A pilot study of screening, brief intervention, and referral for treatment (SBIRT) in non-treatment seeking smokers with HIV

Interventions for tobacco use cessation in people living with HIV

BACKGROUND

The prevalence of tobacco use among people living with HIV (PLWH) is up to four times higher than in the general population. Unfortunately, tobacco use increases the risk of progression to AIDS and death. Individual- and group-level interventions, and system-change interventions that are effective in helping PLWH stop using tobacco can markedly improve the health and quality of life of this population. However, clear evidence to guide policy and practice is lacking, which hinders the integration of tobacco use cessation interventions into routine HIV care. This is an update of a review that was published in 2016. We include 11 new studies.

OBJECTIVES

To assess the benefits, harms and tolerability of interventions for tobacco use cessation among people living with HIV. To compare the benefits, harms and tolerability of interventions for tobacco use cessation that are tailored to the needs of people living with HIV with that of non-tailored cessation interventions.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group's Specialised Register, CENTRAL, MEDLINE, Embase, and PsycINFO in December 2022.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) of individual-/group-level behavioural or pharmacological interventions, or both, for tobacco use cessation, delivered directly to PLWH aged 18 years and over, who use tobacco. We also included RCTs, quasi-RCTs, other non-randomised controlled studies (e.g. controlled before and after studies), and interrupted time series studies of system-change interventions for tobacco use cessation among PLWH. For system-change interventions, participants could be PLWH receiving care, or staff working in healthcare settings and providing care to PLWH; but studies where intervention delivery was by research personnel were excluded. For both individual-/group-level interventions, and system-change interventions, any comparator was eligible.

DATA COLLECTION AND ANALYSIS

We followed standard Cochrane methods, and used GRADE to assess certainty of the evidence. The primary measure of benefit was tobacco use cessation at a minimum of six months. Primary measures for harm were adverse events (AEs) and serious adverse events (SAEs). We also measured quit attempts or quit episodes, the receipt of a tobacco use cessation intervention, quality of life, HIV viral load, CD4 count, and the incidence of opportunistic infections.

MAIN RESULTS

We identified 17 studies (16 RCTs and one non-randomised study) with a total of 9959 participants; 11 studies are new to this update. Nine studies contributed to meta-analyses (2741 participants). Fifteen studies evaluated individual-/group-level interventions, and two evaluated system-change interventions. Twelve studies were from the USA, two from Switzerland, and there were single studies for France, Russia and South Africa. All studies focused on cigarette smoking cessation. All studies received funding from independent national- or institutional-level funding. Three studies received study medication free of charge from a pharmaceutical company. Of the 16 RCTs, three were at low risk of bias overall, five were at high risk, and eight were at unclear risk. Behavioural support or system-change interventions versus no or less intensive behavioural support Low-certainty evidence (7 studies, 2314 participants) did not demonstrate a clear benefit for tobacco use cessation rates in PLWH randomised to receive behavioural support compared with brief advice or no intervention: risk ratio (RR) 1.11, 95% confidence interval (CI) 0.87 to 1.42, with no evidence of heterogeneity. Abstinence at six months or more was 10% (n = 108/1121) in the control group and 11% (n = 127/1193) in the intervention group. There was no evidence of an effect on tobacco use cessation on system-change interventions: calling the quitline and transferring the call to the patient whilst they are still in hospital ('warm handoff') versus fax referral (RR 3.18, 95% CI 0.76 to 13.99; 1 study, 25 participants; very low-certainty evidence). None of the studies in this comparison assessed SAE. Pharmacological interventions versus placebo, no intervention, or another pharmacotherapy Moderate-certainty evidence (2 studies, 427 participants) suggested that varenicline may help more PLWH to quit smoking than placebo (RR 1.95, 95% CI 1.05 to 3.62) with no evidence of heterogeneity. Abstinence at six months or more was 7% (n = 14/215) in the placebo control group and 13% (n = 27/212) in the varenicline group. There was no evidence of intervention effects from individual studies on behavioural support plus nicotine replacement therapy (NRT) versus brief advice (RR 8.00, 95% CI 0.51 to 126.67; 15 participants; very low-certainty evidence), behavioural support plus NRT versus behavioural support alone (RR 1.47, 95% CI 0.92 to 2.36; 560 participants; low-certainty evidence), varenicline versus NRT (RR 0.93, 95% CI 0.48 to 1.83; 200 participants; very low-certainty evidence), and cytisine versus NRT (RR 1.18, 95% CI 0.66 to 2.11; 200 participants; very low-certainty evidence). Low-certainty evidence (2 studies, 427 participants) did not detect a difference between varenicline and placebo in the proportion of participants experiencing SAEs (8% (n = 17/212) versus 7% (n = 15/215), respectively; RR 1.14, 95% CI 0.58 to 2.22) with no evidence of heterogeneity. Low-certainty evidence from one study indicated similar SAE rates between behavioural support plus NRT and behavioural support only (1.8% (n = 5/279) versus 1.4% (n = 4/281), respectively; RR 1.26, 95% CI 0.34 to 4.64). No studies assessed SAEs for the following: behavioural support plus NRT versus brief advice; varenicline versus NRT and cytisine versus NRT.

AUTHORS' CONCLUSIONS

There is no clear evidence to support or refute the use of behavioural support over brief advice, one type of behavioural support over another, behavioural support plus NRT over behavioural support alone or brief advice, varenicline over NRT, or cytisine over NRT for tobacco use cessation for six months or more among PLWH. Nor is there clear evidence to support or refute the use of system-change interventions such as warm handoff over fax referral, to increase tobacco use cessation or receipt of cessation interventions among PLWH who use tobacco. However, the results must be considered in the context of the small number of studies included. Varenicline likely helps PLWH to quit smoking for six months or more compared to control. We did not find evidence of difference in SAE rates between varenicline and placebo, although the certainty of the evidence is low.

Patient-reported outcome measures in adult HIV care: A rapid scoping review of targeted outcomes and instruments used

OBJECTIVE

There is international interest in the integration of patient-reported outcome measures (PROMs) into routine HIV care, but little work has synthesized the content of published initiatives. We conducted a rapid scoping review primarily to identify their selected patient-reported outcomes and respective instruments.

METHODS

Four databases were searched on 4 May 2022 (Medline, Embase, CINAHL and PsychINFO) for relevant English language documents published from 2005 onwards. Dual review of at least 20% of records, full texts and data extraction was performed. Outcomes and instruments were classified with an adapted 14-domain taxonomy. Instruments with evidence of validation were described.

RESULTS

Of 13 062 records generated for review, we retained a final sample of 94 documents, referring to 60 distinct initiatives led mostly in the USA (n = 29; 48% of initiatives), Europe (n = 16; 27%) and Africa (n = 9; 15%). The measured patient-reported outcome domains were: mental health (n = 42; 70%), substance use (n = 23; 38%), self-management (n = 16; 27%), symptoms (n = 12; 20%), sexual/reproductive health (n = 12; 20%), physical health (n = 9; 15%), treatment (n= 8; 13%), cognition (n = 7; 12%), quality of life (n = 7; 12%), violence/abuse (n = 6; 10%), stigma (n = 6; 10%), socioeconomic issues (n = 5; 8%), social support (n = 3; 5%) and body/facial appearance (n = 1; 2%). Initiatives measured 2.6 outcome domains, on average (range = 1-11). In total, 62 distinct validated PROMs were identified, with 53 initiatives (88%) employing at least one (M = 2.2). Overwhelmingly, the most used instrument was any version of the Patient Health Questionnaire to measure symptoms of depression, employed by over a third (26; 43%) of initiatives.

CONCLUSION

Published PROM initiatives in HIV care have spanned 19 countries and disproportionately target mental health and substance use.

Design and rationale of the Botswana Smoking Abstinence Reinforcement Trial: a protocol for a stepped-wedge cluster randomized trial

BACKGROUND

With expanded and sustained availability of HIV treatment resulting in substantial improvements in life expectancy, the need to address modifiable risk factors associated with leading causes of death among people living with HIV/AIDS (PLWH), such as tobacco smoking, has increased. Tobacco use is highly prevalent among PLWH, especially in southern Africa, where HIV is heavily concentrated, and many people who smoke would like to quit but are unable to do so without assistance. SBIRT (Screening, Brief Intervention and Referral to Treatment) is a well-established evidence-based approach successful at supporting smoking cessation in a variety of settings. Varenicline is efficacious in supporting smoking cessation. We intend to assess the effectiveness of SBIRT and varenicline on smoking cessation among PLWH in Botswana and the effectiveness of our implementation.

METHODS

BSMART (Botswana Smoking Abstinence Reinforcement Trial) is a stepped-wedge, cluster randomized, hybrid Type 2 effectiveness-implementation study guided by the RE-AIM framework, to evaluate the effectiveness and implementation of an SBIRT intervention consisting of the 5As compared to an enhanced standard of care. SBIRT will be delivered by trained lay health workers (LHWs), followed by referral to treatment with varenicline prescribed and monitored by trained nurse prescribers in a network of outpatient HIV care facilities. Seven hundred and fifty people living with HIV who smoke daily and have been receiving HIV care and treatment at one of 15 health facilities will be recruited if they are up to 18 years of age and willing to provide informed consent to participate in the study.

DISCUSSION

BSMART tests a scalable approach to achieve and sustain smoking abstinence implemented in a sustainable way. Integrating an evidence-based approach such as SBIRT, into an HIV care system presents an important opportunity to establish and evaluate a modifiable cancer prevention strategy in a middle-income country (MIC) setting where both LHW and non-physician clinicians are widely used. The findings, including the preliminary cost-effectiveness, will provide evidence to guide the Botswanan government and similar countries as they strive to provide affordable smoking cessation support at scale.

CLINICAL TRIAL REGISTRATION

NCT05694637 Registered on 7 December 2022 on clinicaltrials.gov, https://clinicaltrials.gov/search?locStr=Botswana&country=Botswana&cond=Smoking%20Cessation&intr=SBIRT.

The Effect of a Tobacco Use Reduction Program on the Prevalence of Smoking and Tobacco Use and Quitting Behavior Among People Living With HIV/AIDS in Michigan

HIV has evolved from a serious infectious disease to a manageable chronic disease. Tobacco use has a devastating effect on the health of people living with HIV/AIDS (PLWH). The Michigan Tobacco Use Reduction Program for PLWH was established in 2015 to learn about tobacco use among PLWH, gather information on entities that provide health care services to PLWH, and improve tobacco treatment services for this population. The program offers evidence-based treatment interventions to all PLWH who are tobacco users, eligible for the Ryan White HIV/AIDS Program, and served by AIDS service organizations in Michigan. This evaluation had 3 primary outcomes: 1) rates of smoking and tobacco use among program clients, 2) the percentage of clients who made a quit attempt in the previous 12 months, and 3) the types of tobacco cessation methods used by clients. All data were self-reported in 3 surveys, one each in 2015, 2017, and 2021. The rate of cigarette smoking overall among clients decreased significantly from 49.5% in 2015 to 41.5% in 2017. The percentage of clients who made a quit attempt increased from 37.0% in 2015 to 41.9% in 2017; in 2021, this rate was 54.4%. By age, in all 3 survey years, the highest rate of tobacco use was among clients aged 35 to 44 years (range, 48.4%-57.4%). Smoking rates declined significantly from 2015 to 2017 among African American (50.5% to 42.8%) and White clients (49.8% to 39.9%). The most frequently used method of tobacco cessation was medications prescribed by a physician (range, 20%-30%). State tobacco control programs are encouraged to collaborate with their state HIV/AIDS bureaus to create similar programs to treat tobacco use among PLWH.

Screening, brief intervention, and referral to treatment for tobacco consumption, alcohol misuse, and physical inactivity: an equity-informed rapid review

OBJECTIVE

This rapid review systematically synthesizes evidence of the effectiveness of the Screening, Brief Intervention, and Referral (SBIR/T) approach for tobacco use, alcohol misuse, and physical inactivity.

STUDY DESIGN

This was a rapid review.

METHODS

We searched primary studies between 2012 and 2022 in seven electronic databases. The search strategy used concepts related to alcohol-related disorders, intoxication, cigarette, nicotine, physical activity, exercise, sedentary, screening, therapy, and referral. We reviewed both title/abstract and full-text using a priori set inclusion and exclusion criteria to identify the eligible studies. We appraised study quality, extracted data, and summarized the characteristics of the included studies. We applied health equity lenses in the synthesis.

RESULTS

Of the 44 included studies, most focused on alcohol misuse. SBIR/T improved patients' attitudes toward alcohol behavior change, improved readiness and referral initiation for change, and effectively reduced alcohol consumption. Few studies pertained to smoking and physical inactivity. Most studies on smoking demonstrated effectiveness pertaining to patients' acceptance of referral recommendations, improved readiness and attempts to quitting smoking, and reduced or cessation of smoking. Findings were mixed about the effectiveness of SBIR/T in improving physical activity. Minimal studies exist on the impacts of SBIR/T for these three risk factors on healthcare resource use or costs. Studies considering diverse population characteristics in the design and effectiveness assessment of the SBIR/T intervention are lacking.

CONCLUSIONS

More research on the impacts of SBIR/T on tobacco use, alcohol misuse, and physical inactivity is required to inform the planning and delivery of SBIR/T for general and disadvantaged populations.

COPD in People with HIV: Epidemiology, Pathogenesis, Management, and Prevention Strategies

Chronic obstructive pulmonary disease (COPD) is a progressive respiratory disorder characterized by airflow limitation and persistent respiratory symptoms. People with HIV (PWH) are particularly vulnerable to COPD development; PWH have demonstrated both higher rates of COPD and an earlier and more rapid decline in lung function than their seronegative counterparts, even after accounting for differences in cigarette smoking. Factors contributing to this HIV-associated difference include chronic immune activation and inflammation, accelerated aging, a predilection for pulmonary infections, alterations in the lung microbiome, and the interplay between HIV and inhalational toxins. In this review, we discuss what is known about the epidemiology and pathobiology of COPD among PWH and outline screening, diagnostic, prevention, and treatment strategies.

Tobacco Harm Reduction with Vaporised Nicotine (THRiVe): A Feasibility Trial of Nicotine Vaping Products for Smoking Cessation Among People Living with HIV

People living with HIV (PLHIV) have high rates of tobacco smoking. Nicotine vaping products (NVPs) may promote tobacco smoking cessation and/or harm reduction. This study aimed to trial the feasibility of NVPs for promoting tobacco smoking cessation among PLHIV. The Tobacco Harm Reduction with Vaporised Nicotine (THRiVe) study was a mixed-methods trial among 29 PLHIV who used tobacco daily. Participants trialled a 12-week intervention of NVPs. This study reports descriptive analyses of quantitative data on tobacco abstinence and associated adverse events. Short-term abstinence (7-day point prevalence; i.e., no tobacco use for 7 days) was achieved by 35% of participants at Week 12 and 31% reported short-term abstinence at Week 24. Sustained medium-term abstinence (8 weeks' abstinence) was achieved by 15% of participants at Week 12 and 31% at Week 24. Most adverse events were mild. NVPs may represent a feasible and potentially effective short-to-medium term tobacco smoking cessation aid and/or harm reduction strategy among PLHIV.

A Review of Chronic Comorbidities in Adults Living With HIV: State of the Science

ABSTRACT

People living with HIV are living longer, high-quality lives; however, as they age, this population is at increased risk for developing chronic comorbidities, including cardiovascular disease, certain types of cancer (e.g., lung, anal, and liver), and diabetes mellitus. The purpose of this state-of-the-science review is to provide an evidence-based summary on common physical comorbidities experienced by people living and aging with HIV. We focus on those chronic conditions that are prevalent and growing and share behavioral risk factors that are common in people living with HIV. We will discuss the current evidence on the epidemiology, physiology, prevention strategies, screening, and treatment options for people living with HIV across resource settings.

Evaluation of an integrated treatment to address smoking cessation and anxiety/depressive symptoms among people living with HIV: Study protocol for a randomized controlled trial

BACKGROUND

Interventions that target anxiety/depressive symptoms in the context of smoking treatment have shown promise irrespective of psychiatric diagnosis. Yet, these tailored treatments are largely absent for persons who smoke and are living with HIV (SLWH).

OBJECTIVE

To evaluate a novel, smoking cessation intervention that addresses anxiety/depression and HIV-related health (QUIT) against a time-matched control (TMC) and a standard of care (SOC) condition.

METHODS

SLWH (N = 180) will be recruited and enrolled from 3 medical clinics in Boston, MA, and Houston, TX. The trial will consist of a baseline assessment, a 10-week intervention/assessment period, and follow-up assessments, accounting for a total study duration of approximately 8 months. All participants will complete a baseline visit and a pre-randomization standardized psychoeducation visit, and will then be randomized to one of three conditions: QUIT, TMC, or SOC. QUIT and TMC will consist of nine 60-min, cognitive behavioral therapy-based, individual weekly counseling sessions using standard smoking cessation counseling; additionally, QUIT will target anxiety and depressive symptoms by addressing underlying mechanisms related to mood and quit difficulty. SOC participants will complete weekly self-report surveys for nine weeks. All participants will be encouraged to quit at Session 7 and will be offered nicotine replacement therapy to help.

CONCLUSIONS

QUIT is designed to improve smoking cessation in SLWH by addressing anxiety and depression and HIV-related health issues. If successful, the QUIT intervention would be ready for implementation and dissemination into "real-world" behavioral health and social service settings consistent with the four objectives outlined in NIDA's Strategic Plan.

Patterns of lapses and recoveries during a quit attempt using varenicline and behavioral counseling among smokers with and without HIV

Addressing tobacco use among HIV+ smokers is a priority. Lack of knowledge about how HIV+ smokers respond to tobacco use treatments limits our ability to effectively treat this population of smokers. Using data from 2 clinical trials that provided 12 weeks of varenicline and behavioral counseling, 1 with smokers with HIV (n = 89) and 1 with smokers without HIV (n = 179), we used mixed logistic regression modeling to compare point-prevalence abstinence rates and adherence to the initial target quit date (TQD) and Cox regression for repeated outcomes to evaluate lapse and recovery dynamics between the groups. Sixty percent of HIV- smokers refrained from smoking at the TQD while only 33% of HIV+ smokers did (odds ratio [OR] = 0.32, 95% CI [0.18, 0.56], p < .001). The point-prevalence abstinence rates at Week 12 were 31% (HIV-) and 28% (HIV+; OR = 0.7, 95% CI [0.42, 1.16], p = .16) and the point prevalence abstinence rates at Week 24 were 22% (HIV-) and 15% (HIV+; OR = 0.87, 95% CI [0.49, 1.57], p = .65). Although there was no interaction between HIV status and lapse risk, χ2(3) < 1, there was a significant interaction for the recovery model, (χ2(3) = 20.4, p < 0.001): as the number of events increased, the time to the next recovery became longer among smokers with HIV, compared to smokers without HIV. Although HIV+ smokers were treated effectively with varenicline, compared to HIV- smokers, they showed significantly lower initial cessation at the TQD and took increasingly longer to recover following lapses. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Smoking-Cessation Interventions in Appalachia: A Systematic Review and Meta-Analysis

CONTEXT

Appalachia, a socioeconomically disadvantaged rural region in the eastern U.S., has one of the nation's highest prevalence rates of smoking and some of the poorest health outcomes. Effective interventions that lower smoking rates in Appalachia have great potential to reduce health disparities and preventable illness; however, a better understanding of effective interventions is needed.

EVIDENCE ACQUISITION

This review included trials that evaluated the impact of smoking-cessation programs among populations living in Appalachia. The search was carried out on October 9, 2018 and comprised the Cochrane Central Register of Controlled Trials, Medline, Embase, and Scopus for academic journal articles published in English, with no date restrictions. After preliminary screening, potentially relevant full-text articles were independently reviewed by the authors with a Cohen's κ of 0.72, leading to the final inclusion of 9 articles.

EVIDENCE SYNTHESIS

Eligible studies were assessed qualitatively for heterogeneity and risk of bias. Six of the 9 included studies had extractable data related to dichotomous smoking status and reported a measure of association suitable for inclusion in a meta-analysis. For those 6 studies, the pooled RR and pooled OR were estimated using random effects models, with an I² index demonstrating substantial heterogeneity. A funnel plot of the 6 trials appeared relatively symmetric.

CONCLUSIONS

Participation in smoking-cessation interventions increased the probability of smoking abstinence among Appalachian smokers by an estimated 2.33 times (pooled RR=2.33, 95% CI=1.03, 5.25, p=0.04). Given the low number of studies, their substantial heterogeneity, and high risk of bias, the evidence of the effectiveness of smoking-cessation interventions in Appalachia must be interpreted with caution.

Substance Use Screening in HIV Care Settings: a Review and Critique of the Literature

PURPOSE OF REVIEW

People living with human immunodeficiency virus/AIDS (PLWHA) experience high prevalence of substance use disorders (SUD). HIV care settings represent a unique opportunity to identify possible SUD, to provide SUD interventions, and to improve linkage to SUD treatment. The aims of this paper are to (a) review and critique the extant literature examining substance use screening approaches among PLWHA in HIV care settings and (b) provide recommendations for future clinical practice.

RECENT FINDINGS

Twenty-one peer-reviewed articles that examined substance screening approaches employed in HIV and other primary care settings were included in the review. There was limited literature reporting on the implementation and evaluation of substance use screening practices within HIV care settings, and methodological rigor varied across studies. Further, the use of validated substance use screening measures or incorporation of other substance use screening approaches (e.g., use of urine drug testing) within routine HIV care practice is limited. Strategies to implement routine substance use screening within HIV care and incorporate additional substance use assessment, brief interventions, and referral to specialty substance use treatment are discussed. Use of self-report substance use screening measures using web- or computer-delivered approaches that can be integrated within electronic health record systems is particularly promising. HIV care practices should consider potential models to optimally screen and treat SUD. Co-location of HIV and SUD treatment services may be optimal; when co-located services are not possible, strategies to consistently provide brief intervention approaches and referrals to specialty SUD treatment are needed.

A pilot study to examine the acceptability and health effects of electronic cigarettes in HIV-positive smokers

INTRODUCTION

Some HIV-positive smokers report ambivalence about quitting. Switching to electronic cigarettes (ECs) may be a viable option to reduce the negative health effects for smokers who are unable or unwilling to quit smoking combustible cigarettes (CCs). This study examined the acceptability and health-related effects of ECs in HIV-positive smokers who were not seeking smoking cessation treatment.

METHODS

HIV-positive smokers (N = 19) were enrolled and followed for 12 weeks. Cartridge-based ECs were provided at baseline, and E-liquid was provided weekly for 8 weeks. At baseline, weeks 1-8, and week 12, EC and CC use, cardiopulmonary function, respiratory symptoms, and carbon monoxide (CO) levels were measured.

RESULTS

At week 8, cigarettes per day (CPD) were reduced by more than 80%, with reduction maintained at week 12 (p's < .001). Cigarette dependence scores were 40% lower at week 8 than at baseline (p <  .001). Seven (36.8%) participants reported transitioning completely from CCs to ECs. Mean CO decreased significantly from BL to week 8 (p < .05) and remained significantly lower at week 12 (p <  .001). Intention to quit increased significantly over time.

CONCLUSIONS

Switching from CCs to ECs in HIV-positive smokers who are not ready to quit smoking in the next 30 days appears to be feasible. Beneficial effects were seen, such as reduced CPD, reduced CO and CC dependence, and increased motivation to quit. ECs may be promising as a harm reduction approach among HIV-positive smokers who are unable or unwilling to quit smoking.

A Qualitative Systematic Review of Cigarette Smoking Cessation Interventions for Persons Living with HIV

Persons living with HIV (PLWH) have disproportionately high rates of both cigarette smoking and tobacco-induced negative health outcomes. The goal of this qualitative systematic review was to identify gaps in the existing literature and future directions for smoking cessation support for PLWH. Three online databases were searched from their inception through December 31, 2017, using designated search terms. Peer-reviewed English-language articles that documented an intervention designed to increase smoking cessation among PLWH were reviewed. Data were abstracted using a standardized form to document study and intervention characteristics and results. Thirty-two articles, describing 28 unique intervention studies, met inclusion criteria. Interventions consisted primarily of combinations of counseling, pharmacotherapy, and the use of information and communications technology; few interventions were implemented at the clinic level. Thirteen interventions resulted in significant improvements in cessation-related outcomes. Information and communications technology and clinic-level interventions had the greatest potential for increasing smoking cessation among PLWH. Efficacious interventions designed for PLWH in the US South, and for groups of PLWH facing additional health disparities (e.g., communities of color and sexual and gender minorities), are needed. There is also a need for more rigorous research designs to test the efficacy of interventions designed to increase cessation-related outcomes among PLWH.

Delivery and implementation of an algorithm for smoking cessation treatment for people living with HIV and AIDS

Compared to the general population, persons living with HIV (PLWH) have higher rates of tobacco use and an increased risk of morbidity from tobacco-related diseases. We conducted a single-arm pilot study of the real-world feasibility of integrating a smoking cessation decisional algorithm within routine clinic visits to engage non-treatment-seeking smokers in smoking cessation therapies. Smokers had an initial study visit during routine care followed by phone contacts at one and three months. Participants completed a baseline survey, followed by the algorithm which resulted in a recommendation for a smoking cessation medication, which was prescribed during the visit. Follow-up phone surveys assessed changes in smoking behavior and use of cessation medications at 1 and 3 months. Participants' (N = 60) self-reported smoking decreased from a baseline average of 14.4 cigarettes/day to 7.1 cigarettes/day at 3 months (p = .001). Nicotine dependence (FTND) decreased from 5.6 at baseline to 3.6 at 3 months (p < .001). Twenty-seven (45%) made a 24-h quit attempt and 39 (65%) used cessation medication. Insurance prior-authorization delayed medication receipt for seven participants and insurance denial occurred for one. Motivational status did not significantly influence outcomes. The algorithm was successful in engaging participants to use cessation medications and change smoking behaviors.

A pilot investigation of the effect of electronic cigarettes on smoking behavior among opioid-dependent smokers

INTRODUCTION

Compared to the general population, smoking rates are 2-4 times higher among individuals with opioid use disorders (OUDs). These smokers also have poor long-term cessation rates, even with pharmacotherapy or other interventions. Low success rates with traditional approaches may prompt smokers with OUDs to try more novel products like electronic cigarettes (ECIGs). This pilot study was designed to examine the feasibility, acceptability, and effect of ECIGs on smoking behavior among smokers with OUD.

METHODS

Participants (N = 25) were daily smokers receiving buprenorphine/naloxone for OUD at an outpatient clinic. They were randomized to use a second-generation ECIG (0 or 18 ng/ml nicotine) ad libitum for two weeks while completing assessments via text messaging daily, and also via in-person visits at baseline, end of the two-week intervention, and a 4-week follow-up.

RESULTS

Feasibility was evidenced by high enrollment (93.9%) and retention (70.9%) rates. ECIG adherence was relatively high as measured by self-report (80.6% active, 91.7% placebo), while the average volume of liquid used per week was low (~3 ml). Both ECIG doses produced reductions in self-reported cigarettes per day that were not supported by average carbon monoxide levels. Biologically-confirmed smoking abstinence was observed in 8% of participants.

CONCLUSIONS

Preliminary results suggest that smokers with OUD are interested in using ECIGs, but their adherence may be less than ideal. Poor medication adherence rates are often observed in this disparate population, and future work should consider the use of other ECIG device types and a combination of methods to verify and quantify ECIG use.

Study protocol testing toolkit versus usual care for implementation of screening, brief intervention, referral to treatment in hospitals: a phased cluster randomized approach

BACKGROUND

Alarming rates of unhealthy alcohol, non-prescription drug, and tobacco use highlight the preventable health risks of substance abuse and the urgent need to activate clinicians to recognize and treat risky use. Screening, brief intervention, and referral to treatment (SBIRT) is an efficacious and effective processes to identify, reduce and prevent risky use of substances. This paper describes a study protocol testing implementation of a toolkit to enhance use of SBIRT in acute care settings to recognize and address patient risky alcohol, drug, and tobacco use.

METHODS

This study uses a phased cluster randomized mixed method design to test nurse-led implementation of an SBIRT toolkit on one medical-surgical unit at 14 acute care hospitals (critical access, community and academic health centers). Medical surgical units will be randomly assigned to implement the SBIRT toolkit (engagement and communication, assessment, planning, training, and evaluation tools) or a wait-list usual care control group that begins implementation 6 months later. Primary endpoints are documentation of SBIRT delivery in randomly selected electronic medical records at baseline, 6 months and 12 months after group 1 implementation (61 records per unit per time period, N = 2562). Two surveys will be administered to unit nurses: smoking cessation activities will be assessed at baseline and SBIRT use will be assessed on randomly-selected days after implementation. In addition, site coordinators will complete a baseline capacity assessment, an implementation fidelity survey post-implementation, and a structured interview at the end of the study. Multilevel mixed-effects effects logistic and linear models will be used to analyze use of SBIRT and cost outcomes.

DISCUSSION

This study will guide subsequent SBIRT implementation, dissemination, and spread across rural, community and urban healthcare systems throughout the state and beyond. The long-term objective is to activate clinicians to recognize, intervene and refer people with risky substance use to improve health and decrease substance use disorders. Trial registration ClinicalTrials.gov NCT03560076.

Perceived barriers to smoking cessation and perceptions of electronic cigarettes among persons living with HIV

Smoking is more prevalent in persons living with HIV than the general population and is linked to increased morbidity and mortality. Some have suggested that based on current knowledge of harms and benefits, it may be feasible to advise smokers who are unable or unwilling to quit to switch to electronic cigarettes (ECs) as a less harmful alternative. We conducted 25 qualitative interviews with HIV-positive current or former smokers to explore perceived barriers to smoking cessation and perceptions of ECs. A high level of nicotine dependence, smoking as a form of stress management, motivational factors (including lack of readiness, low self-efficacy, ambivalence toward quitting), and having a social network of smokers were identified as cessation barriers. Low knowledge of ECs and uncertainty about EC safety and efficacy were barriers to EC uptake. However, current smokers indicated a willingness to try ECs. This study provides evidence that HIV-positive smokers face significant individual and environmental barriers to cessation. ECs may have potential as a harm reduction strategy in this population; however, there is a significant need for education regarding use and relative safety.

A randomized, controlled pilot study of warm handoff versus fax referral for hospital-initiated smoking cessation among people living with HIV/AIDS

INTRODUCTION

The prevalence of smoking among people living with HIV/AIDS (PLWHA) remains higher than the general population. Life expectancy among PLWHA has increased over the past decade, however, PLWHA who smoke will die younger than their non-smoking peers. The primary aim of this pilot study was to examine the effects of warm handoff versus fax referral to the quitline for smoking cessation among hospitalized smokers living with HIV/AIDS.

METHODS

25 smokers with a diagnosis of HIV/AIDS hospitalized at a Midwestern academic medical center in 2012-2013 (19 male; mean age=47.7; 48% African-American) were identified, approached, and randomized to one of two treatment arms. At the bedside for patients in warm handoff, staff telephoned the quitline for on-the-spot enrollment and counseling. Participants randomized to fax were fax-referred to the quitline on the day of discharge. The quitline provided continued outpatient counseling to participants in both conditions. The main outcome was verified tobacco abstinence at 6-months post randomization.

RESULTS

Enrollment and participation in quitline counseling was high among both warm handoff (100%) and fax-referred (71.4%) PLWHA participants. Nearly all completed follow up for outcome data collection at 6months. Verified abstinent rates were 45.5% in warm handoff versus 14.3% in fax referral at 6months (not significant).

CONCLUSIONS

Hospitalized smokers living with HIV/AIDS were highly engaged in quitline services. Warm handoff seems a promising intervention for hospitalized PLWHA that requires further exploration. Clinical Trials Registration NCT01305928.

Changes in Specific Substance Involvement Scores among SBIRT recipients in an HIV primary care setting

Background

Substance use is common among people living with HIV (PLHIV) and is associated with worse outcomes along the HIV care continuum. One potentially effective clinic-based approach to addressing unhealthy substance use is screening, brief intervention, and referral to treatment (SBIRT).

Methods

We conducted a two-arm randomized trial to examine the effects of a self-administered, computerized SBIRT intervention compared to a clinician-administered SBIRT intervention in an HIV primary clinic. Patients were surveyed before receiving the intervention and again at 1, 3, and 6 months. We administered the WHO Alcohol, Smoking and Substance Involvement Screening Test to determine Specific Substance Involvement Scores (SSIS) and to assign participants to categories of lower, moderate, or high risk to health and other problems for each substance. We collapsed moderate or severe risk responses into a single moderate–high risk category. Based on low rates of participation in the computerized arm, we conducted an “as treated” analysis to examine 6-month changes in mean SSIS among SBIRT intervention participants.

Results

For the overall sample (n = 208), baseline mean SSIS were in the moderate risk category for alcohol, tobacco, cannabis, cocaine, amphetamine, sedatives and opioids. Of those enrolled, 134 (64.4%) received the intervention, and 109 (52.4%) completed the 6-month follow up. There was a statistically significant decline in mean SSIS for all substances except tobacco and cannabis among participants who were at moderate–high risk at baseline. We also observed a statistically significant increase in mean SSIS for all substances except amphetamines and sedatives among participants who were at lower risk at baseline.

Conclusions

Substance use among patients in this urban, safety-net, HIV primary care clinic was near universal, and moderate risk substance use was common. Among participants who received the SBIRT intervention, mean SSISs decreased among those at moderate–high risk at baseline, but increased among those at lower risk at baseline over the 6-month study period. Additional research should examine the clinical significance of SSIS changes for PLHIV, which SBIRT components drive changes in substance use scores, and what other interventions might support those patients at lower risk to maintain health and engagement along the HIV care continuum.

Trial registration ClinicalTrials.gov study NCT01300806

A Pilot Study of Tobacco Screening and Referral for Smoking Cessation Program among HIV-Infected Patients in France

BACKGROUND

The prevalence of tobacco smoking is high among patients living with HIV, supporting the need for effective targeted interventions.

MATERIALS AND METHODS

All current smokers at our outpatient HIV clinic were invited to participate in a smoking cessation program.

RESULTS

Of the 716 patients living with HIV, 280 (39%) reported active smoking and were younger, more recently HIV infected and more frequently infected due to intravenous drug use (IDU). One hundred forty-seven (53%) smokers agreed to participate in the smoking cessation program and had a higher Fagerström score and were less likely IDU. During follow-up, 41 (28%) smokers withdrew from the program. After 6 months, 60 (57%) of the 106 smokers who completed the intervention had stopped tobacco smoking and were more likely to use varenicline, adjusting for a history of depression.

CONCLUSION

Our smoking cessation program was feasible. However, strategies to reach and retain in smoking cessation program specific groups such as IDU are needed to improve the smoking cessation cascade.

Sex Differences in Tobacco Use Among Persons Living With HIV/AIDS: A Systematic Review and Meta-Analysis

BACKGROUND

Persons living with HIV/AIDS (PLWH) smoke at higher rates than other adults and experience HIV-related and non-HIV-related adverse smoking consequences. This study conducted a systematic review to synthesize current knowledge about sex differences in smoking behaviors among PLWH.

METHODS

Over 3000 abstracts from MEDLINE were reviewed and 79 publications met all the review inclusion criteria (ie, reported data on smoking behaviors for PLWH by sex). Sufficient data were available to conduct a meta-analysis for one smoking variable: current smoking prevalence.

RESULTS

Across studies (n = 51), the meta-analytic prevalence of current smoking among female PLWH was 36.3% (95% confidence interval [CI]: 28.0% to 45.4%) and male PLWH was 50.3% (95% CI: 44.4% to 56.2%; meta-analytic odds ratio = 1.78, 95% CI: 1.29 to 2.45). When analyses were repeated just on the US studies (n = 23), the prevalence of current smoking was not significantly different for female PLWH (55.1%, 95% CI: 47.6% to 62.5%) compared with male PLWH (55.5%, 95% CI: 48.2% to 62.5%; meta-analytic odds ratio = 1.04, 95% CI: 0.86 to 1.26). Few studies reported data by sex for other smoking variables (eg, quit attempts, noncigarette tobacco product use) and results for many variables were mixed.

DISCUSSION

Unlike the general US population, there was no difference in smoking prevalence for female versus male PLWH (both >50%) indicating that HIV infection status was associated with a greater relative increase in smoking for women than men. More research is needed in all areas of smoking behavior of PLWH to understand similarities and differences by sex to provide the best interventions to reduce the high smoking prevalence for all sexes.

Prevalence of Substance Use in an HIV Primary Care Safety Net Clinic: A Call for Screening

Substance use complicates HIV care and prevention. Primary care clinics are an ideal setting to screen for and offer interventions for unhealthy alcohol and drug use; however, few HIV clinics routinely screen for substance use. We enrolled 208 clinic patients at an urban underserved HIV primary care clinic. We screened the patients for substance use with the Alcohol, Smoking, and Substance Involvement Score Test and measured urine toxicology. Of the 168 participants who completed screening, the majority reported tobacco or nonprescribed substance use in the previous 3 months. More African American participants reported low or no risk amphetamine use compared to Hispanic, White, or Other race participants (p < .001). Implementing standard clinic practice for screening and assessing substance use in HIV primary care clinics is needed.

Screening for depression among youth with HIV in an integrated care setting

Youth living with HIV (YLWH) are at risk for depression. Depressive symptoms can impact treatment engagement, health outcomes, and quality of life. Early identification of symptoms can guide treatment planning. This study aimed to identify trends in depressive symptoms for YLWH in a specialty-care clinic and follow-up clinical treatment procedures. An archival review of a clinical database provided depression screening information for a sample of 130 YLWH between 11 and 25 years old in the southeastern United States. Findings indicated that approximately 24% of the sample screened positive for depression-risk. Most commonly endorsed symptoms included fatigue (54.3%) and sleep difficulties (48.5%). Depressive symptoms did not differ significantly by age, gender, race, ethnicity, or sexual orientation. Youth who acquired HIV behaviorally were more likely to endorse the critical item (i.e., self-harm and/or suicidal ideation) than youth who acquired HIV perinatally. Forty-percent of the sample (i.e., 51 youth) had a follow-up treatment plan. YLWH who endorsed the critical item were more likely to receive follow-up action when compared to those who did not endorse the item. Despite limitations of the study, findings have important implications for clinical care and future research.

Tobacco Use, Use Disorders, and Smoking Cessation Interventions in Persons Living With HIV

Cigarette smoking remains highly prevalent among persons living with human immunodeficiency virus (HIV), estimated to be 40-75 %, and is significantly higher than what is observed among the general population. Health risks of smoking in this population include cardiovascular disease; bacterial pneumonia, chronic obstructive pulmonary disease, and other respiratory conditions; lung cancer and other malignancies; adverse cognitive and neurological outcomes; low birth weight, preterm birth, and small-for-gestational-age infants; and overall mortality. Smokers with HIV now lose more life years to smoking than they do to the HIV itself. A majority of smokers living with HIV report being interested in cessation, and a significant proportion has made recent quit attempts. There is a general paucity of large, randomized controlled trials of smoking cessation interventions among smokers living with HIV, and among the existing research, cessation rates are suboptimal. Greater resources and effort should be allocated to developing and evaluating cessation treatment modalities for smokers living with HIV. Efforts to individualize and tailor treatments to address specific client needs and comorbidities are warranted. HIV care providers and other health professionals can play a key role in improving health among this population by regularly screening for smoking and promoting cessation.

Does Motivation Matter? Analysis of a Randomized Trial of Proactive Outreach to VA Smokers

BACKGROUND

Current guidelines advise providers to assess smokers' readiness to quit, then offer cessation therapies to smokers planning to quit and motivational interventions to smokers not planning to quit.

OBJECTIVES

We examined the relationship between baseline stage of change (SOC), treatment utilization, and smoking cessation to determine whether the effect of a proactive smoking cessation intervention was dependent on smokers' level of motivation to quit.

DESIGN

Secondary analysis of a multicenter randomized controlled trial.

PARTICIPANTS

A total of 3006 current smokers, aged 18-80 years, at four Veterans Affairs (VA) medical centers.

INTERVENTIONS

Proactive care included proactive outreach (mailed invitation followed by telephone outreach), offer of smoking cessation services (telephone or face-to-face), and access to pharmacotherapy. Usual care participants had access to VA smoking cessation services and state telephone quitlines.

MAIN MEASURES

Baseline SOC measured with Readiness to Quit Ladder, and 6-month prolonged abstinence self-reported at 1 year.

KEY RESULTS

At baseline, 35.8 % of smokers were in preparation, 38.2 % in contemplation, and 26.0 % in precontemplation. The overall interaction between SOC and treatment arm was not statistically significant (p = 0.30). Among smokers in preparation, 21.1 % of proactive care participants achieved 6-month prolonged abstinence, compared to 13.1 % of usual care participants (OR, 1.8 [95 % CI, 1.2-2.6]). Similarly, proactive care increased abstinence among smokers in contemplation (11.0 % vs. 6.5 %; OR, 1.8 [95 % CI, 1.1-2.8]). Smokers in precontemplation quit smoking at similar rates (5.3 % vs. 5.6 %; OR, 0.9 [95 % CI, 0.5-1.9]). Within each stage, uptake of smoking cessation treatments increased with higher SOC and with proactive care as compared with usual care.

LIMITATIONS

Mostly male participants limits generalizability. Randomization was not stratified by SOC.

CONCLUSIONS

Proactive care increased treatment uptake compared to usual care across all SOC. Proactive care increased smoking cessation among smokers in preparation and contemplation but not in precontemplation. Proactively offering cessation therapies to smokers at all SOC will increase treatment utilization and population-level smoking cessation.

Interventions for tobacco use cessation in people living with HIV and AIDS

BACKGROUND

Tobacco use is highly prevalent amongst people living with HIV/AIDS (PLWHA) and has a substantial impact on morbidity and mortality.

OBJECTIVES

To assess the effectiveness of interventions to motivate and assist tobacco use cessation for people living with HIV/AIDS (PLWHA), and to evaluate the risks of any harms associated with those interventions.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group's Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, and PsycINFO in June 2015. We also searched EThOS, ProQuest, four clinical trial registries, reference lists of articles, and searched for conference abstracts using Web of Science and handsearched speciality conference databases.

SELECTION CRITERIA

Controlled trials of behavioural or pharmacological interventions for tobacco cessation for PLWHA.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted all data using a standardised electronic data collection form. They extracted data on the nature of the intervention, participants, and proportion achieving abstinence and they contacted study authors to obtain missing information. We collected data on long-term (greater than or equal to six months) and short-term (less than six months) outcomes. Where appropriate, we performed meta-analysis and estimated the pooled effects using the Mantel-Haenszel fixed-effect method. Two authors independently assessed and reported the risk of bias according to prespecified criteria.

MAIN RESULTS

We identified 14 studies relevant to this review, of which we included 12 in a meta-analysis (n = 2087). All studies provided an intervention combining behavioural support and pharmacotherapy, and in most studies this was compared to a less intensive control, typically comprising a brief behavioural intervention plus pharmacotherapy.There was moderate quality evidence from six studies for the long-term abstinence outcome, which showed no evidence of effect for more intense cessation interventions: (risk ratio (RR) 1.00, 95% confidence interval (CI) 0.72 to 1.39) with no evidence of heterogeneity (I(2) = 0%). The pooled long-term abstinence was 8% in both intervention and control conditions. There was very low quality evidence from 11 studies that more intense tobacco cessation interventions were effective in achieving short-term abstinence (RR 1.51, 95% CI 1.15 to 2.00); there was moderate heterogeneity (I(2) = 42%). Abstinence in the control group at short-term follow-up was 8% (n = 67/848) and in the intervention group was 13% (n = 118/937). The effect of tailoring the intervention for PLWHA was unclear. We further investigated the effect of intensity of behavioural intervention via number of sessions and total duration of contact. We failed to detect evidence of a difference in effect according to either measure of intensity, although there were few studies in each subgroup. It was not possible to perform the planned analysis of adverse events or HIV outcomes since these were not reported in more than one study.

AUTHORS' CONCLUSIONS

There is moderate quality evidence that combined tobacco cessation interventions provide similar outcomes to controls in PLWHA in the long-term. There is very low quality evidence that combined tobacco cessation interventions were effective in helping PLWHA achieve short-term abstinence. Despite this, tobacco cessation interventions should be offered to PLWHA, since even non-sustained periods of abstinence have proven benefits. Further large, well designed studies of cessation interventions for PLWHA are needed.

Smoking Cessation for People Living With HIV/AIDS: A Literature Review and Synthesis

INTRODUCTION

People living with HIV/AIDS (PLWHA) are more likely to smoke cigarettes than are individuals in the general population. The health implications of tobacco use are substantially more dire among PLWHA than among otherwise healthy smokers, including higher rates of various cancers, cardiovascular disease, inflammation, and lung infections. Efficacious behavioral and medication treatments for treating nicotine dependence have rarely been investigated in PLWHA.

METHODS

We present a review of studies examining the efficacy of smoking cessation interventions.

RESULTS AND CONCLUSIONS

The literature reveals some limited evidence for the efficacy of behavioral interventions. However, the research literature on these interventions is sparse and the efficacy findings are mixed. Studies exploring the use of mobile technologies for reducing treatment barriers are becoming more prevalent. Few published trials have directly examined the efficacy of pharmacological smoking cessation interventions among PLWHA. Specific gaps in the treatment literature are discussed in detail, and a strategy is presented for developing a greater understanding of factors that contribute to the efficacy of smoking cessation among PLWHA.

IMPLICATIONS

This paper provides the most comprehensive review to date on smoking cessation intervention research conducted with PLWHA. It also discusses specific gaps in the literature that should be a priority for future research.

Combined pharmacotherapy and behavioural interventions for smoking cessation

BACKGROUND

Both behavioural support (including brief advice and counselling) and pharmacotherapies (including nicotine replacement therapy (NRT), varenicline and bupropion) are effective in helping people to stop smoking. Combining both treatment approaches is recommended where possible, but the size of the treatment effect with different combinations and in different settings and populations is unclear.

OBJECTIVES

To assess the effect of combining behavioural support and medication to aid smoking cessation, compared to a minimal intervention or usual care, and to identify whether there are different effects depending on characteristics of the treatment setting, intervention, population treated, or take-up of treatment.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group Specialised Register in July 2015 for records with any mention of pharmacotherapy, including any type of NRT, bupropion, nortriptyline or varenicline.

SELECTION CRITERIA

Randomized or quasi-randomized controlled trials evaluating combinations of pharmacotherapy and behavioural support for smoking cessation, compared to a control receiving usual care or brief advice or less intensive behavioural support. We excluded trials recruiting only pregnant women, trials recruiting only adolescents, and trials with less than six months follow-up.

DATA COLLECTION AND ANALYSIS

Search results were prescreened by one author and inclusion or exclusion of potentially relevant trials was agreed by two authors. Data was extracted by one author and checked by another.The main outcome measure was abstinence from smoking after at least six months of follow-up. We used the most rigorous definition of abstinence for each trial, and biochemically validated rates if available. We calculated the risk ratio (RR) and 95% confidence interval (CI) for each study. Where appropriate, we performed meta-analysis using a Mantel-Haenszel fixed-effect model.

MAIN RESULTS

Fifty-three studies with a total of more than 25,000 participants met the inclusion criteria. A large proportion of studies recruited people in healthcare settings or with specific health needs. Most studies provided NRT. Behavioural support was typically provided by specialists in cessation counselling, who offered between four and eight contact sessions. The planned maximum duration of contact was typically more than 30 minutes but less than 300 minutes. Overall, studies were at low or unclear risk of bias, and findings were not sensitive to the exclusion of any of the six studies rated at high risk of bias in one domain. One large study (the Lung Health Study) contributed heterogeneity due to a substantially larger treatment effect than seen in other studies (RR 3.88, 95% CI 3.35 to 4.50). Since this study used a particularly intensive intervention which included extended availability of nicotine gum, multiple group sessions and long term maintenance and recycling contacts, the results may not be comparable with the interventions used in other studies, and hence it was not pooled in other analyses. Based on the remaining 52 studies (19,488 participants) there was high quality evidence (using GRADE) for a benefit of combined pharmacotherapy and behavioural treatment compared to usual care, brief advice or less intensive behavioural support (RR 1.83, 95% CI 1.68 to 1.98) with moderate statistical heterogeneity (I² = 36%).The pooled estimate for 43 trials that recruited participants in healthcare settings (RR 1.97, 95% CI 1.79 to 2.18) was higher than for eight trials with community-based recruitment (RR 1.53, 95% CI 1.33 to 1.76). Compared to the first version of the review, previous weak evidence of differences in other subgroup analyses has disappeared. We did not detect differences between subgroups defined by motivation to quit, treatment provider, number or duration of support sessions, or take-up of treatment.

AUTHORS' CONCLUSIONS

Interventions that combine pharmacotherapy and behavioural support increase smoking cessation success compared to a minimal intervention or usual care. Updating this review with an additional 12 studies (5,000 participants) did not materially change the effect estimate. Although trials differed in the details of their populations and interventions, we did not detect any factors that modified treatment effects apart from the recruitment setting. We did not find evidence from indirect comparisons that offering more intensive behavioural support was associated with larger treatment effects.

Screening, Brief Intervention, and Referral to Treatment in a rural Ryan White Part C HIV clinic

About 24% of people living with HIV nationally are identified as needing treatment for alcohol or illicit drug use. Screening, Brief Intervention, and Referral to Treatment (SBIRT) has evolved as a strategy to assess and intervene with substance abuse behaviors in various clinical settings. However, less is known about the processes and outcomes of using the SBIRT intervention in outpatient HIV clinics. This paper presents a descriptive analysis of de-identified existing SBIRT results data from an outpatient HIV clinic located in western Colorado. From 2008 to 2013, a total of 1616 SBIRT evaluations were done, which included duplicate patients because some individual patients were screened more than once in a given year. Over this time period, 37-49% of encounters per year were notable for tobacco use, 8-21% for alcohol use, 6-16% for marijuana use, 3-9% for amphetamine use, and 0-2% for illicit opioid use. Unique, unduplicated patient data from 2013 revealed 40% of patients used tobacco, 16% used alcohol, and 11% used methamphetamine. Analyses highlighted that the majority of our patient population (58% in 2013) used and/or abused tobacco, alcohol, and/or illicit substances. An alarming finding was the increase in methamphetamine use over time with more than 50-fold prevalence of use in our population compared to national rates.

An Algorithm Approach to Determining Smoking Cessation Treatment for Persons Living With HIV/AIDS: Results of a Pilot Trial

BACKGROUND

Smoking now represents one of the biggest modifiable risk factors for disease and mortality in people living with HIV (PLHIV). To produce significant changes in smoking rates among this population, treatments will need to be both acceptable to the larger segment of PLHIV smokers and feasible to implement in busy HIV clinics. The purpose of this study was to evaluate the feasibility and effects of a novel proactive algorithm-based intervention in an HIV/AIDS clinic.

METHODS

PLHIV smokers (N = 100) were proactively identified through their electronic medical records and were subsequently randomized at baseline to receive a 12-week pharmacotherapy-based algorithm treatment or treatment as usual. Participants were tracked in-person for 12 weeks. Participants provided information on smoking behaviors and associated constructs of cessation at each follow-up session.

RESULTS

The findings revealed that many smokers reported using prescribed medications when provided with a supply of cessation medication as determined by an algorithm. Compared with smokers receiving treatment as usual, PLHIV smokers prescribed these medications reported more quit attempts and greater reduction in smoking. Proxy measures of cessation readiness (eg, motivation, self-efficacy) also favored participants receiving algorithm treatment.

CONCLUSIONS

This algorithm-derived treatment produced positive changes across a number of important clinical markers associated with smoking cessation. Given these promising findings coupled with the brief nature of this treatment, the overall pattern of results suggests strong potential for dissemination into clinical settings and significant promise for further advancing clinical health outcomes in this population.

Behavioral Interventions to Enhance Smoking Cessation

In the United States, the rate of cigarette smoking has significantly declined over the past 2 decades, but much more work is needed, as almost 20% of adults still smoke and smoking continues to be the leading preventable cause of death. Furthermore, rates of smoking in certain subpopulations have remained relatively stable and have historically been neglected in smoking cessation research. Pharmacotherapy (both prescription and over-the-counter) and behavioral support are known to aid cessation, and their combination is more effective than either alone. There are significant barriers to access, use, and adherence, however, especially with pharmacotherapy. Therefore, the purpose of this review is to provide an update and overview of the numerous behavioral approaches that have been used to enhance smoking cessation. The research described can be classified into the type of approach used, the setting in which it is delivered, and the population targeted. Regardless of the classification, all the approaches attempt to provide smokers with the information, motivation, and behavioral skills thought to be necessary for achieving initial cessation and sustained abstinence. Recommendations for future research on behavioral smoking cessation are also included.

Mediators of a smoking cessation intervention for persons living with HIV/AIDS

BACKGROUND

Cigarette smoking among persons living with HIV (PLWH) is a pressing public health concern, and efforts to evaluate cessation treatments are needed. The purpose of the present study was to assess potential mechanisms of a cell phone-delivered intervention for HIV-positive smokers.

METHODS

Data from 350 PLWH enrolled in a randomized smoking cessation treatment trial were utilized. Participants were randomized to either usual care (UC) or a cell phone intervention (CPI) group. The independent variable of interest was treatment group membership, while the dependent variable of interest was smoking abstinence at a 3-month follow-up. The hypothesized treatment mechanisms were depression, anxiety, social support, quit motivation and self-efficacy change scores.

RESULTS

Abstinence rates in the UC and CPI groups were 4.7% (8 of 172) and 15.7% (28 of 178), respectively. The CPI group (vs. UC) experienced a larger decline in depression between baseline and the 3-month follow-up, and a decline in anxiety. Self-efficacy increased for the CPI group and declined for the UC group. Quit motivation and social support change scores did not differ by treatment group. Only self-efficacy met the predefined criteria for mediation. The effect of the cell phone intervention on smoking abstinence through change in self-efficacy was statistically significant (p<0.001) and accounted for 17% of the total effect of the intervention on abstinence.

CONCLUSIONS

The findings further emphasize the important mechanistic function of self-efficacy in promoting smoking cessation for PLWH. Additional efforts are required to disentangle the relationships between emotional, distress motivation, and efficacious smoking cessation treatment.

Substance use in older HIV-infected patients

PURPOSE OF REVIEW

Substance use may persist throughout the life course and has a substantial impact on health outcomes globally. As HIV-infected individuals are disproportionately impacted by substance use and living longer, it is critical that providers and researchers alike understand the impact of substance use on older, HIV-infected patients and potential treatment options. To this end, we conducted a review of the literature focusing on the most commonly used substances to outline the epidemiology, health consequences, treatment options and latest research relevant to older, HIV-infected patients.

RECENT FINDINGS

Substance use impacts older, HIV-infected patients with regards to HIV-related and non-HIV-related outcomes. Counseling strategies are available for marijuana and stimulant use disorders. Brief counseling is useful alongside medications for alcohol, tobacco and opioid use disorders. Many medications for alcohol, tobacco and opioid use disorders are safe in the setting of antiretroviral therapy. Unfortunately, few interventions targeting substance use in older, HIV-infected patients have been developed and evaluated.

SUMMARY

As older, HIV-infected patients continue to experience substance use and its related health consequences, there will be a growing need for the development of safe and effective interventions, which address the complex needs of this population.

Short-term fluctuations in motivation to quit smoking in a sample of smokers in Hawaii

BACKGROUND

Despite its potential for usefulness in informing the development of smoking cessation interventions, short-term fluctuations in motivation to quit is a relatively understudied topic.

OBJECTIVES

To assess the prevalence of smokers' day-to-day fluctuations in motivation to quit, and to assess associations of day-to-day fluctuations in motivation to quit with several established cessation-related variables.

METHODS

A cross-sectional survey was administered to smokers in Hawaii (N = 1,567). To assess short-term fluctuations in motivation to quit smoking, participants were asked to respond "True" or "False" to the statement: "My motivation to quit smoking changes from one day to the next." Other items measured desire to quit smoking, intention to quit, confidence in quitting, cigarette dependence, and other cessation-related variables.

RESULTS

"My motivation to quit smoking changes from one day to the next" was endorsed as true by 64.7% of smokers, and false by 35.3%. Analyses revealed that smokers who indicated fluctuating motivation were significantly more interested in quitting as compared to smokers without fluctuations. Fluctuations in motivation to quit also were associated with greater confidence in quitting, lesser cigarette dependence, and more recent quitting activity (all p < .01).

CONCLUSIONS

Day-to-day fluctuations in motivation to quit are common. Day-to-day fluctuations in motivation to quit are strongly associated with higher motivation to quit, greater confidence in future quitting, and other positive cessation-relevant trends.

Factors associated with tobacco smoking and cessation among HIV-infected individuals under care in Rio de Janeiro, Brazil

Worldwide the prevalence of smoking among people living with HIV/AIDS is elevated compared to the general population. This probably reflects the cluster of individual characteristics that have shared risk factors for HIV infection and smoking. A cross-sectional study, enrolling a convenience sample from a Brazilian HIV clinical cohort was conducted to evaluate the prevalence of tobacco smoking and the factors associated with current smoking and abstinence. A total of 2,775 HIV-infected individuals were interviewed: 46.2% have never smoked, 29.9% were current smokers and 23.9% were former smokers. Current smokers had a higher prevalence of alcohol and illicit drug use when compared to the other two groups. A higher proportion of heterosexual individuals were former smokers or never smokers while among men who have sex with men (MSM) a higher proportion were current smokers. Former smokers had been more frequently diagnosed with high blood pressure, diabetes mellitus, cardiovascular diseases and depression, while for current smokers lung diseases were more frequent. Former smokers and current smokers were more likely to have had any hospital admission (42.0% and 41.2%, respectively) than participants who never smoked (33.5%) (p<0.001). Multivariate model results showed that current smokers (versus never smokers) were more likely to be less educated, to report the use of alcohol, crack and cocaine and to present clinical comorbidities. Former smokers (versus current smokers) were more likely to be older, to have smoked for a shorter amount of time and to have smoked >31 cigarettes/day. MSM (compared to heterosexuals) and cocaine users (versus non-users) had lower odds of being former smokers. Considering our results, smoking cessation interventions should be tailored to younger individuals, MSM and substance users.

Emergency Department-Based Brief Intervention to Reduce Risky Driving: A Life Course Perspective

Screening, Brief Intervention, and Referral to Treatment (SBIRT) has promise as a clinical intervention for health-compromising behaviors. We used a randomized controlled design in an Emergency Department (ED) setting to determine the efficacy of a nurse-delivered SBIRT to address risky driving in people 18 to 44 years of age. Risky drivers (n = 476) were randomized to brief intervention (BIG), contact-control (CCG), or no-contact-control (NCG) groups and were followed at 3, 6, 9, and 12 months. Outcomes included safety belt use, speeding, and driving through traffic lights. Safety belt use, times speeding between 10 and 19 mph over speed limit, and times driving through a yellow light declined significantly in the BIG as compared with the CCG at 3, 6, and 9 months. SBIRT reduced risky driving in our sample, but its effects did not persist after 9 months. We suggest that SBIRT has the potential to reduce vehicular-related injury in the 9 months after a brief intervention.

Risk of coronary heart disease in patients with HIV infection

The lives of individuals infected with HIV who have access to combination antiretroviral therapy (cART) are substantially prolonged, which increases the risk of developing non-AIDS comorbidities, including coronary heart disease (CHD). In Europe and the USA, individuals with HIV infection have a ∼1.5-fold increased risk of myocardial infarction relative to uninfected individuals. In Africa, the relative risk of myocardial infarction is unknown, but broadened access to life-extending cART suggests that rates of CHD will rise in this and other resource-constrained regions. Atherogenesis in HIV is affected by complex interactions between traditional and immune risk factors. cART has varied, regimen-specific effects on metabolic risk factors. Overall, cART seems to lessen proatherogenic immune activation, but does not eliminate it even in patients in whom viraemia is suppressed. Current strategies to decrease the risk of CHD in individuals infected with HIV include early initiation of cART regimens with the fewest metabolic adverse effects, and careful management of traditional CHD risk factors throughout treatment. Future strategies to prevent CHD in patients with HIV infection might involve the use of HIV-tailored CHD risk-prediction paradigms and the administration of therapies alongside cART that will further decrease proatherogenic HIV-specific immune activation.

How to address smoking cessation in HIV patients

Tobacco consumption is the modifiable risk factor contributing most to the development of non-AIDS-defining events among persons living with HIV/AIDS (PLWHA). Clinicians' awareness of this problem is critical and not yet adequate. Practical information issued by public health authorities or contained in experts' clinical guidelines regarding how to address smoking cessation in PLWHA is scarce. The aim of this review is to provide physicians with comprehensive and practical information regarding how to identify HIV-positive patients willing to stop smoking and those more likely to succeed, how to choose the most suitable strategy for an individual patient, and how to help the patient during the process. In the light of current evidence on the efficacy and benefits of stopping smoking in PLWHA, physicians must actively pursue smoking cessation as a major objective in the clinical care of PLWHA.

Beliefs, experience, and interest in pharmacotherapy among smokers with HIV

OBJECTIVES

To examine beliefs, prior use, and interest in using pharmacotherapy among people living with HIV/AIDS (PLWHA).

METHODS

Cross-sectional survey of smokers in a midwestern HIV clinic.

RESULTS

The sample (N = 146) included 69% men, 82% African Americans, 45% were in precontemplation for quitting, and 46% were interested in using pharmacotherapy. Primary reasons for non-use included cost and a belief that they would be able to quit on their own. Physician assistance was the strongest correlate of prior use. Perceived benefits and self-efficacy were the strongest correlates of willingness to use pharmacotherapy.

CONCLUSIONS

Future interventions should address misconceptions, perceived benefits, and self-efficacy for using cessation aids. Physicians should offer pharmacotherapy to all smokers.