Cigarette smoking is more common in people infected with HIV (40% to 70%) than in the general U.S. population (19.8%),1-3 and it is an important modifiable risk factor for cardiovascular and pulmonary disease.4 Until the advent of antiretroviral therapy (ART), HIV-infected smokers did not expect to live long enough to develop these conditions.5 Advances in treatment have increased life expectancy for people living with HIV, making smoking cessation an important priority.
HIV-infected smokers are at greater risk for chronic diseases associated with tobacco use (Table 1).1,3,8,10-14 Cardiovascular disease (CVD) risk is particularly high for HIV-infected smokers on ART, because both antiretroviral medication and smoking elevate this risk.1,3 Smoking also undercuts the effects of ART, reducing viral suppression and immunologic response.2,6,7 People with HIV who smoke significantly increase their risk for AIDS-defining opportunistic infections and HIV-associated malignancies - even if they take highly active antiretroviral therapy (HAART)7,8 Finally, smoking is an independent risk factor for poor ART adherence.7,9
Smoking also increases mortality in people with HIV. In a study of women taking HAART, those who smoked within the previous 6 months had 50% higher mortality than nonsmokers.7 Other studies found that middle-aged Americans with HIV15 and aging HIV-infected veterans11 experienced mortality that was more than twice as high as that in current smokers who were not HIV positive.
HIV-infected smokers can reduce some morbidity and mortality risks by quitting. Former smokers are significantly less likely than current smokers to develop CVD, bacterial pneumonia and cancers unrelated to AIDS.8,10,12 Several longitudinal studies of people with HIV documented significantly lower mortality in former vs. current smokers.8,11,15
Barriers to Cessation
Next to the initiation of appropriate ART regimens, smoking cessation may be the single most important intervention for improving long-term survival and quality of life in people infected by HIV.16 But healthcare providers have not consistently addressed cessation as a high-priority concern.2 In one U.S. survey, 97% of HIV medical care providers agreed it was important for HIV-infected smokers to quit, but fewer than half routinely provided self-help smoking cessation materials, recommended quitlines or prescribed pharmacologic cessation aids.17 In a study of New York City healthcare professionals, 95% agreed that addressing nicotine addiction in HIV-infected patients was important, but fewer than 70% consistently assessed current or previous tobacco use in these patients, and just more than half offered individual cessation counseling or provided nicotine replacement therapy (NRT).18
Providers in these studies identified many system barriers, including: competition from health issues perceived as more urgent; overloaded appointment schedules; cost and reimbursement issues impeding access to therapy; limited provider knowledge of smoking cessation treatments; doubts about treatment efficacy; and low provider confidence in the ability to deliver treatment successfully.2,17,18 Despite evidence that many HIV-infected smokers are interested in quitting and have tried to quit,1,18,19 many providers also perceived HIV-infected smokers as uninterested in or resistant to smoking cessation.18
Clinical factors strongly linked to tobacco use in the general population (especially depression and co-occurring alcohol and/or illicit drug abuse) present additional barriers to quitting for HIV-infected people.2,3,5 Psychiatric comorbidity and substance abuse are so prevalent among people with HIV that cessation interventions that do not address these issues are unsuitable for this population.19 Other factors that reinforce tobacco use (low socioeconomic status, high stress, low self-efficacy and social networks comprised primarily of smokers) are disproportionately common in people with HIV.2,3
Helping HIV-Infected Smokers Quit
Provider-initiated cessation counseling improves smoker quit rates, and even brief counseling sessions are effective if repeated.4 HIV-infected patients visit healthcare settings often, so clinicians who care for smokers with HIV are well-positioned to help them quit.2. However, even under the best of circumstances, success rates are rather low. Multiple quit attempts and relapses are typical.4 How, then, can NPs and PAs help patients with HIV stop smoking?
The "5 A's" (Ask, Advise, Assess, Assist, Arrange), a tool recommended by the U.S. clinical practice guidelines for tobacco cessation,4 provides a starting point.6 Within this framework, healthcare providers can incorporate brief counseling sessions, pharmacotherapy and referral to more intensive cessation programs (such as state quitlines).4 The guidelines recommend the 5 A's as a standardized approach for promoting smoking cessation in all populations.4 But few HIV specialists use this framework when discussing smoking with their patients.17
Because the guidelines present the 5 A's in a context that focuses on smoking as a single health issue, clinicians may perceive this approach as having limited applicability to patients with multiple complex health issues. However, training HIV clinic staff in this model can improve quit rates.20 For best results, the framework should be tailored to HIV-infected smokers by including systematic assessment of highly prevalent comorbidities that are recognized barriers to successful smoking cessation (psychiatric conditions; drug and alcohol abuse)5 and addressing these comorbidities with individualized cessation strategies.9
Adapting the 5 A's
Ask. Smoking status can be determined while reviewing medical history or obtaining vital signs.4,6 Ask if patients currently smoke or used to smoke, ask former smokers when and how they quit, and ask current and former smokers how long they smoked and how many packs per day. Document responses,20 flagging those of current and former smokers with chart reminders to check smoking status at subsequent visits.21 Conclude this step for nonsmokers and former smokers by congratulating them on their healthy choice. With current smokers, proceed to the "Advise" step.
National guidelines advise providers to review smoking status for every patient at each visit.4 However, generic repetition of this procedure may not be in the best interest of HIV-infected patients seeking urgent treatment for other medical issues. It also could alienate lifelong nonsmokers who might interpret repeated queries as evidence that the clinician disregarded their initial response. Implementing each step in the 5 A's requires sensitivity to each patient's unique circumstances and complex health concerns.
Advise. Using clear, strong, specific, personalized language, advise HIV-infected smokers to quit.4,6 Remind them that smoking puts them at high risk for poor health outcomes. Use statements such as, "Smoking makes your antiretroviral medication less effective" or "Continuing to smoke increases your risk for AIDS-defining infections like recurrent pneumonia." Next, assess desire and ability to quit.
Assess. Evaluate the HIV-infected smoker's nicotine dependence, tobacco use patterns and motivation to quit.20 Then, screen for comorbid depression and alcohol or illicit drug abuse,5 which are common in this population and strongly associated with continued smoking, inability to quit and post-cessation relapse.2,9 Evaluate other potential barriers to quitting,21 such as inadequate access to and coverage for cessation treatment, weak social support, patient beliefs that reinforce smoking behavior, and reliance on smoking to cope with stressful circumstances or self-manage pain 2,5 If patients are interested in quitting and willing to try, proceed to the "Assist" step. For patients unwilling to stop smoking, the "5 R's" (discussing Relevant reasons to quit, Risks of smoking, Rewards of quitting, Roadblocks to quitting, and Repeating these messages during subsequent visits) may help build motivation to quit.4
Assist. All smoking cessation plans should include pharmacotherapy (unless medically contraindicated) and behavioral interventions.4 Work with the patient to tailor an individualized quit plan that provides both access to appropriate medication and counseling to address previously identified barriers to cessation.2 Counseling should include education and encouragement as well as behavioral training to help patients identify situations that trigger smoking and develop effective coping strategies.4 The "Assist" step concludes with patient and provider setting a quit date.4
Arrange. With the quit plan in place, arrange to provide continued support through clinical appointments or phone contact: within a week, within a month and additionally as needed.4 At each follow-up, congratulate patients who have not smoked since the previous contact, and help those who have been less successful develop strategies to overcome ongoing challenges and barriers.6
First-line medications for smoking cessation include five NRT modalities and two non-nicotine medications.4 Consult Belcon's recent review in ADVANCE for NPs & PAs21 for information about dosage, duration, cost and common adverse effects for each treatment.
NRT provides small doses of nicotine to replace the nicotine that a patient previously received by smoking; it is available over the counter as chewing gum, lozenges and transdermal patches, and by prescription in nicotine inhalers and nicotine nasal sprays.4,6,21 Bupropion SR (Zyban) and varenicline (Chantix) pills are available by prescription only. In small clinical trials with HIV-infected smokers, both bupropion (n = 21)22 and varenicline (n = 36)16 showed promise as cessation aids. Bupropion is indicated for smoking cessation and the treatment of depression. It can be combined with NRT and may be helpful for some depressed HIV-infected smokers.6,9 Some antiretrovirals inhibit bupropion metabolism in vitro, but no clinically significant interactions have been reported in HIV-infected patients taking bupropion while on ART.1,22 Varenicline appears to be more effective for cessation than NRT or bupropion; medication interactions have not been reported in patients on ART,1 and in one trial it improved CD4 counts in HIV-infected smokers.16 However, varenicline must be used with caution if kidney function is impaired,6 and its use increases the risk of adverse cardiovascular events.16
Both varenicline and bupropion carry "black box" warnings that psychiatric adverse events may occur when they are used for smoking cessation.23 Comparing adverse-event reports of self-injury, suicidal behavior and serious depression for both medications and NRT, Moore and colleagues found somewhat higher risk with bupropion and much higher risk with varenicline. They concluded that varenicline could no longer be considered suitable for first-line use.23 Because psychiatric comorbidity is common in HIV-infected smokers, psychiatric symptoms must be carefully monitored when using bupropion to promote cessation, and varenicline should be avoided altogether.
Strategies for HIV-Infected Smokers
Interventions combining NRT with education and behavioral training have helped HIV-infected smokers quit (Table 2).1,24,25 A particularly promising approach supplemented NRT-based standard treatment by providing prepaid cell phones and delivering ongoing counseling through regularly scheduled phone calls. Smokers receiving supplemental cell phone counseling were 3.6 times more likely to quit, had 20% higher biochemically verified abstinence after three months, and experienced less depression and anxiety than those on standard treatment.
HIV-infected patients have a high prevalence of smoking and are particularly vulnerable to its adverse health outcomes. In this population, the number and magnitude of barriers to cessation are challenging. NPs and PAs can help HIV-infected smokers quit by combining counseling and pharmacotherapy in a patient-centered approach tailored to each person's unique circumstances.
1. Nahvi S, Cooperman NA. The need for smoking cessation among HIV-positive smokers. AIDS Educ Prev. 2009;21(3 Suppl):14-27.
2. Reynolds NR. Cigarette smoking and HIV: more evidence for action. AIDS Educ Prev. 2009;21(3 Suppl):106-121.
3. Vidrine DJ. Cigarette smoking and HIV/AIDS: health implications, smoker characteristics and cessation strategies. AIDS Educ Prev. 2009;21(3 Suppl):3-13.
4. Fiore MC, et al. Treating tobacco use and dependence: 2008 update. Clinical Practice Guideline. Rockville, MD: Agency for Healthcare Research and Quality (AHRQ); 2008. http://www.ahrq.gov/clinic/tobacco/treating_tobacco_use08.pdf
5. Burkhalter JE, et al. Tobacco use and readiness to quit smoking in low-income HIV-infected persons. Nicotine Tob Res. 2005;7(4):511-522.
6. Bouchard-Miller K, et al. Smoking cessation for persons living with HIV: a review of currently available interventions. J Assoc Nurses AIDS Care. 2010;21(1):3-10.
7. Feldman JG, et al. Association of cigarette smoking with HIV prognosis among women in the HAART era: a report from the Women's Interagency HIV study. Am J Public Health. 2006;96(6):1060-1065.
8. Lifson AR, et al. Smoking-related health risks among persons with HIV in the Strategies for Management of Antiretroviral Therapy clinical trial. Am J Public Health. 2010;100(10):1896-1903.
9. Webb MS, et al. Medication adherence in HIV-infected smokers: the mediating role of depressive symptoms. AIDS Educ Prev. 2009;21(3 Suppl):94-105.
10. Petoumenos K, et al. Rates of cardiovascular disease following smoking cessation in patients with HIV infection: results from the D:A:D study. HIV Med. 2011;12(7):412-421.
11. Crothers K, et al. Impact of cigarette smoking on mortality in HIV-positive and HIV-negative veterans. AIDS Educ Prev. 2009;21(3 Suppl):40-53.
12. Bénard A, et al. Bacterial pneumonia among HIV-infected patients: decreased risk after tobacco smoking cessation. ANRS CO3 Aquitaine Cohort, 2000-2007. PLoS One. 2010;5(1):e8896.
13. Vidrine DJ, et al. A randomized trial of a proactive cellular telephone intervention for smokers living with HIV/AIDS. AIDS. 2006;20(2):253-260.
14. Míguez-Burbano MJ, et al. Ignoring the obvious missing piece of chronic kidney disease in HIV: cigarette smoking. J Assoc Nurses AIDS Care. 2010;21(1):16-24.
15. Cockerham L, et al. Association of HIV infection, demographic and cardiovascular risk factors with all-cause mortality in the recent HAART era. J Acquir Immune Defic Syndr. 2010;53(1):102-106.
16. Cui Q, et al. Safety and tolerability of varenicline tartrate (Champix®/Chantix®) for smoking cessation in HIV-infected subjects: A pilot open-label study. AIDS Patient Care STDs. 2012;26(1):2-19.
17. Shuter J, et al. Provider beliefs and practices relating to tobacco use in patients living with HIV/AIDS: a national survey. AIDS Behav. 2011;16(2):288-294.
18. Tesoriero JM, et al. Smoking among HIV positive New Yorkers: prevalence, frequency, and opportunities for cessation. AIDS Behav. 2010;14(4):824-835.
19. Bénard A, et al. Tobacco addiction and HIV infection: toward the implementation of cessation programs. ANRS CO3 Aquitaine Cohort. AIDS Patient Care STDs. 2007;21(7):458-468.
20. Zwiebel MA, et al. Smoking cessation efforts in one New York City HIV clinic. J Assoc Nurses AIDS Care. 2010;21(1):11-15.
21. Belcon AL. Smoking cessation pharmacotherapy: a concise overview. Adv NPs PAs. 2011;2(4):33-34.
22. Pedrol-Clotet E, et al. [Bupropion use for smoking cessation in HIV-infected patients receiving antiretroviral therapy] (in Spanish). Enferm Infecc Microbiol Clin. 2006;24(8):509-511.
23. Moore TJ, et al. Suicidal behavior and depression in smoking cessation treatments. PLoS One. 2011;6(11):e27016.
24. Ingersoll KS, et al. A test of motivational plus nicotine replacement interventions for HIV positive smokers. AIDS Behav. 2009;13(3):545-554.
25. Lloyd-Richardson EE, et al. Motivation and patch treatment for HIV+ smokers: a randomized controlled trial. Addiction. 2009;104(11):1891-900.
John M. Brion is an assistant professor at Duke University School of Nursing in Durham, N.C. Julie Barroso is an adult nurse practitioner who is a professor at Duke University School of Nursing. Elizabeth P. Flint is a research analyst at Duke University School of Nursing. Elizabeth Manly is a nurse at Durham Regional Hospital in Durham. Meghan Worley is a nurse at the University of North Carolina Hospital in Chapel Hill. The authors have completed disclosure statements and report no relationships related to this article.