Data indicate that people living with HIV smoke tobacco at a rate that is nearly three times that of the general population. Smoking significantly impacts the progression and outcome of HIV disease, and has been identified as a leading contributor to premature mortality among people with HIV. “It is clear that the single greatest health behavior change that could reduce mortality in this patient population is smoking cessation,” says Seth Himelhoch, MD, MPH.
According to Dr. Himelhoch, the two main treatment strategies to assist people with quitting smoking are medication and behavioral interventions. “Behavioral interventions are effective in the general population for smoking cessation,” he says. “However, over the last decade, we’re increasingly recognizing that more tailored behavioral approaches that acknowledge the high burden of mental health and substance abuse problems among people with HIV may be needed to improve quit rates.”
An In-Depth Review
For a study published in the Journal of Acquired Immune Deficiency Syndromes, Dr. Himelhoch and colleagues conducted a systematic review and meta-analysis to address whether or not behavioral interventions aimed at smoking cessation can help increase smoking abstinence as measured by expired carbon monoxide (ECO) 7-day point prevalence abstinence (PPA) rates among HIV-infected smokers. The authors analyzed eight randomized controlled studies conducted between January 1980 and February 2016. These investigations included a total of 1,822 subjects.
All of the studies in the analysis included nicotine replacement therapy as part of the intervention. Study interventions ranged from four to 11 sessions, with five of the studies including at least eight sessions. Behavioral interventions took the form of telephone counseling in three studies, group therapy in one study, computer-based interventions in two studies, and individual therapy in three studies. All studies had a primary endpoint of ECO-verified 7-day PPA and compared the intervention with brief counseling or self-help control conditions (usual care).
“The most important finding from our research was that behavioral smoking cessation interventions were in fact efficacious in many cases,” says Dr. Himelhoch. Three of the eight trials that were reviewed in the analysis reported treatment efficacy. One study showed that a nurse-managed, peer-led, smoking cessation intervention led to a statistically significant increase in abstinence from smoking at 8 weeks when compared with usual care (Table). Two studies found statistically significant increases in abstinence at 3 months among patients randomized to telephone intervention groups when compared with usual care.
Dr. Himelhoch notes that five trials did not show treatment efficacy for the studied intervention. One study that compared motivational enhancement with standard care found no difference in smoking abstinence rates at 6 months. Researchers who compared computer- and web-based interventions to usual care in two other studies also found no differences in abstinence rates. In addition, investigators observed no differences in abstinence rates at 3 months when group therapy and four in-person sessions were compared with usual care in two other studies.
Although web-based interventions offer flexibility in scheduling and tend to be less expensive, the two web-based studies in the meta-analysis had non-significant results. One of the trials found that a higher educational level was associated with more web page visits and higher rates of quitting smoking, suggesting that literacy or web experience may be important predictors of success with web-based interventions, according to Dr. Himelhoch and colleagues.
Other research suggests that peer-based interventions may bridge potential barriers relating to language, culture, and class, which may help explain why they were successful in the review and have appeared to be promising in other areas of research. Interventions involving peer support specialists yielded statistically significant large effect sizes in one of the two trials that assessed them, suggesting that they may provide a particularly promising means for delivering targeted behavioral interventions in HIV-infected smokers, says Dr. Himelhoch.
“Abstinence for people with HIV who smoke may be difficult but not impossible to achieve,” Dr. Himelhoch notes. “However, behavioral interventions—especially those that are more tailored to the needs of those with HIV—are likely to double abstinence rates. Interventions consisting of eight or more sessions appeared to have the greatest treatment efficacy.”
Results of the study suggest that there are several effective treatment interventions for people living with HIV who smoke and want to quit, according to Dr. Himelhoch. “The key is to raise awareness of these options among clinicians. Healthcare providers also need to continue to screen for smoking behaviors consistently and provide advice about the benefit of quitting. In addition, clinicians need to actively assess readiness to quit and offer treatments for those who are ready to quit. In many cases, people with HIV who smoke generally want to quit. We need to be responsive to this issue because of its enormous impact on the health and well-being of our patients.”
Readings & Resources (click to view)
Asheena K, Yuelei D, Jonathan S, Himelhoch S. Behavioral interventions for tobacco use in HIV-infected smokers: a meta-analysis. JAIDS. 2016;72:527-533. Available at
Burkhalter J, Springer C, Chhabra ROstroff J, Rapkin B. Tobacco use and readiness to quit smoking in low-income HIV-infected persons. Nicotine Tob Res. 2005;7:511-522.
Kwong J, Bouchard-Miller K. Smoking cessation for persons living with HIV: a review of currently available interventions. J Assoc Nurses AIDS Care. 2010;21:3-10.
Lifson A, Lando H. Smoking and HIV: prevalence, health risks, and cessation strategies. Curr HIV/AIDS Rep. 2012;9:223-230.
Mamary E, Bahrs D, Martinez S. Cigarette smoking and the desire to quit among individuals living with HIV. AIDS Patient Care STDS. 2002;16:39-42.