Project Exhale: preliminary evaluation of a tailored smoking cessation treatment for HIV-positive African American smokers

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.

Optimizing tobacco treatment delivery for people with HIV: trial protocol for a randomized controlled trial

BACKGROUND

With advances in antiretroviral therapy, people with HIV (PWH) are living longer and are less likely to die from AIDS-related complications. Yet, prior research has shown that smoking is often not addressed in the context of HIV care, and few individuals are offered cessation treatment. Optimizing tobacco treatment delivery for PWH may increase engagement with evidence-based treatments and successful quit attempts.

METHODS

The current study is a type 1 hybrid effectiveness-implementation trial to evaluate the impact of a proactive, opt-out tobacco treatment intervention on cessation outcomes and advance understanding of key barriers and facilitators of implementation processes. A total of 230 PWH who smoke will be recruited from an infectious diseases clinic at an academic medical center and will be randomized to receive (1) treatment as usual (TAU) or (2) Proactive Outreach with Medication Opt-out for Tobacco Treatment Engagement (PrOMOTE). Primary outcomes include: biochemically verified 7-day point prevalence abstinence (PPA) rates, continuous abstinence (Weeks 9-12), and the number of 24-hour quit attempts at the end of study treatment (Week 12). Secondary outcomes include: participant reach (proportion reached out of contact attempts), implementation fidelity (including number of prescriptions written), participant adherence to prescribed pharmacotherapy, acceptability (participant and provider satisfaction with intervention delivery and content), and perceived barriers.

DISCUSSION

This study will examine a novel approach to optimizing tobacco treatment delivery for PWH. Integrating effectiveness and implementation results will help define best practices for engaging PWH with evidence-based tobacco treatment interventions. The intervention is low-cost, has the potential to be highly scalable, and could be translatable to other ambulatory HIV clinic settings.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT05019495 (August 24, 2021).

Peer navigation for smoking cessation in smokers with HIV: Protocol for a randomized clinical trial

BACKGROUND

Smoking prevalence in persons with HIV (PWH) is high (40%) and cessation rates remain low. Lack of social support and poor adherence to nicotine replacement therapy (NRT) are related to poor cessation outcomes; thus, both factors represent possible targets for smoking cessation interventions. Peer navigators (PNs) have been integrated into HIV care with great success to improve engagement and adherence to antiretroviral therapy. However, no clinical trial has evaluated the potential for PNs to provide social support and improve NRT adherence for smoking cessation. We developed a treatment protocol that targets social support, adherence, and self-efficacy for quitting by incorporating PNs into a smoking cessation program. This randomized trial will test whether this approach results in higher rates of 7-day point prevalence abstinence at 12- and 24-weeks, compared to standard treatment.

METHODS

Seventy-two smokers with HIV will be randomized to either Peer Navigation Social Support for smoking cessation (PNSS-S) or standard cessation counseling. All participants will meet with a nurse for a smoking cessation counseling session, which will include discussion of FDA-approved cessation pharmacotherapy. Participants assigned to PNSS-S will receive weekly phone calls from the PN for 12 weeks. The PN will address readiness to quit, using medication to quit, common barriers to cessation, high risk situations, slip management, and maintaining abstinence. Smoking cessation outcomes will be measured at 4, 12, and 24 weeks following the baseline appointment.

CONCLUSION

Results from this study will provide preliminary evidence of whether incorporating a peer navigator-based intervention into smoking cessation treatment can improve smoking cessation outcomes in PWH.

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.

Learner Verification: A Methodology to Create Suitable Education Materials

Background:

Learner verification and revision (LV&R) is a research methodological approach to inform educational message design with the aim of producing suitable, actionable, and literacy appropriate messages to aid in awareness, adoption of healthy behaviors, and decision-making. It consists of a series of participatory steps that engage users throughout materials development, revision, and refinement. This approach is congruent with Healthy People 2030 communication objectives to improve access to information among diverse, multicultural, multilingual populations, and enhance health care quality toward health equity.

Brief description of activity:

To illustrate LV&R, we describe its use in three cancer education projects that produced targeted information about (1) inherited breast cancer among African Americans (brochure); (2) colorectal cancer screening among Latinos (photo novella and DVD); and (3) smoking-relapse prevention among patients receiving cancer treatment (video). We discuss rationale for its application in the three exemplars and extrapolate lessons learned from our experiences when using this approach.

Implementation:

A qualitative approach entailing individual or group-based discussions helped to examine the elements of learner verification (i.e., attraction, comprehension, self-efficacy, cultural acceptability, persuasion). The following steps are reported: (1) preparation of materials, interview guide, and recruitment; (2) interviewing of participants; and (3) evaluation of responses. Data were analyzed by use of a coding system that placed participant responses from each of the elements into data summary matrices. Findings informed revisions and refinement of materials.

Results:

LV&R was effectively applied across the three cancer education projects to enhance the suitability of the materials. As a result, the materials were improved by using clearer, more salient language to enhance comprehension and cultural acceptability, by integrating design elements such as prompts, headers, and stylistic edits to reduce text density, incorporating preferred colors and graphics to improve aesthetic appeal, and including actionable terms and words to bolster motivation and self-efficacy.

Lessons learned:

Results suggest that LV&R methodology can improve suitability of education materials through systematic, iterative steps that engage diverse, multicultural, multilingual populations. This approach is a critical participa-tory strategy toward health equity, and is appropriate in a variety of education, research, and clinical practice settings to improve health communications. [HLRP: Health Literacy Research and Practice. 2021;5(1):e49–e59.]

Plain Language Summary:

This article describes the use of a systematic approach called “learner verification” used for developing educational materials. This approach involves obtaining feedback from audience members to ensure that the information is understandable, attractive in design, motivating, and culturally relevant.

Feasibility of implementing a novel behavioural smoking cessation intervention amongst human immunodeficiency virus-infected smokers in a resource-limited setting: A single-arm pilot trial

Background

Tobacco use is prevalent amongst individuals infected with human immunodeficiency virus (HIV). In resource-constrained settings, pharmacological smoking cessation interventions are unfeasible because of their high cost. There is a need to develop and evaluate behavioural interventions to address the unique challenges of tobacco use in the HIV-infected populations in these settings.

Objectives

The authors aimed to assess the feasibility and acceptability of the Behavioural Activation/Problem Solving for Smoking Cessation (BAPS-SC) intervention programme to determine whether it should be tested in an adequately powered randomised controlled trial.

Method

The authors merged behavioural activation therapy (BAT) with the principles of problem-solving therapy to create a novel five-session counselling model to address the unique challenges of tobacco cessation amongst those infected with HIV. Feasibility measures included the rate of enrolment amongst those eligible and the retention rate and descriptive analysis of intervention acceptability. The authors' secondary outcome was 7-day point smoking prevalence abstinence, confirmed with breath carbon monoxide.

Results

A total of 128 individuals were screened over 8 weeks with 50 deemed eligible and 40 enrolled (80%). Retention at week 12 was 53% (21/40). The 7-day point prevalence abstinence, co-confirmed, at week 12 was 37.5% (15/40). All respondents indicated that they would recommend BAPS-SC to other smokers who want to quit, and would be willing to participate in the programme again up to the point of exit if they did not stop smoking.

Conclusion

A full-scale randomised control trial comparing BAPS-SC with usual practice is warranted to evaluate the efficacy of this novel intervention in these settings.

Understanding the Prevalence of Smoking Among People Living with HIV (PLHIV) in Australia and Factors Associated with Smoking and Quitting

Understanding contributors to smoking and quitting cigarettes is important to developing effective cessation programs and addressing smoking related morbidity and mortality among people living with HIV (PLHIV). Using data from a large cross-sectional study of Australian PLHIV we provide a smoking prevalence estimate and explore the relationship between socio-demographic variables and smoking status. We also explore the relationship between HIV diagnosis and antiretroviral therapy (ART) initiation and quitting smoking. Of the 1011 respondents included in the analysis, 30.6% were current smokers. The strongest predictor of smoking was regular cannabis use (AOR 6.2, 95% CI 3.6-10.8) while the strongest predictor of being a past smoker was receiving ART (AOR 2.4, 95% CI 1.2-4.7). Quitting also increased around the time of diagnosis and ART initiation, highlighting the potential for these events to be optimal times to address smoking among PLHIV.

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.

Evaluation of a Randomized Clinical Trial Comparing the Effectiveness of a Culturally Targeted and Nontargeted Smoking Cessation Intervention for Lesbian, Gay, Bisexual, and Transgender Smokers

PURPOSE

To examine the benefits of a culturally targeted compared with a nontargeted smoking cessation intervention on smoking cessation outcomes among lesbian, gay, bisexual, and transgender (LGBT) smokers.

METHODS

A prospective randomized design was used to evaluate the added benefits of an LGBT culturally targeted Courage to Quit (CTQ-CT) smoking cessation treatment (N = 172) compared with the standard intervention (CTQ; N = 173). The smoking cessation program consisted of six treatment sessions combined with 8 weeks of nicotine replacement therapy. The primary smoking cessation outcome was 7-day point prevalence quit rates. Secondary outcomes examined included changes in nicotine dependence, nicotine withdrawal, cigarettes per day, smoking urges, self-efficacy, and readiness to quit.

RESULTS

Overall quit rates were 31.9% at 1 month, 21.1% at 3 months, 25.8% at 6 months, and 22.3% at 12 months. Quit rates did not differ between treatment groups [1 month OR = 0.81 (0.32, 2.09), 3 months OR = 0.65 (0.23, 1.78), 6 months OR = 0.45 (0.17, 1.21), 12 months OR = 0.70 (0.26, 1.91)]. Compared with baseline levels, all secondary smoking cessation outcomes measured were improved at 1 month and were maintained at 12-month follow-up. Compared with the CTQ, the CTQ-CT intervention was more highly rated on program effectiveness (d = 0.2, p = .011), intervention techniques (d = 0.2, p = .014), the treatment manual (d = 0.3, p < .001), and being targeted to the needs of LGBT smokers (d = 0.5, p < .0001).

CONCLUSIONS

LGBT smokers receiving the CTQ intervention achieved smoking cessation outcomes in the range reported for other demographic groups. Cultural targeting improved the acceptability of the intervention but did not confer any additional benefit for smoking cessation outcomes.

IMPLICATIONS

Study results have implications for understanding the benefits of culturally targeted compared with nontargeted smoking cessation interventions for improving smoking cessation outcomes among LGBT smokers. Shorter and longer term 7-day point prevalence quit rates associated with the targeted and nontargeted interventions were modest but comparable with other group-based interventions delivered in a community setting. Although cultural targeting improved the overall acceptability of the intervention, no added benefits were observed for the culturally targeted intervention on either the primary or secondary outcomes.

Conceptualizing patient-centered care for substance use disorder treatment: findings from a systematic scoping review

BACKGROUND

Despite ongoing efforts aimed to improve treatment engagement for people with substance-related disorders, evidence shows modest rates of utilization as well as client-perceived barriers to care. Patient-centered care (PCC) is one widely recognized approach that has been recommended as an evidence-based practice to improve the quality of substance use disorder treatment. PCC includes four core principles: a holistic and individualized focus to care, shared decision-making and enhanced therapeutic alliance.

AIMS

This scoping review aimed to explore which PCC principles have been described and how they have defined and measured among people with substance-related disorders.

METHODS

Following the iterative stages of the Arksey and O'Malley scoping review methodology, empirical (from Medline, Embase, PsycINFO, CINAHL and ISI Web of Science) and grey literature references were eligible if they focused on people accessing treatment for substance-related disorders and described PCC. Two reviewers independently screened the title/abstract and full-texts of references. Descriptive analyses and a directed content analysis were performed on extracted data.

FINDINGS

One-hundred and forty-nine references met inclusion from the 2951 de-duplicated references screened. Therapeutic alliance was the most frequent principle of PCC described by references (72%); this was consistently defined by characteristics of empathy and non-judgment. Shared decision-making was identified in 36% of references and was primarily defined by client and provider strategies of negotiation in the treatment planning process. Individualized care was described by 30% of references and included individualized assessment and treatment delivery efforts. Holistic care was identified in 23% of references; it included an integrated delivery of substance use, health and psychosocial services via comprehensive care settings or coordination. Substance use and treatment engagement outcomes were most frequently described, regardless of PCC principle.

CONCLUSIONS

This review represents a necessary first step to explore how PCC has been defined and measured for people accessing substance use disorder treatment. The directed content analysis revealed population and context-specific evidence regarding the defining characteristics of PCC-principles that can be used to further support the implementation of PCC.

Use of Smoking Cessation Aids in a Convenience Sample of PLHIV in a Canadian Tertiary Care Clinic

Background:

Tobacco smoking is among the most significant predictors of cardiovascular disease and lung cancer in People Living with HIV (PLHIV). Smoking rates in this population are high, necessitating more effective smoking cessation strategies. We conducted a descriptive analysis of tobacco-related clinical and sociodemographic characteristics of smokers at a tertiary care HIV clinic in Montreal and an exploratory analysis of smoking cessation methods in order to identify potential areas of improvement in the clinic’s approach to smoking cessation.

Methods:

A convenience sample of patients completed a 10-minute questionnaire on tobacco-related behaviours and outcomes. Use of smoking cessation methods was compared using McNemar’s exact test with a Bonferroni correction for multiple testing (p<0.01 considered significant).

Results:

Seventy-two PLHIV participated. Two-thirds of our total participants were interested in quitting within six months, but the use of effective cessation strategies was low, particularly for counseling and oral therapy. Overall, oral therapy (e.g. varenicline) (16.7%) and counseling for cessation (5.6%) were used less than nicotine patches (50.0%) or ‘other’ methods (50.0%), which included abstinence and nicotine gum (p<0.001).

Conclusion:

Despite a small and potentially unrepresentative sample of HIV positive tobacco smokers at our clinic, this study could help guide further research aiming to determine and address barriers to smoking cessation and access to effective smoking cessation aids in PLHIV. Future studies might consider factors that affect motivation to quit, such as co-morbid mental health and substance use disorders, or the attitudes of HIV healthcare providers.

Adaptation of a Proactive Smoking Cessation Intervention to Increase Tobacco Quitline Use by LGBT Smokers

PURPOSE

The study purpose was to evaluate the content of a proactive population health management intervention aimed at promoting uptake of smoking cessation treatments offered by the Illinois Tobacco Quitline (ITQL) among lesbian, gay, bisexual, and transgender (LGBT)-identified smokers.

METHODS

This study represents a partnership between a community-based health center and university researchers. As part of the study, focus groups and in-depth interviews were conducted with LGBT smokers (N = 30). First, we conducted focus groups to obtain feedback on the readability, acceptability, and motivational salience of a targeted and nontargeteed proactive outreach letter. After revisions, a series of in-depth interviews were conducted to evaluate finalized materials. Focus groups and interviews were systematically analyzed.

RESULTS

Based on feedback, the revised intervention letter was rated more positively than the initial version, with 80% of participants indicating that they found the information in the letter to be useful. Further, more participants reported that the letter would motivate them to accept a call from a quitline counselor compared with the initial version (47.6% vs. 60.0%, respectively). In the final iteration, 60% of participants preferred the targeted letter, 30% preferred the non-targeted letter, and 10% had no preference. In the first iteration, outreach text messages were rated as unacceptable or completely unacceptable by 54% of participants. The revised text messages and protocols were seen as unacceptable by only 10% of participants.

CONCLUSIONS

The development and testing of population-based and cost-effective interventions is critical to the reduction of LGBT smoking disparities. The study protocol and intervention materials were well-received by participants. In a future study, we will evaluate the efficacy of the intervention in increasing use of the quitline among LGBT smokers.

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.

Tobacco use cessation interventions for lesbian, gay, bisexual, transgender and queer youth and young adults: A scoping review

Smoking prevalence among LGBTQ + youth and young adults is alarmingly high compared to their non-LGBTQ + peers. The purpose of the scoping review was to assess the current state of smoking prevention and cessation intervention research for LGBTQ + youth and young adults, identify and describe these interventions and their effectiveness, and identify gaps in both practice and research.

A search for published literature was conducted in PubMed, Scopus, CINAHL, PsychInfo, and LGBT Life, as well as an in-depth search of the grey literature. All English articles published or written between January 2000 and February 2016 were extracted.

The search identified 24 records, of which 21 were included; 11 from peer reviewed sources and 10 from the grey literature. Of these 21, only one study targeted young adults and only one study had smoking prevention as an objective. Records were extracted into evidence tables using a modified PICO framework and a narrative synthesis was conducted. The evidence to date is drawn from methodologically weak studies; however, group cessation counselling demonstrates high quit rates and community-based programs have been implemented, although very little evidence of outcomes exist. Better-controlled research studies are needed and limited evidence exists to guide implementation of interventions for LGBTQ + youth and young adults.

This scoping review identified a large research gap in the area of prevention and cessation interventions for LGBTQ youth and young adults. There is a need for effective, community-informed, and engaged interventions specific to LGBTQ + youth and young adults for the prevention and cessation of tobacco.

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We conducted a scoping review on cessation programs for LGBTQ + young adults.

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A large research gap in the area of tobacco control for LGBTQ + young adults exists.

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Tobacco control interventions specific to LGBTQ + youth and young adults are needed.

A Qualitative Study of the Barriers to and Facilitators of Smoking Cessation Among Lesbian, Gay, Bisexual, and Transgender Smokers Who Are Interested in Quitting

PURPOSE

Lesbian, gay, bisexual, and transgender (LGBT) individuals are significantly more likely to smoke compared with their heterosexual and cisgender counterparts. The purpose of this study was to explore barriers to and facilitators of smoking cessation readiness among LGBT smokers.

METHODS

This descriptive study used a qualitative approach. Four 90-minute focus groups (eligibility criteria: age ≥21, self-identify as LGBT, current smoker, interest in quitting smoking) were conducted. Participants also completed a brief survey that measured additional demographic characteristics and smoking behaviors. Topics explored included quit experiences, attitudes and beliefs, barriers to and facilitators of cessation, and cultural factors related to smoking behaviors. Established qualitative methods were used to conduct the focus groups and data analysis.

RESULTS

The mean age of participants (N = 31) was 37.1 years with the majority identifying as male (58.1%). The sample group was racially diverse: 32% were African American, 39% were White, and 29% were more than one race. Interest in quitting was high (M = 9.0, range 0-10). Barriers to smoking cessation fell under the broad themes of individual-level factors, cultural factors, psychosocial factors, and access to treatment. Facilitators of smoking cessation included stage of readiness, health concerns, social stigma, a shift in social norms, financial costs, and improving dating prospects.

CONCLUSIONS

Interest in smoking cessation was high in this sample of LGBT smokers and influenced by a range of facilitators. Nevertheless, several general and culturally specific barriers to smoking cessation readiness were identified. The study results have implications for future research and the development of outreach, prevention, and treatment programs.

Smoking Cessation in Pulmonary Care Subjects: A Mixed Methods Analysis of Treatment-Seeking Participation and Preferences

BACKGROUND

African-American smokers experience disproportionate COPD morbidity. As a front-line COPD behavioral management strategy, smoking cessation is less prevalent among African-American smokers. Identifying barriers and predictors to smoking cessation in this population is important to bridging this disparity.

METHODS

In this study, the predictors of enrollment and attendance to a 3-session urban hospital smoking cessation program were examined. A retrospective chart review was conducted for all pulmonary clinic patients who smoked and were referred to the cessation program between June 2013 and May 2014. Demographic, smoking behavior, cardiopulmonary, and health status variables were extracted (N = 253). Second, a qualitative assessment of the beliefs and barriers for smoking cessation and physical activity were examined in a sub-sample of the population (n = 41).

RESULTS

One-hundred forty-seven of the pulmonary subjects (58%) enrolled in the cessation program, and 40 attended all sessions (16% of the total sample). Participants with COPD (odds ratio = 4.65, P = .030), or had a mother who had cancer (odds ratio = 4.49, P = .027), were more likely to attend the program. Qualitatively, pulmonary care patients who wanted to quit smoking and be more physically active cited: strong beliefs about the inability to engage in these behaviors, belief that quitting and increased activity might exacerbate poor health, and an inability to obtain pharmacotherapy as barriers to adopting these behaviors.

CONCLUSIONS

Smoking cessation program attendance in this sample of mostly African-American smokers was poor. Increased knowledge about cessation benefits and access to full-course pharmacotherapy, particularly in those without a COPD diagnosis and who do not have a maternal history of cancer, may be high-priority targets to promote cessation program uptake in this population. Increased knowledge and access to safe forms of physical activity may also be beneficial.

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.

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.

Non-cigarette tobacco and poly-tobacco use among persons living with HIV drawn from a nationally representative sample

INTRODUCTION

Smoking is more prevalent among persons living with HIV (PLWH) than the general population. Little is known about the prevalence of non-cigarette tobacco and poly-tobacco use (PTU; using multiple tobacco products) among this population, which, in the general population is associated with poor health and cessation outcomes. We aimed to characterize the prevalence of cigarette and non-cigarette tobacco use, PTU, and correlates of tobacco use status among a nationally-representative sample of PLWH.

METHODS

Data came from 472 HIV-positive adults from the 2005-2013 National Survey on Drug Use and Health (NSDUH).

RESULTS

The prevalence of PTU overall was 8.7% (95% CI=5.6-13.2), and 16.6% (95% CI=10.2-25.7) among past-year tobacco users. In multinomial logistic regression analyses, participants with a high school education or greater (aRRR=2.03, 95% CI=1.03-4.00) were more likely to be non-tobacco users than single product users. Past year drug users (aRRR=0.35, 95% CI=0.19-0.66) and past month binge drinkers (aRRR=0.24, 95% CI=0.12-0.50) were less likely to be non-tobacco users than single product users. Compared to 18-25 year olds, individuals age 26-34 (aRRR=0.13, 95% CI=0.03-0.65) and 35+ (aRRR=0.24, 95% CI=0.09-0.63), and with lifetime anxiety disorder(s) (aRRR=0.18, 95% CI=0.06-0.57) were less likely to be PTUs as compared to single product users. Individuals who reported liking to test themselves by doing risky things were more likely to be PTUs than single product users (aRRR=2.95, 95% CI=1.27-6.84).

CONCLUSIONS

PTU was slightly higher than in the general population, and should be taken into account when developing cessation interventions tailored to tobacco users living with HIV.

Outcomes of a Tailored Intervention for Cigarette Smoking Cessation Among Latinos Living With HIV/AIDS

INTRODUCTION

Tobacco use has emerged as a leading killer among persons living with HIV, with effective approaches to tobacco treatment still unknown. HIV infection is nearly 3 times as prevalent in Latinos than in non-Latino Whites. This study reports the results of a randomized trial comparing a tailored intervention to brief counseling for smoking cessation among Latino smokers living with HIV (LSLWH).

METHODS

LSLWH (N = 302; 36% female, 10% employed full-time, 49% born in United States) were randomized to 4 in-person sessions of a tailored intervention (Aurora) or 2 in-person sessions of brief advice (enhanced standard care [ESC]). Both groups received 8 weeks of nicotine replacement therapy (NRT) patch. Biochemically validated 6- and 12-month 7-day point-prevalence abstinence (PPA) rates were compared, along with secondary outcomes (e.g., reduction to light smoking, NRT adherence).

RESULTS

Seven-day PPA rates reached 8% versus 11% at 6 months and 6% versus 7% at 12 months, for Aurora and ESC, respectively, with no between-group differences (p values > .40). Significant changes from baseline to 6 and 12 months among intervention targets were noted (percentage reduction in heavy smoking and dependence; increases in knowledge and self-efficacy). Baseline smoking frequency, older age, and higher intensity of patch use during the trial emerged as significant predictors of abstinence at 6 months.

CONCLUSIONS

There was no evidence that the tailored intervention improved cessation rates. Interventions that encourage use of, and adherence to, empirically validated cessation aids require further development to reduce tobacco-related death and disease in this vulnerable population.

Associations between Tobacco, Alcohol, and Drug Use with Coronary Artery Plaque among HIV-Infected and Uninfected Men in the Multicenter AIDS Cohort Study

BACKGROUND

We characterized associations between smoking, alcohol, and recreational drug use and coronary plaque by HIV serostatus within the Multicenter AIDS Cohort Study (MACS).

METHODS

MACS participants (N = 1005, 621 HIV+ and 384 HIV-) underwent non-contrast CT scanning to measure coronary artery calcium; 764 underwent coronary CT angiograms to evaluate plaque type and extent. Self-reported use of alcohol, tobacco, smoked/inhaled cocaine, methamphetamine, ecstasy, marijuana, inhaled nitrites, and erectile dysfunction drugs was obtained at semi-annual visits beginning 10 years prior to CT scanning. Multivariable logistic and linear regression models were performed, stratified by HIV serostatus.

RESULTS

Among HIV+ men, current smoking, former smoking, and cumulative pack years of smoking were positively associated with multiple coronary plaque measures (coronary artery calcium presence and extent, total plaque presence and extent, calcified plaque presence, and stenosis >50%). Smoking was significantly associated with fewer plaque measures of comparable effect size among HIV- men; current smoking and calcified plaque extent was the only such association. Heavy alcohol use (>14 drinks/week) was associated with stenosis >50% among HIV+ men. Among HIV- men, low/moderate (1-14 drinks/week) and heavy alcohol use were inversely associated with coronary artery calcium and calcified plaque extent. Few significant associations between other recreational drug use and plaque measures were observed.

CONCLUSION

Smoking is strongly associated with coronary plaque among HIV+ men, underscoring the value of smoking cessation for HIV+ persons. Alcohol use may protect against coronary artery calcium and calcified plaque progression in HIV- (but not HIV+) men. Few positive associations were observed between recreational drug use and coronary plaque measures.

Exploring Issues of Comorbid Conditions in People Who Smoke

Smoking affects comorbid disease outcomes, and patients with comorbid conditions may have unique characteristics that are important to consider when treating tobacco use. However, addressing tobacco in patients being treated for comorbid conditions is not a consistent practice. Recognizing the need for a "call-to-action" to address tobacco use in people with comorbid conditions, the Tobacco Treatment Network within the Society for Research on Nicotine and Tobacco (SRNT) convened a Comorbidities Workgroup to explore the relationship between smoking and comorbid disease to identify common themes including: the harms associated with continued tobacco use, the frequency of comorbid disease and tobacco use, the potential effect of comorbid disease on the ability to quit tobacco use, the association between tobacco use and suboptimal disease-specific treatment response, and evidence regarding potential approaches to improve addressing tobacco use in patients with comorbid disease. Five candidate conditions (psychiatric, cancer, cardiovascular, pulmonary, and human immunodeficiency virus infected patients) were explored. Across comorbid conditions, smoking adversely affects treatment efficacy and promotes other adverse health conditions. People with comorbid conditions who smoke are motivated to quit and respond to evidence-based smoking cessation treatments. However, tobacco cessation is not regularly incorporated into the clinical care of many individuals with comorbidities. Optimal strategies for addressing tobacco use within each comorbid disease are also not well defined. Further work is needed to disseminate evidence-based care into clinical practice for smokers with comorbid disease and addiction research should consider comorbid conditions as an important construct to explore.

IMPLICATIONS

This article explores how physical and psychiatric conditions may interact in the treatment of tobacco dependence, and discusses the need for smoking cessation as a critical component of comorbid condition management. Five common comorbid domains-psychiatric, cancer, pulmonary, cardiovascular, and human immunodeficiency virus (HIV)-are highlighted to illustrate how these different conditions might interact with smoking with respect to prevalence and harm, motivation to quit, and cessation treatment utilization and success.

HIV and smoking: associated risks and prevention strategies

High rates of smoking among persons living with HIV (PLWH) may reduce the effectiveness of HIV treatment and contribute to significant morbidity and mortality. Factors associated with smoking in PLWH include mental health comorbidity, alcohol and drug use, health-related quality of life, smoking among social networks and supports, and lack of access to care. PLWH smokers are at a higher risk of numerous HIV-associated infections and non-HIV related morbidity, including a decreased response to antiretroviral treatment, impaired immune functioning, reduced cognitive functioning, decreased lung functioning, and cardiovascular disease. Seventeen smoking cessation interventions were identified, of which seven were randomized controlled trials. The most effective studies combined behavioral and pharmacotherapy treatments that incorporated comprehensive assessments, multiple sessions, and cognitive-behavioral and motivational strategies. Smoking cessation interventions that are tailored to the unique needs of diverse samples and incorporate strategies to reduce the risk of relapse are essential to advancing health outcomes in PLWH.

The role of BMI change on smoking abstinence in a sample of HIV-infected smokers

The prevalence of cigarette smoking among persons living with HIV/AIDS (PLWHA) is approximately 40%, significantly higher than that of the general population. Identifying predictors of successful smoking cessation for PLWHA is necessary to alleviate the morbidity and mortality associated with smoking in this population. Weight gain has been associated with smoking relapse in the general population, but has not been studied among PLWHA. Data from 474 PLWHA enrolled in a smoking cessation randomized clinical trial were analyzed to examine the effect of BMI change, from baseline to 3-month follow-up, on smoking outcomes using multiple logistic regression. The odds of 7-day smoking abstinence at 3-month follow-up were 4.22 (95% CI = 1.65, 10.82) times higher for participants classified as BMI decrease and 4.22 (95% CI = 1.62, 11.01) times higher for participants classified as BMI increase as compared to participants with a minimal increase or decrease in BMI. In this sample, both weight gain and loss following smoking cessation were significantly associated with abstinence at 3-month follow-up among HIV-infected smokers. Further research and a better understanding of predictors of abstinence will encourage more tailored interventions, with the potential to reduce morbidity and mortality.

Examining the effect of patient-centred care on outcomes

Within patient-centered care (PCC), the individual is viewed as an active member of the healthcare team. While there has been recent interest in conducting systematic reviews to examine the effectiveness of PCC interventions, various studies fall short in explaining the type of intervention most effective in producing significant changes to desired outcomes. The purpose of this systematic review was to determine the characteristics of PCC interventions that have demonstrated effectiveness in enhancing the quality of care and performance of self-care behaviours. A systematic review of 40 studies that addressed PCC interventions, included samples over the age of 18 years, and were published between 1995 and 2014 was performed. Descriptive statistics were used to delineate study, participant, and intervention characteristics. Results suggest PCC-based interventions are not effective when delivered to individuals living with chronic illnesses.

Evaluating the Effects of an Interdisciplinary Practice Model with Pharmacist Collaboration on HIV Patient Co-Morbidities

Treatment of HIV now occurs largely within the primary care setting, and the principal focus of most visits has become the management of chronic disease states. The clinical pharmacist's potential role in improving chronic disease outcomes for HIV patients is unknown. A retrospective cohort study was performed for HIV-positive patients also diagnosed with diabetes, hypertension, or hyperlipidemia. Characteristics and outcomes in 96 patients treated by an interdisciplinary team that included a clinical pharmacist (i.e., the intervention group) were compared to those in 50 patients treated by an individual healthcare provider (i.e., the control group). Primary outcomes were changes from baseline over 18 months of HbA1c, low density lipoprotein (LDL), and blood pressure, respectively. Secondary outcomes included number of drug-drug interactions, HIV viral load, CD4 count, percent change in smoking status, and percent of patients treated to cardiovascular guideline recommendations. The interdisciplinary team had a significant improvement in lipid management over the control group (LDL: -8.8 vs. +8.4 mg/dL; p=0.014), and the smoking cessation rate over the study period was doubled in the interdisciplinary group (20.4% vs. 11.8%). Among those with an indication for aspirin, a significantly higher percentage of patients were prescribed the medication in the interdisciplinary group compared to the control group (85.5% vs. 64.9%; p=0.014). An informal cost analysis estimated savings of more than $3000 per patient treated by the interdisciplinary team. Based on these results, pharmacist involvement in an HIV primary care clinic appears to lead to more appropriate management of chronic co-morbidities in a cost-effective manner.

Screening for Chronic Obstructive Pulmonary Disease (COPD) in an Urban HIV Clinic: A Pilot Study

Increased smoking and a detrimental response to tobacco smoke in the lungs of HIV/AIDS patients result in an increased risk for COPD. We aimed to determine the predictive value of a COPD screening strategy validated in the general population and to identify HIV-related factors associated with decreased lung function. Subjects at least 35 years of age at an HIV clinic in New York City completed a COPD screening questionnaire and peak flow measurement. Those with abnormal results and a random one-third of normal screens had spirometry. 235 individuals were included and 89 completed spirometry. Eleven (12%) had undiagnosed airway obstruction and 5 had COPD. A combination of a positive questionnaire and abnormal peak flow yielded a sensitivity of 20% (specificity 93%) for detection of COPD. Peak flow alone had a sensitivity of 80% (specificity 80%). Abnormal peak flow was associated with an AIDS diagnosis (p=0.04), lower nadir (p=0.001), and current CD4 counts (p=0.001). Nadir CD4 remained associated in multivariate analysis (p=0.05). Decreased FEV1 (<80% predicted) was associated with lower CD4 count nadir (p=0.04) and detectable current HIV viral load (p=0.01) in multivariate analysis. Questionnaire and peak flow together had low sensitivity, but abnormal peak flow shows potential as a screening tool for COPD in HIV/AIDS. These data suggest that lung function may be influenced by HIV-related factors.

Cigarette smoking prevalence among adults with HIV compared with the general adult population in the United States: cross-sectional surveys

BACKGROUND

The negative health effects of cigarette smoking and HIV infection are synergistic.

OBJECTIVE

To compare the prevalence of current cigarette smoking and smoking cessation between adults with HIV receiving medical care and adults in the general population.

DESIGN

Nationally representative cross-sectional surveys.

SETTING

United States.

PATIENTS

4217 adults with HIV who participated in the Medical Monitoring Project and 27 731 U.S. adults who participated in the National Health Interview Survey in 2009.

MEASUREMENTS

The main exposure was cigarette smoking. The outcome measures were weighted prevalence of cigarette smoking and quit ratio (ratio of former smokers to the sum of former and current smokers).

RESULTS

Of the estimated 419 945 adults with HIV receiving medical care, 42.4% (95% CI, 39.7% to 45.1%) were current cigarette smokers, 20.3% (CI, 18.6% to 22.1%) were former smokers, and 37.3% (CI, 34.9% to 39.6%) had never smoked. Compared with the U.S. adult population, in which an estimated 20.6% of adults smoked cigarettes in 2009, adults with HIV were nearly twice as likely to smoke (adjusted prevalence difference, 17.0 percentage points [CI, 14.0 to 20.1 percentage points]) but were less likely to quit smoking (quit ratio, 32.4% vs. 51.7%). Among adults with HIV, factors independently associated with greater smoking prevalence were older age, non-Hispanic white or non-Hispanic black race, lower educational level, poverty, homelessness, incarceration, substance use, binge alcohol use, depression, and not achieving a suppressed HIV viral load.

LIMITATION

Cross-sectional design with some generalizability limitations.

CONCLUSION

Adults with HIV were more likely to smoke and less likely to quit smoking than the general adult population. Tobacco screening and cessation strategies are important considerations as part of routine HIV care.

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.

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.

Promotion of tobacco use cessation for lesbian, gay, bisexual, and transgender people: a systematic review

CONTEXT

Lesbian, gay, bisexual, and transgender (LGBT) people are at increased risk for the adverse effects of tobacco use, given their high prevalence of use, especially smoking. Evidence regarding cessation is limited. To determine if efficacious interventions are available and to aid the development of interventions, a systematic review was conducted of grey and peer-reviewed literature describing clinical, community, and policy interventions, as well as knowledge, attitudes, and behaviors regarding tobacco use cessation among LGBT people.

EVIDENCE ACQUISITION

Eight databases for articles from 1987 to April 23, 2014, were searched. In February-November 2013, authors and researchers were contacted to identify grey literature.

EVIDENCE SYNTHESIS

The search identified 57 records, of which 51 were included and 22 were from the grey literature; these were abstracted into evidence tables, and a narrative synthesis was conducted in October 2013-May 2014. Group cessation curricula tailored for LGBT populations were found feasible to implement and show evidence of effectiveness. Community interventions have been implemented by and for LGBT communities, although these interventions showed feasibility, no rigorous outcome evaluations exist. Clinical interventions show little difference between LGBT and heterosexual people. Focus groups suggest that care is needed in selecting the messaging used in media campaigns.

CONCLUSIONS

LGBT-serving organizations should implement existing evidence-based tobacco-dependence treatment and clinical systems to support treatment of tobacco use. A clear commitment from government and funders is needed to investigate whether sexual orientation and gender identity moderate the impacts of policy interventions, media campaigns, and clinical interventions.

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.

Evaluation of a Smoking Cessation Program for HIV Infected Individuals in an Urban HIV Clinic: Challenges and Lessons Learned

Introduction. HIV infected persons have high prevalence of smoking and tobacco-associated health risks. Few studies describe smoking cessation programs targeting this population. The Infectious Disease Practice (IDP) in Newark, New Jersey, initiated a smoking cessation program (SCP) for HIV infected smokers. We report participation, abstinence rates, and predictors of abstinence. Methods. This is a prospective cohort study, comparing participants to non-SCP smokers, during April 1, 2011, to October 31, 2012. Intervention included one individualized counseling session with an offer of pharmacotherapy. Univariate and multivariate analyses were performed with self-reported seven-day point prevalence abstinence at six months as primary outcome measure. Results. Among 1545 IDP patients, 774 (51%) were current smokers of whom 123 (16%) participated in the SCP. Mean six-month abstinence rate amongst SCP participants was 16%. A history of cocaine or heroin use was predictive of continued smoking (odds ratio [OR] adjusted 0.20, 95% confidence interval [CI] 0.07-0.55) while smokers in the preparation stage of change were more likely abstinent at six months (OR adjusted 8.26, 95% CI 1.02-66.67). Conclusions. A low-intensity smoking cessation intervention in an HIV treatment setting is effective in a minority of participants. Further research is needed to better address barriers to smoking cessation such as substance use.

Design of a comparative effectiveness evaluation of a culturally tailored versus standard community-based smoking cessation treatment program for LGBT smokers

Background

Smoking prevalence rates among the lesbian, gay, bisexual, and transgender (LGBT) population are significantly higher than the general population. However, there is limited research on smoking cessation treatments in this group, particularly on culturally targeted interventions. Moreover, there are few interventions that address culturally specific psychosocial variables (e.g., minority stress) that may influence outcomes. This paper describes the protocol for a comparative effectiveness trial testing an evidence-based smoking cessation program, Courage to Quit, against a culturally tailored version for LGBT smokers, and examines the role of culturally specific psychosocial variables on cessation outcomes.

Methods/Design

To examine the effectiveness of a culturally targeted versus standard smoking cessation intervention, the study utilizes a 2-arm block, randomized, control trial (RCT) design. Adult LGBT participants (n = 400) are randomized to one of the two programs each consisting of a six-session group program delivered in a community center and an eight week supply of the transdermal nicotine patch. Four individualized telephone counseling sessions occur at weeks 2, 5, 7, and 9, at times of greatest risk for relapse. Study outcome measures are collected at baseline, and 1, 3, 6, and 12 months post quit date. Primary outcomes are expired air carbon monoxide verified 7-day point-prevalence quit rates at each measurement period. Secondary outcomes assess changes in cravings, withdrawal symptoms, smoking cessation self-efficacy, and treatment adherence. Additionally, study staff examines the role of culturally specific psychosocial variables on cessation outcomes using path analysis.

Discussion

Determining the efficacy of culturally specific versus standard evidence based approaches to smoking cessation is a critical issue facing the field today. This study provides a model for the development and implementation of a culturally tailored smoking cessation intervention for LGBT participants and addresses a gap in the field by examining the role of culturally psychosocial variables associated with cessation outcomes.

Trial registration

U.S. National Institutes of Health Clinical Trials NCT01633567 Registered 30 May 2012.

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.

Smoking Cessation Interventions in HIV-Infected Adults in North America: A Literature Review

Cigarette smoking is more prevalent in HIV-infected adults when compared to the general population (50-70%) and is linked to increased morbidity and mortality in this population. Of important clinical relevance, however, 40% of HIV-infected smokers express a willingness to attempt smoking cessation and two-thirds are interested in or considering quitting when asked. The purpose of this paper is to provide a state of the science review of the extant literature on smoking cessation interventions in HIV-infected adults. A comprehensive search of a computerized database for articles appearing in peer-reviewed journals was conducted. The integrative review included 10 articles from medical and nursing journals. Smoking cessation rates ranged from 6%-50% across studies employing pharmacologic and behavioral approaches. Samples sizes were frequently small and the effect was often not sustained over time. Emotional distress was related to smoking behaviors and may have been a barrier to successful smoking cessation. Adherence to pharmacologic therapy often declined over time and may have contributed to low cessation rates. Nicotine replacement therapy combined with a cell phone-delivered intensive counseling intervention showed promising results. Given the high prevalence of smoking among adults infected with HIV, this review supports the need for the development and implementation of innovative and effective interventions tailored to this population that will ultimately result in lower smoking prevalence and improved overall health.