettes are smoked by individuals in response to a variety of physical and psychological stimuli and the outcome commonly appraised as beneficial (e.g., “I feel better, my stress is under control”) and selection of this behavior thus reinforced. However, the act of smoking a cigarette is also reinforced by the related physical dependence that develops which creates an independent, undesirable stimulus when nicotine is not available, that must be acted upon to attain a status appraised as acceptable.

A variety of factors set the stage for the self-regulating process and influence how the individual interprets stimuli and perception of viable options. At the most basic level, the individual’s sense of self, who he/she is relation to the world, develops through his/her genetic makeup and physical and psychological capacities and vulnerabilities (physical-mental health) in interaction with his/her social circumstances. The social circumstances obviously vary by the cultural and socioeconomic environment as well as by a host of commonplace and chance events that occur over the lifetime. These operate to shape an individual’s perceived options and expectations, which in turn influence the moment by moment interpretation of stimuli and selection of self-regulating actions.

Clearly, the self-regulating process is highly nuanced and individualized. However, research has enabled identification of factors that tend to operate similarly across individuals. Several factors discussed above characterize the situational and physical-mental health context that appears to sustain cigarette use of many persons living with HIV as well as engagement in other high risk self-regulating actions (e.g., other substance use) that further reinforce tobacco use and complicate treatment.

EVIDENCE-BASED TREATMENT FOR HIV-POSITIVE SMOKERS

In 2000, Niaura et al., (2000) called for action, asserting “the time is now” for attention to be paid to smoking cessation among persons living with HIV. Yet 8 years later, there is remarkably little information demonstrating the efficacy of smoking cessation treatments among HIV-positive individuals despite the high prevalence and high risk for significant HIV-related comorbidities. The recently updated Public Health Services treatment guidelines recommend standard smoking cessation treatments for HIV-positive smokers (Fiore et al, 2008). Although the treatments have not been tested in HIV-positive populations, it is suggested that the potential for success is good as interventions shown to be effective in one population are generally effective in other populations. It is not clear though which of the available intervention approaches are most likely to optimize smoking cessation among HIV-positive persons interested in quitting, particularly among those with multiple risk factors. For example, the use of pharmacotherapy improves smoking quit rates in the general population and is recommended for persons living with HIV alone or in combination with other behavioral treatment modalities (unless medically contraindicated) (Fiore et al., 2008). Seven first-line medications including five nicotine (nicotine gum, nicotine inhaler, nicotine lozenge, nicotine nasal spray, nicotine patch) and two nonnicotine (bupropion and varenicline), have been shown to reliably increase long-term smoking abstinence rates across a host of cohorts. Yet it is not clear which of the available pharmacotherapies are most suited to HIV-positive individuals. Buproprion, for example, seems to work well for some people and have little effect for others and there is some potential for interaction with other medications that may be taken by HIV-positive individuals (Hesse, von Moltke, Shader, & Greenblatt, 2001; Thompson, Silverman, Dzeng, & Treisman, 2006). The more recently available varenicline has been gaining in favor and would appear to be a promising adjunct to other smoking cessation modalities for persons living with HIV because of its mechanism of action. In contrast to other pharmacotherapies, varenicline is a nicotine receptor partial agonist that reduces the pleasurable effects of cigarettes and urges to smoke. There is some question though about the overall safety of varenicline among persons living with HIV. There is potential for varenicline to interact with other medications used in the treatment of HIV, but this has not been fully examined. Varenicline also places persons with impaired renal function at increased risk for toxic reactions, a significant consideration given the noted rise in renal disease among HIV-positive persons (De Silva et al., 2007). Varenicline also poses risk to HIV-positive persons with a history of a psychiatric illness as it may cause exacerbation or recurrence of an old psychiatric illness. Depressed mood, suicidal ideation, and actual suicidal behavior are among the adverse neuropsychiatric events that have been reported.

The scant preliminary data that is specific to persons living with HIV suggests that in comparison to a conventional, less intensive intervention, a more intensive approach that combines behavioral and pharmacologic treatments shows better potential. Gritz et al. (2007) and Vidrine et al. (2006) compared physician advice to quit, written materials, and nicotine patch to a more intensive approach that combined behavioral and pharmacologic treatments (physician advice to quit, written materials, nicotine patch plus eight proactive counseling sessions delivered via cell phone) in a preliminary efficacy trail and found that the intensive treatment group at 3-month follow-up data was significantly more likely to have quit smoking compared to participants receiving only the standard-care treatment (36.8% vs. 10.3%, p < .01). A larger efficacy trial of the intervention is currently under way and will provide additional, much needed data on possible mediators and moderators of treatment outcomes (R01CA097893). A limited number of other ongoing smoking cessation trials are examining the efficacy of motivational interventions and other pharmacotherapies among HIV-positive smokers (R01HL090313, R01DA018079, and R01DA012344).

Given the complexity of factors that influence the smoking behavior among many persons living with HIV, it may be valuable to consider other models that have shown success in directing effective behavioral change among HIV-positive cohorts, such as adherence interventions. As discussed above, nonadherence to antiretroviral therapy shares cofactors and cooccurs with other risk behaviors, including tobacco use, and interventions designed to address HIV treatment nonadherence may thus have elements that would be of use in the design of effective smoking cessation strategies. For example, an intervention drawn from a self-regulation framework (as described earlier), shows promise in altering adherence behavior in preliminary research (Reynolds et al., 2008) and could be adapted to smoking cessation treatment. Consistent with the self-regulation model (Figure 1), the intervention is premised on the understanding that while patients may become knowledgeable about a desirable health behavior, it is unlikely that the information will be acted upon or sustained if the behavior is inconsistent or incompatible with existing belief/interpretive systems that are supported by the individual’s context and typically resistant to change. Traditional educational interventions may not succeed because they attempt to teach new behaviors without first addressing the well-established interpretive systems that are driving the selection of current (self-regulating) behaviors. Unlike traditional educational interventions that have not been successful in improving adherence behavior, the adherence intervention places emphasis on how HIV-positive individuals interpret their illness and context. An individualized, contextualized repertoire of information, skills and affective support is hence provided using a process of conceptual change and reinforcement over time (by nurses per telephone) to support the development of skills to recognize, self-manage and solve problems with self-regulating actions that lower risk.

Considered with respect to smoking cessation, a similar intervention might be used, but adapted to address belief systems that support tobacco use as well as alternate skills for self-regulating aversive stimuli (e.g., stress) which in addition to pharmacotherapy for symptoms of craving, might include complementary actions such as meditation or accessing social support. The intervention would also need to attend to germane comorbidities/cooccurring risk factors which are also an element of the adherence intervention.

DISCUSSION AND RECOMMENDATIONS

Available information establishes the significance of several factors associated with the high rates of smoking among persons living with HIV. These include biophysical vulnerabilities, regular sources of environmental and psychological stress, depression, social segregation and networks that limit options, including access to treatment, and support belief systems that not only sustain cigarette smoking but the engagement of other cooccurring behaviors (e.g., other substance use) that may reinforce tobacco use and have adverse short and long-term consequences for health. These factors are not especially unique to persons living with HIV, but rather are well-established predictors of nicotine addiction observed in other populations. However, what may differentiate HIV-positive smokers from other cohorts is the potential of persons who are infected with HIV to possess an unusually high number of biophysical, psychological, and social characteristics that interact to reinforce tobacco use, as well as other risky behaviors. It would not be atypical for an HIV-positive cigarette smoker to be socioeconomically disadvantaged, socially discriminated, stressed, depressed, abusing other substances and have low self-efficacy and social support. In fact, having several such interacting attributes is more likely the norm than the exception among many persons living with HIV. Although it is clear that these factors interact to perpetuate smoking as well as other detrimental health behaviors among persons living with HIV, it is less clear how to intervene effectively.

Certainly, among the available evidenced-based smoking cessation strategies, multifaceted biobehavioral approaches will likely have the greatest potential for success. Available models used to guide the design of smoking cessation interventions largely center on motivation to quit. Interventions guided by these models use psychoeducational strategies that focus on stimulating interest and self-efficacy to quit and pharmacotherapy to diminish nicotine withdrawal. This approach is relevant to persons living with HIV as suggested by the scant information currently available. However, research is needed to further a more nuanced conceptual understanding of the interacting biobehavioral and environmental mechanisms that influence the smoking behavior of persons living with HIV. Given the complexity of factors that influence the smoking behavior among many persons living with HIV, it would appear that to enhance overall success, alternate models may need to be considered that take significant cofactors into account that are not well addressed by available strategies.

Additional research is needed that not only tests models that guide interventions targeting single risk behaviors such as cigarette smoking, but that inform the development of models that guide the sequence of treatment when several health problems coexist (e.g., psychiatric, substance use, and medical disorders) and inform the extent to which concurrent, interacting risk behaviors should be treated in tandem. For example, incorporation of observations acquired in neurobiological research may prove fruitful. An improved understanding of addictive behavior in concert with biologic and environmental elements has the potential to enhance and eventually guide selection of the most appropriate therapy personalized to the individual.

Adaptation of models (e.g., self-regulation as described in this review) that have been used in the development of interventions to support improvement of other important health behaviors of persons living with HIV such as adherence may also be useful. Nonadherence to antiretroviral therapy cooccurs with other risk behaviors and there are common correlates (e.g., substance use and depression). This suggests that intervention elements designed to address HIV treatment nonadherence may be also be effective in reducing other risk behaviors or indicate the potential of an integrated intervention approach that concurrently addresses adherence and other risk behaviors. This may ultimately render a more effective treatment approach and may prove to be a more clinically feasible, viable approach for translation into health care settings.

Finally, although the complex biological, psychological, and social lives of many persons living with HIV invite innovations in interventions that target the individual, the systematic integration of treatment into HIV health care settings may prove to be one of the primary challenges in effecting successful smoking cessation treatment. There is a need to enhance resources and models of HIV care that maximize the ability of providers to prioritize and address primary and secondary prevention as well as the acute care management of comorbidities to improve the long-term health status and quality of life outcomes of persons living with HIV.

In conclusion, smoking cessation treatment for persons living with HIV has been low or absent on the health agendas of HIV researchers and providers despite the fact that an unusually high number of persons living with HIV smoke and are at risk for accelerated development of significant comorbidities. Scientific and ethical considerations urge an improved understanding and inclusion of effective smoking cessation treatment in contemporary models of HIV care. Health policy and integrated, comprehensive practice models informed by research that is both clinically relevant and internally valid is needed.

Acknowledgments

Support for this study came from the following sources: NIH, NHLBI, R01HL090313; NIH, NIAID, Adult AIDS Clinical Trials Group, AI38858, AI069419; NIH, NIMH, R01 MH078773; and NIH, NINR, T32NR008346, R01NR005108.

The author acknowledges the principal investigator of R01HL090313, Philip Diaz, MD, and coinvestigator, Mary Ellen Wewers, PhD, MPH, for her long-term support and advocacy for smoking cessation treatment targeting persons living with HIV. She also thanks the National Institutes of Health, NIAID, NIDA, NCI, and FIC for hosting the “Current Issues in Cigarette Smoking and HIV/AIDS Workshop,” October 9, 2007, to highlight the important understudied issues related to cigarette smoking among HIV-infected persons.

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