Integrated Treatment for Smoking Cessation, Anxiety, and Depressed Mood in People Living With HIV: A Randomized Controlled Trial

HIV, smoking, and the brain: a convergence of neurotoxicities

PURPOSE OF REVIEW

The purpose of this review is to characterize the combined effects of tobacco smoking and human immunodeficiency virus (HIV) infection in people with HIV (PWH) and identify possible therapeutic targets through shared mechanisms for neurotoxicity.

RECENT FINDINGS

HIV and tobacco smoke can exert neurotoxicity through shared mechanisms such as brain volume changes, microglial dysregulation, and dysregulation of the cholinergic anti-inflammatory pathway (CAP) through the alpha7-nicotinic acetylcholine receptor (nAChR). Evidence also suggests the potential for synergistic effects of HIV and tobacco smoking on neurotoxicity. People with HIV (PWH) are disproportionately affected by both neurocognitive impairment (NCI) and tobacco smoking compared to the general population. Both HIV and tobacco smoking are known to have neurotoxic effects and have the potential for clinically significant impacts on brain health and cognitive functioning. Less, however, is known about how PWH may be uniquely affected by the interactive neurotoxic effects of both HIV and tobacco smoking. Evidence suggests that smoking and HIV can have synergistic effects on neurotoxicity and NCI in PWH. Some mechanisms for neurotoxicity include increased oxidative stress from microglial activation and dysfunction in the alpha7- nAChR cholinergic anti-inflammatory pathway leading to increased neuroinflammation and neuronal apoptosis. Mechanisms may vary by cell type and brain region, however, and there is a need for more human-facing, longitudinal studies on smoking in PWH.

Transdiagnostic Risk Factors for Reasons for Smoking: Evaluating the Concurrent Role of Distress Tolerance and Anxiety Sensitivity

BACKGROUND

Although rates of cigarette smoking have declined in the US, many individuals report experiencing significant barriers to quitting smoking, including poor mental health. Two prominent affective vulnerability factors that independently underlie both smoking behavior and processes and mental health include distress tolerance and anxiety sensitivity. However, limited work has examined the concurrent role of these factors on motivational reasons for smoking.

METHOD

The current study is a secondary analysis of baseline data from a nationally recruited sample of individuals (N = 156; Mage = 29.74, SD = 7.72; 69.2% female) interested in participating in a digitally delivered intervention for comorbid smoking and low distress tolerance. Two-step hierarchical linear regression was used to examine the unique role of self-reported distress tolerance and anxiety sensitivity in relation to reasons for smoking (i.e., habitual, negative affect reduction, addictive, pleasurable/relaxation, stimulation, and sensorimotor manipulation).

RESULTS

Results indicated that lower levels of distress tolerance and greater levels of anxiety sensitivity were associated with greater sensorimotor manipulation reasons for smoking. Only distress tolerance was related to addictive, negative affect reduction, and stimulation reasons for smoking, whereas only anxiety sensitivity was related to habitual reasons for smoking.

CONCLUSION

The current findings suggest that there is an explanatory utility for unique and multi-risk effects for distress tolerance and anxiety sensitivity for understanding smoking motives.

Combustible cigarette smokers versus dual combustible and electronic users: Evaluation of differences in anxiety, depression, and transdiagnostic constructs among Latinx adults

Research on dual combustible and electronic nicotine use among Latinx persons is needed to better understand patterns of use because this group is an established tobacco disparities population. Negative emotional symptoms and related processes (e.g., reactive transdiagnostic vulnerabilities) have been among the most prominent factors linked to the onset, maintenance, and relapse of smoking. As such, the current study sought to compare levels of mental health symptoms among combustible users compared to dual combustible and electronic users among Latinx persons who smoke. The current sample consisted of 297 adult Latinx daily cigarette smokers (Mage = 35.90 years; SD = 8.87; age range 18-61; 36.4% female), of which 92 reported current dual use of an e-cigarette (Mage = 33.34 years; SD = 7.75; age range 19-60; 28.3% female). Differences in anxiety, depression, anxiety sensitivity, emotion dysregulation, and distress tolerance were examined, and we hypothesized that dual users would showcase higher mental health problems. Results indicated that adult Latinx dual users evidenced greater levels of anxiety, depression, emotional dysregulation, anxiety sensitivity, and lower levels of distress tolerance compared to combustible users. The current study sheds light on the clinical importance of affective differences among dual versus combustible Latinx smokers.

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.

Evaluating the Efficacy of Psycho-Behavioral Interventions for Cardiovascular Risk among People Living with HIV: A Systematic Review and Meta-Synthesis of Randomized Controlled Trials

People with HIV (PWH) are disproportionately affected by cardiovascular disease (CVD). Psycho-behavioral therapies are capable of targeting the pathophysiology underlying HIV-CVD comorbidity. This study synthesized findings from randomized controlled trials (RCTs) of psycho-behavioral therapies for reducing CVD risk among PWH following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Inclusion criteria were: (1) utilized an RCT design, (2) evaluated a cognitive-behavioral or mindfulness-based therapy, (3) sampled adults (age ≥18 years) with HIV, (4) measured a behavioral (e.g., diet) or biological (e.g., immune functioning) CVD risk factor, and (5) published in an English-language peer-reviewed journal. Electronic searches were conducted in six databases (e.g., MEDLINE) using controlled vocabulary and free-text synonyms for HIV, psycho-behavioral therapy, and CVD risk. Data were independently extracted with consensus reached. Outcomes were immune activation, tobacco-smoking, stress, inflammation, and physical activity from 33 studies. There were stronger effects for psycho-behavioral interventions compared to controls on CD4 (Hedge's g=0.262, 95% Confidence Interval [CI]=0.127, 0.396) and tobacco-smoking abstinence (Hedge's g=0.537, 95% CI=0.215, 0.86). There were no differences or insufficient data for stress, inflammation, or physical activity. No eligible studies examined psycho-behavioral interventions on blood pressure, lipids, or weight in PWH. There is increasing importance to further invest in broader CVD risk reduction effort for PWH that include psycho-behavioral intervention strategies.

Efficacy and implementation of exercise-based smoking cessation treatment for adults with high anxiety sensitivity (STEP): Study protocol for a randomized controlled trial

Anxiety sensitivity (AS), reflecting the fear of bodily sensations, is a transdiagnostic vulnerability factor that underpins both affective psychopathology and smoking. Phase II research supports the efficacy of a 15-week community-based intervention (STEP) that combines high-intensity exercise offered by the YMCA with standard smoking cessation treatment (tobacco quitline and nicotine replacement therapy) for sedentary smokers with elevated AS. This Phase III study aims to enroll 360 adults to evaluate whether STEP efficacy for achieving smoking abstinence generalizes to Black and Hispanic smokers with elevated AS.

Differences in smoking behavior and beliefs about abstinence among Latinx individuals with and without depression who smoke cigarettes

There is a well-established relation between depression and smoking in the general population. However, past work focused on Latinx persons who smoke in relation to depressed affect has yielded inconsistent findings. The present investigation aimed to build on past research and evaluate differences among English-speaking Latinx adults who smoke combustible cigarettes with and without probable depression in terms of cigarette dependence, perceived barriers for quitting, severity of problems when quitting, and smoking abstinence expectancies. The current sample included 338 adult Latinx daily cigarette smokers (Mage = 35.53 years; SD = 8.65; age range 18-61; 37.3% female) that were recruited nationally throughout the US. Results indicated that among Latinx persons who smoke, those with probable depression (compared to those without) demonstrated higher levels of cigarette dependence, more severe problems when trying to quit, greater perceived barriers for quitting, and increased negative abstinence expectancies after adjusting for sociodemographic and concurrent substance use variables. Future work could build from this research to elucidate the role of depression in the maintenance and relapse of smoking among the Latinx population.

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.

The Relationship Between Cigarette Dependence and Cessation Methods: Implications for Smoking Cessation Among People With HIV

OBJECTIVE

These analyses investigate how dependence may be related to cessation method choice and how this relationship may vary by subpopulation among people with HIV (PWH) who smoke cigarettes.

METHOD

PWH who smoke (N = 71) were recruited from clinics in Boston, MA. The Fagerström Test for Nicotine Dependence (FTND) and Smoking History Questionnaire (SHQ) were completed to assess for cigarette dependence, past-week cigarettes per day (CPD), and past cessation method use. Logistic regression examined the association between dependence and previous cessation methods for the whole sample, and moderation analyses assessed this relationship by age and race.

RESULTS

Higher FTND was associated with less use of behavioral modification methods (odds ratio [OR] = 0.658, 95% CI [0.435, 0.994], p = .047). Higher past-week CPD was associated with use of the American Cancer Society/American Lung Association (ACS/ALA) programs (OR = 1.159, 95% CI [1.011, 1.328], p = .035) and telephone counselling (OR = 1.142, 95% CI [1.006, 1.295], p = .040]). Older participants with more past-week CPD were more likely to have used the ACS/ALA programs (B = 0.0169, 95% CI [0.0008, 0.0331], p = .0401), and White participants with more past-week CPD were less likely to have tried to quit "cold turkey" (B = 0.1676, 95% CI [0.0027, 0.3326], p = .0464).

CONCLUSIONS

These preliminary results suggest that there is likely not a "one-size-fits-all" approach to cessation for PWH who smoke, especially within subpopulations (i.e., age and race). Implications include ensuring access to multiple cessation methods, identifying methods that could be culturally appropriate outside of the clinical intervention setting, and providing education and support on cessation methods offered.

HIV and hypertension epidemiology

PURPOSE OF REVIEW

The aim of this study was to provide an overview of the burden, pathogenesis, and recent recommendations for treating hypertension among people living with HIV (PLWH). This review is relevant because of the increase in the prevalence of HIV as a chronic disease and the intersection of the increasing prevalence of hypertension.

RECENT FINDINGS

The contribution of HIV to the pathogenesis of hypertension is complex and still incompletely understood. Evidence suggests that chronic inflammation from HIV, antiretroviral treatment (ART), and comorbidities such as renal disease and insulin resistance contribute to developing hypertension in PLWH. Treatment is not distinct from guidelines for HIV-noninfected people. Nonpharmacological guidelines such as decreasing blood pressure by promoting a healthy lifestyle emphasizing exercise, weight loss, and smoking cessation are still recommended in the literature. The pharmacological management of hypertension in PLWH is similar, but special attention must be given to specific drugs with potential interaction with ART regimens. Further research is needed to investigate the pathways and effects of hypertension on HIV.

SUMMARY

There are different pathways to the pathogenesis of hypertension in PLWH. Clinicians should take it into consideration to provide more precise management of hypertension in PLWH. Further research into the subject is still required.

Latinx Individuals Who Smoke Daily with and without a Probable Anxiety Disorder: Differences in Smoking Behavior and Beliefs about Abstinence

There is a well-established relation between anxiety psychopathology and smoking in the general population. However, little work focuses on Latinx/Hispanic (hereafter Latinx) persons who smoke from this comorbidity perspective. The present investigation aimed to explore differences among English-speaking Latinx adults who live in the United States (US) and smoke cigarettes with and without a probable anxiety disorder in terms of cigarette dependence, perceived barriers for quitting, severity of problems when quitting, and smoking abstinence expectancies. The sample included 338 adult Latinx daily cigarette smokers (Mage = 35.53 years; SD = 8.65; age range 18-61; 37.3% female) who identified as Latinx and were recruited nationally throughout the US. Results indicated that among Latinx persons who smoke, those with a probable anxiety disorder (compared to those without) were more likely to demonstrate higher levels of cigarette dependence, severity of problems when trying to quit, perceived barriers for quitting, and negative abstinence expectancies after adjusting for key variables linked to smoking and anxiety (e.g., hazardous drinking, education). The current findings are the first to document probable anxiety disorder status as a clinically relevant factor for a wide range of smoking variables and beliefs about abstinence among Latinx persons who smoke.

Estimates of prevalence, time-trend, and association of smoking in adults living with HIV, HBV, and HCV (NHANES 1999-2018)

Although the smoking rate of human immunodeficiency virus (HIV), hepatitis B virus (HBV) or hepatitis C virus (HCV) infected people was much higher than that of the general population, smoking cessation interventions have long been ineffective. We aimed to examine the estimates of prevalence, time-trend, and association of smoking among people living with HIV, HBV, or HCV. This cohort was composed of 32,115 individuals from the NHANES database (1999-2018) and they were collected in the US. The time trend analysis of smoking and quitting rates was conducted using different years of survey follow-up and different infected groups. Multivariable logistic regression analysis was used to identify the risk factors related to smoking behavior of these infected people. Compared to non-infected smokers, infected smokers were more likely to be older (aged 30-39, OR = 9.92, CI 6.07-16.21; aged 40-49,OR = 3.51, CI 2.49-4.94), males (1.99, 1.54-2.55), lower education and economic level (1.78, 1.39-2.29; 2.05, 1.59-2.65), unemployed (1.63, 1.21-2.20), suffering depression (1.35, 1.05-1.72), and drug users (7.65, 5.04-11.59). Taken together, our study showed that these complex psychosocial characteristics and unhealthy behavioral factors might be major independent risk factors for increasing smoking rate and decreasing smoking cessation rate among these infected people.

Approach bias retraining to augment smoking cessation: A pilot randomized controlled trial

BACKGROUND

Approach tendency to smoking-related cues has been associated with greater cravings, nicotine dependence, and the likelihood of relapse. In this pilot randomized clinical trial, we examined the efficacy of approach bias retraining (ABR; i.e., increasing avoidance tendency) for enhancing standard smoking cessation treatment (ST).

METHODS

Adult smokers (N = 96) motivated to quit were randomly assigned to 7 weekly in-person treatment sessions consisting of either (1) cognitive-behavioral therapy for smoking cessation (ST) and ABR (ST+ABR) or ST and sham retraining (ST+Sham). All participants also received optional nicotine replacement therapy for up to 8 weeks following the scheduled quit date (week 6). We measured avoidance tendency from weeks 1-7. Point prevalence abstinence (PPA) and prolonged abstinence (PA) were measured up to 3 months following the quit attempt (week 18 follow-up).

RESULTS

Consistent with our hypothesis, participants in ST+ABR evidenced higher abstinence rates than those in ST+Sham at the final follow-up (b=0.71, 95 % CI: [0.14, 1.27], t[1721]=2.46, p = 0.014, OR=2.03, 95 % CI: [1.15, 3.57]). Specifically, PPA and PA rates were 50 % and 66 % in ST+ABR compared to 31 % and 47 % in ST+Sham. As expected, participants assigned to the ST+ABR condition also showed a greater training-compatible increase in avoidance tendency scores relative to those assigned to the ST+Sham condition (b=248.06, 95 % CI: [148.51, 347,62], t[84]=4.96, p < .001).

CONCLUSIONS

The current pilot randomized clinical trial provides initial evidence for the efficacy of integrating standard smoking cessation with ABR. These findings encourage the testing of the long-term efficacy and mechanisms of action of this integrated intervention.

Tobacco Use and Treatment of Tobacco Dependence Among People With Human Immunodeficiency Virus: A Practical Guide for Clinicians

More than 40% of people with human immunodeficiency virus (PWH) in the United States smoke tobacco cigarettes. Among those on antiretroviral therapy, smoking decreases life expectancy more than human immunodeficiency virus (HIV) itself. Most PWH who smoke want to quit, but tobacco dependence treatment has not been widely integrated into HIV care. This article summarizes the epidemiology of tobacco use among PWH, health consequences of tobacco use and benefits of cessation in PWH, and studies of treatment for tobacco dependence among the general population and among PWH. We provide practical guidance for providers to treat tobacco dependence among PWH. A 3-step Ask-Advise-Connect framework includes asking about tobacco use routinely during clinical encounters, advising about tobacco cessation with emphasis on the benefits of cessation, and actively connecting patients to cessation treatments, including prescription of pharmacotherapy (preferably varenicline) and direct connection to behavioral interventions via telephone quitline or other means to increase the likelihood of a successful quit attempt.

Predictors of Adherence to Smoking Cessation Medications among Current and Ex-Smokers in Australia: Findings from a National Cross-Sectional Survey

Background: Adherence to smoking cessation medications (SCMs) improve the rate of successful quitting. This study aimed to evaluate the level of adherence to SCMs and associated factors among smokers and ex-smokers in Australia. Method: A cross-sectional study using an online survey was conducted in Australia. Descriptive statistics were used to present the overall characteristics of participants. Cross-tabulation with Pearson’s chi-square test was performed to evaluate the possible associations between factors. To explore barriers and facilitators of adherence to SCMs, logistic regressions were conducted. Results: Among 201 participants, 57 (28.4%) were found to be adherent to SCMs. The odds of being adherent were found to be higher among participants with good social support (AOR = 3.28, 95% CI of 2.30–6.27). Participants who did not experience anxiety symptoms had higher odds of being adherent to SCMs as compared to smokers who had anxiety symptoms (AOR = 4.41, 95% CI of 3.64–14.68). Having previous experience of using SCMs improved adherence four-fold (AOR = 3.87, 95% CI of 1.11–13.44). Level of nicotine dependence showed a direct association with adherence (AOR = 3.53, 95% CI of 1.40–8.95). Not relapsing while on the medications improved adherence (AOR = 2.88, 95% CI of 1.21–6.88). Conclusion: In a study of smokers and ex-smokers in Australia, the self-reported level of adherence to SCMs was found to be low. Adherence was associated with social, psychological, and medication-related factors. Smoking cessation interventions are recommended to include strategies that can address medication adherence.

Community-based smoking cessation treatment for adults with high anxiety sensitivity: a randomized clinical trial

BACKGROUND AND AIMS

People with anxiety disorders are more likely to smoke and less likely to succeed when they try to quit. Anxiety sensitivity may underlie both phenomena, such that people with high anxiety sensitivity react to interoceptive distress by avoidance. This study aimed to test the efficacy of an exercise program that induced interoceptive distress and thereby created tolerance to this distress in a safe environment.

DESIGN, SETTING AND PARTICIPANTS

Randomized clinical trial at four YMCA branches in Austin, Texas, USA. Participants [n = 150; 130 (86.7%) white; 101 (67.3%) female; mean_age  = 38.6, standard deviation (SD)_age  = 10.4] were adult, daily smokers with high anxiety sensitivity motivated to quit smoking, who reported no regular moderate-intensity exercise.

INTERVENTIONS

Participants were assigned a YMCA personal trainer who guided them through a 15-week intervention aerobic exercise program. Participants assigned to the personalized intervention trained at 60-85% of their heart rate reserve (HRR), whereas participants assigned to the control intervention trained at 20-40% of their HRR. Participants in both groups received standard behavioral support and nicotine replacement therapy.

MEASUREMENTS

The primary outcome was biologically verified 7-day point prevalence abstinence (PPA) at 6-month follow-up.

FINDINGS

Sixty-one per cent of participants were available at the 6-month follow-up. PPA at 6 months was higher in the personalized intervention than the control intervention [27.6 versus 14.8%; odds ratio (OR) = 2.20, 95% confidence interval (CI) = 1.28, 3.80, P = 0.005], assuming missing at random. Anxiety sensitivity declined in both groups with no evidence that this differed between groups.

CONCLUSIONS

An exercise program of high intensity increased abstinence from smoking in people with high anxiety sensitivity, but may not have done so by reducing anxiety sensitivity.

Tobacco Use and Health-Related Quality of Life Among Individuals with Depression Who Are Receiving Treatment for HIV in Cape Town, South Africa

BACKGROUND

Tobacco use is the leading cause of preventable death worldwide, and prevalence rates are high among people living with HIV (PLWH), particularly in men. Depression is also common among PLWH, especially among smokers, who may use tobacco to manage mood. Although HIV and depression have been linked to functional impairment and poor health-related quality of life (HRQOL), little research has examined the degree to which smoking impacts these relationships in low- and middle-income countries with high HIV burden.

METHOD

Participants (N = 289) were people living with HIV (PLWH) who were being assessed for inclusion in a study targeting depression as a barrier to HIV medication adherence. Linear regression models measured the effect of gender on tobacco use (assessed by the WHO-ASSIST) and on each of the five HRQOL functional impairment domains (assessed by the SF-21). Separate multivariable regression models examined the relationships between habitual tobacco use, defined as daily, almost daily, or weekly use, and the HRQOL domains.

RESULTS

The prevalence of habitual tobacco use was 23.9% (48.1% among men, 15.5% among women). Habitual tobacco use was associated with decreased cognitive functioning for the whole sample (B = - 8.99, p < 0.05) and with lower levels of pain-related impairment for men (B = 18.1, p < 0.05). Although men reported more tobacco use (B = 8.50, p < 0.001), they reported less pain-related limitations than women (B = 8.70, p < 0.05).

CONCLUSIONS

In our sample, men reported higher rates of habitual tobacco use than women. Smoking was associated with cognitive impairment and with less pain-related impairment among men. Future smoking cessation treatments tailored to PLWH who have symptoms of depression may benefit from strategies that consider pain management as a pathway to habitual smoking and recognize that motivations for use may differ by gender.

Patterns of E-Cigarette Use Among Primary Care Patients at an Urban Community Center

Tobacco use remains the leading cause of preventable disease and death in the US. The number of tobacco products has grown over the past decade. E-cigarette use has increased rapidly in recent years, but patterns and correlates of use have not been thoroughly assessed. We examined relationships among demographic factors, e-cigarette and conventional cigarette use in a large sample (N = 12,409) of adult patients at a community health center in the Northeastern US. Overall, 13% (N = 1675) of the sample reported ever using e-cigarettes. In logistic regression models, ever having used e-cigarettes was associated with younger age (ages 18-25; OR = 3.5, p < 0.001). Being transgender (OR = 1.8, p < 0.001), bisexual (OR = 1.5, p < 0.001), un-partnered (OR = 1.5, p < 0.001), having a lower income (OR = 1.6, p < 0.001) or a high BMI (OR = 1.4, p = 0.009) were associated with increased odds of use, whereas being a woman (OR = 0.7, p < 0.001) or Black/African American (OR = 0.7, p = 0.007) were associated with lower odds of use. Of the participants who reported e-cigarette use, a majority also endorsed current or former use of conventional cigarettes. Individuals who formerly used conventional cigarettes were nearly three times more likely to report daily e-cigarette use than current users. Among primary care patients at a community health center, e-cigarette use was reported by a sizeable portion of the sample. Overall, odds of use were higher in certain patient populations, and individuals who formally used cigarettes were more likely to report e-cigarette use than individuals who currently smoke, suggesting that e-cigarettes may be functioning as a cessation aid or a strategy to reduce conventional cigarette use.

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.

National Estimates of Prevalence, Time-Trend, and Correlates of Smoking in US People Living with HIV (NHANES 1999-2016)

OBJECTIVE

Approximately one in four deaths among people living with HIV (PLWH) in the United States can be attributed to cigarette smoking. Using a nationally representative sample of PLWH, this study examines the prevalence, time-trends, and correlates of current cigarette smoking among PLWH compared to people without HIV.

DESIGN

Secondary analysis of population-based cross-sectional biobehavioral survey.

METHODS

Data were pooled from the 1999-2016 National Health and Nutrition Examination Survey (NHANES). All adults (20-59 years) who self-reported their smoking status and were tested for HIV (HIV+ = 152; HIV- = 26 305) were included in the analysis. Prevalence with 95% confidence interval (95% CI), trend analysis by year and group (HIV+/HIV-), and multivariable logistic regression analyses were performed with the complex survey design adjustments.

RESULTS

Overall, 47.0% of PLWH were current smokers compared to 25.5% of those without HIV. From 1999 to 2016, the decline in smoking in PLWH was comparable to those without HIV (10.7% vs. 8.0%). PLWH smokers were more likely than PLWH nonsmokers to be substance users (adjusted odds ratio [aOR] = 17.52; 95% CI = 2.04 to 27.8). Compared to smokers without HIV, PLWH smokers were more likely to be older (1.10; 1.06 to 1.14), males (7.96; 2.50 to 25.40), non-Hispanic Black (10.45; 4.13 to 26.45), with depression (Patient Health Questionnaire-9 sum score ≥5) (3.79; 1.22 to 11.79), and less likely to be gay (0.02; 0.00 to 0.07).

CONCLUSION

Cigarette smoking among PLWH is a major public health problem in the United States. Targeted and tailored smoking cessation interventions that incorporate assessment and treatment of depression and co-occurring substance use are critical for PLWH, especially among those who are disproportionately affected by smoking and HIV (sexual minority).

IMPLICATIONS

This study offers important research implications in four areas:1. The decline in smoking among PLWH over 18 years has been modest, and half of PLWH are still smokers.2. More resources and efforts should be allocated to reduce cigarette smoking among PLWH.3. There is a critical need to develop and test culturally tailored smoking cessation interventions for minority subgroups who are most impacted by HIV infection and smoking (non-Hispanic Blacks and men who have sex with men)4. Smoking cessation interventions designed for PLWH should incorporate assessment and treatment of depression and substance use.

Prevalence and impact of comorbid chronic pain and cigarette smoking among people living with HIV

Rates of chronic pain and cigarette smoking are each substantially higher among people living with HIV (PLWH) than in the general population. The goal of these analyses was to examine the prevalence and impact of comorbid chronic pain and cigarette smoking among PLWH. Participants included 3289 PLWH (83% male) who were recruited from five HIV clinics. As expected, the prevalence of smoking was higher among PLWH with chronic pain (41.9%), than PLWH without chronic pain (26.6%, p < .0001), and the prevalence of chronic pain was higher among current smokers (32.9%), than among former (23.6%) or never (17%) smokers (ps < .0001). PLWH who endorsed comorbid chronic pain and smoking (vs. nonsmokers without chronic pain) were more likely to report cocaine/crack and cannabis use, be prescribed long-term opioid therapy, and have virologic failure, even after controlling for relevant sociodemographic and substance-related variables (ps < .05). These results contribute to a growing empirical literature indicating that chronic pain and cigarette smoking frequently co-occur, and extend this work to a large sample of PLWH. Indeed, PLWH may benefit from interventions that are tailored to address bidirectional pain-smoking effects in the context of HIV.

Connecting the dots: a comparison of network analysis and exploratory factor analysis to examine psychosocial syndemic indicators among HIV-negative sexual minority men

Syndemics, or comorbid and mutually reinforcing psychosocial problems, are associated with increased HIV risk among men who have sex with men (MSM). Although the dynamic interplay among syndemic indicators is theorized to be crucial for increasing risk of HIV acquisition, novel approaches are needed to understand how these syndemic problems interrelate. This study examined the associations between nine self-reported syndemic indicators in 194 MSM at high risk of HIV acquisition. We compared exploratory factor analyses (EFA) to a network analysis. In the present study, network analysis consisted of edges representing bidirectional partial polychoric correlations between nodes, which represent psychosocial syndemic indicators. EFA yielded a 1-factor solution including suicidal ideation (SI), injection drug use (IDU), depression, social anxiety, intimate partner violence, substance use, and sexual compulsivity, and excluded heavy drinking and childhood sexual abuse. Network analysis yielded a pattern of interconnectedness with the most central nodes being SI, IDU, substance use, and depression. Statistically significant relationships (absolute edge weights) were found between SI and depression, social anxiety, and IDU, and IDU and substance use. These results suggest that depression and substance use, especially more severe presentations of these conditions such as SI and IDU, are prominent interconnected components of the HIV syndemic among MSM at high risk for HIV acquisition. SI, IDU, substance use, and depression may indeed be prudent targets of intervention. Future research on the inclusion of these syndemic indicators in analytical models involving interaction terms may be warranted.

Contribution of Behavioral Health Factors to Non-AIDS-Related Comorbidities: an Updated Review

PURPOSE OF REVIEW

We summarize recent literature on the contribution of substance use and depression to non-AIDS-related comorbidities. Discussion of recent randomized clinical trials and implementation research to curtail risk attributed to each behavioral health issue is provided.

RECENT FINDINGS

Smoking, unhealthy alcohol use, opioid use, and depression are common among PWH and individually contribute to increased risk for non-AIDS-related comorbidities. The concurrence of these conditions is notable, yet understudied, and provides opportunity for linked-screening and potential treatment of more than one behavioral health factor. Current results from randomized clinical trials are inconsistent. Investigating interventions to reduce the impact of these behavioral health conditions with a focus on implementation into clinical care is important. Non-AIDS-defining cancers, cardiovascular disease, liver disease, and diabetes are leading causes of morbidity in people with HIV. Behavioral health factors including substance use and mental health issues, often co-occurring, likely contribute to the excess risk of non-AIDS-related comorbidities.

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.

Cardiovascular disease in HIV patients: recent advances in predicting and managing risk

INTRODUCTION

Cardiovascular disease (CVD) is one of the leading causes of mortality in virally suppressed people living with HIV (PLWH) and with an aging population, is likely to become one of the leading challenges in maintaining good health outcomes in HIV infection. However, factors driving the risk of CVD in PLWH are multiple and may be different from those of the general population, raising challenges to predicting and managing CVD risk in this population.

AREAS COVERED

In this review, we examine the relevant data regarding CVD in HIV infection including CVD prevalence, pathogenesis, and other contributing factors. We review the data regarding CVD risk prediction in PLWH and summarize factors, both general and HIV specific, that may influence CVD risk in this population. And finally, we discuss appropriate management of CVD risk in PLWH and explore potential therapeutic pathways which may mitigate CVD risk in the future in this population.

EXPERT OPINION

Following a comprehensive review of CVD risk in PLWH, we give our opinion on the primary issues in risk prediction and management of CVD in HIV infected individuals and discuss the future direction of CVD management in this population.

Cognitive Behavioral and Mindfulness-Based Interventions for Smoking Cessation: a Review of the Recent Literature

PURPOSE OF REVIEW

Cigarette smoking is the primary cause of cancer and is the leading preventable cause of morbidity and mortality. Cognitive behavioral therapy (CBT) is one of the most well-established and efficacious interventions for smoking cessation. The study of mindfulness-based interventions (MBIs) has increased exponentially in recent years, showing efficacy for smoking cessation as well. This review highlights research from the past 5 years examining CBT and MBIs for smoking cessation.

RECENT FINDINGS

Both CBT and MBIs are efficacious for special populations (e.g., low SES; pregnant smokers) and have shown initial efficacy when delivered via mhealth/ehealth. CBT has shown efficacy when combined with another behavioral treatment (e.g., ACT). Continued research is needed on CBT and MBIs that have high potential for scalability. Understanding whether they are beneficial for certain populations (e.g., cancer survivors), along with determining for whom CBT vs MBIs are most effective, is also needed.

Enhancing panic and smoking reduction treatment with D-Cycloserine: A pilot randomized clinical trial

In this placebo-controlled randomized clinical trial, we examined the efficacy of 250 mg d-cycloserine (DCS) for enhancing the effects of cognitive behavior therapy targeting anxiety sensitivity reduction in the context of smoking cessation treatment among adults with a history of panic attacks. We hypothesized that DCS would enhance treatment of our mechanistic targets-anxiety sensitivity and panic and related symptoms-and result in greater smoking abstinence. A total of 53 smokers were randomized to a 7-week integrated treatment and received study medication (DCS or placebo) prior to sessions 3-5; these sessions emphasized interoceptive exposure practice. Nicotine replacement therapy was initiated at session 5 (quit date). We found that DCS augmentation led to greater reductions of one (anxiety sensitivity) of two of our mechanistic targets at early but not late assessments, and that engaging that target predicted better smoking outcomes. However, there was no evidence of group (DCS vs. placebo) differences in smoking cessation success at treatment endpoint or follow-up evaluations. Hence, although we found that DCS can enhance treatment targeting a smoking maintaining factor, additional strategies appear to be needed to significantly affect smoking outcomes.

Additional behavioural support as an adjunct to pharmacotherapy for smoking cessation

BACKGROUND

Pharmacotherapies for smoking cessation increase the likelihood of achieving abstinence in a quit attempt. It is plausible that providing support, or, if support is offered, offering more intensive support or support including particular components may increase abstinence further.

OBJECTIVES

To evaluate the effect of adding or increasing the intensity of behavioural support for people using smoking cessation medications, and to assess whether there are different effects depending on the type of pharmacotherapy, or the amount of support in each condition. We also looked at studies which directly compare behavioural interventions matched for contact time, where pharmacotherapy is provided to both groups (e.g. tests of different components or approaches to behavioural support as an adjunct to pharmacotherapy).

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group Specialised Register, clinicaltrials.gov, and the ICTRP in June 2018 for records with any mention of pharmacotherapy, including any type of nicotine replacement therapy (NRT), bupropion, nortriptyline or varenicline, that evaluated the addition of personal support or compared two or more intensities of behavioural support.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials in which all participants received pharmacotherapy for smoking cessation and conditions differed by the amount or type of behavioural support. The intervention condition had to involve person-to-person contact (defined as face-to-face or telephone). The control condition could receive less intensive personal contact, a different type of personal contact, written information, or no behavioural support at all. We excluded trials recruiting only pregnant women and trials which did not set out to assess smoking cessation at six months or longer.

DATA COLLECTION AND ANALYSIS

For this update, screening and data extraction followed standard Cochrane methods. 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 random-effects model.

MAIN RESULTS

Eighty-three studies, 36 of which were new to this update, met the inclusion criteria, representing 29,536 participants. Overall, we judged 16 studies to be at low risk of bias and 21 studies to be at high risk of bias. All other studies were judged to be at unclear risk of bias. Results were not sensitive to the exclusion of studies at high risk of bias. We pooled all studies comparing more versus less support in the main analysis. Findings demonstrated a benefit of behavioural support in addition to pharmacotherapy. When all studies of additional behavioural therapy were pooled, there was evidence of a statistically significant benefit from additional support (RR 1.15, 95% CI 1.08 to 1.22, I² = 8%, 65 studies, n = 23,331) for abstinence at longest follow-up, and this effect was not different when we compared subgroups by type of pharmacotherapy or intensity of contact. This effect was similar in the subgroup of eight studies in which the control group received no behavioural support (RR 1.20, 95% CI 1.02 to 1.43, I² = 20%, n = 4,018). Seventeen studies compared interventions matched for contact time but that differed in terms of the behavioural components or approaches employed. Of the 15 comparisons, all had small numbers of participants and events. Only one detected a statistically significant effect, favouring a health education approach (which the authors described as standard counselling containing information and advice) over motivational interviewing approach (RR 0.56, 95% CI 0.33 to 0.94, n = 378).

AUTHORS' CONCLUSIONS

There is high-certainty evidence that providing behavioural support in person or via telephone for people using pharmacotherapy to stop smoking increases quit rates. Increasing the amount of behavioural support is likely to increase the chance of success by about 10% to 20%, based on a pooled estimate from 65 trials. Subgroup analysis suggests that the incremental benefit from more support is similar over a range of levels of baseline support. More research is needed to assess the effectiveness of specific components that comprise behavioural support.

Perceived cancer-related benefits of quitting smoking and associations with quit intentions among recently diagnosed cancer patients

One third of smokers diagnosed with cancer continue smoking, perhaps due to low perceived cancer-related benefits of cessation. To examine perceived cancer-related benefits of quitting among newly diagnosed cancer patients who smoke and associations with quit intentions, baseline measures from patients (N = 303) enrolled in a randomized controlled trial were analyzed using hierarchical regression models and bootstrapping. Higher perceived cancer-related benefits of quitting were associated with having a smoking-related cancer and less education. Perceived cancer-related benefits of quitting and quit intentions were positively correlated, particularly among patients with smoking-related cancers. For smokers with smoking-related cancers, perceived cancer-related benefits of quitting are correlated with quit intentions.

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.