Randomized Trial of a Web-Based Tobacco Treatment and Online Community Support for People With HIV Attempting to Quit Smoking Cigarettes

Efficacy of Smoking Cessation Interventions among People with HIV in Kenya

BACKGROUND

People with human immunodeficiency virus (HIV) smoke at much higher rates than the general population, resulting in higher risk for tobacco-related morbidity and mortality. The efficacy of smoking cessation interventions among people with HIV in lower-middle-income countries remains unclear.

METHODS

We conducted a randomized, 2 × 2 factorial design trial based in Nairobi, Kenya, to evaluate the efficacy of bupropion versus placebo, and a culturally tailored behavioral cessation therapy, called Positively Smoke Free (PSF), versus standard of care for people with HIV who smoke. The primary outcome was 7-day point prevalence abstinence confirmed by exhaled carbon monoxide <7 ppm at 36 weeks.

RESULTS

Between June 2020 and August 2023, 300 participants were randomly assigned. Most participants were men (71.4%) who were moderately dependent on nicotine (Fagerström Test of Cigarette Dependence, mean [SD]: 4.5 [2.3]; range: 0-10; higher scores represent greater physical dependence on nicotine); nearly all participants (99.7%) were taking antiretroviral medication. At 36 weeks, 31.3% of participants who received bupropion were abstinent from smoking, compared with 13.3% in the placebo group (odds ratio, 2.95; 95% confidence interval [CI], 1.64-5.32, P<0.001). Among participants randomized to receive PSF therapy, 29.5% were abstinent from smoking, compared with 14.9% in the standard of care group (odds ratio, 2.39; 95% CI, 1.34-4.25, P=0.003). The combination of bupropion+PSF was associated with increased abstinence compared with either bupropion (38.9% vs. 23.6%; odds ratio, 2.06; 95% CI, 1.00-4.23) or PSF (38.9% vs. 20.3%; odds ratio, 2.50; 95% CI, 1.20-5.24) alone. Participants randomized to receive bupropion were significantly more likely to report excessive sweating compared with placebo (50.7% vs. 37.6%; P=0.024).

CONCLUSIONS

Both bupropion and PSF cessation counseling were effective in promoting abstinence from smoking at 36 weeks. The combined intervention was associated with higher abstinence rates than either therapy alone. (The National Cancer Institute provided support for this trial through grant R01CA225419.).

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.

Technology-based interventions for tobacco smoking prevention and treatment: a 20-year bibliometric analysis (2003-2022)

BACKGROUND

Substance abuse, particularly tobacco smoking, is a significant global public health concern. Efforts have been made to reduce smoking prevalence and promote cessation, but challenges, such as nicotine addiction, marketing tactics by tobacco industry, and cultural acceptability hinder progress. Technology has emerged as a potential tool to address these challenges by providing innovative scalable interventions. The objective of the study was to analyze and map scientific literature on technology-based intervention for tobacco prevention and treatment.

METHODS

A bibliometric methodology was conducted. Scopus database was used to retrieve relevant research articles published between 2003 and 2022. The analysis included publication trends, key contributors, research hotspots, research themes, the most impactful articles, and emerging research topics.

RESULTS

A total of 639 articles were found, with a slow and fluctuating growth pattern observed after 2011. The Journal of Medical Internet Research was the most prominent journal in the field. The United States was the leading country in the field, followed up by the United Kingdom, and the Netherlands. Research hotspots included smoking cessation, randomized controlled trials, and technology-based methods such as internet, mHealth, smartphone apps, text messages, and social media. Four primary research themes were identified: development of smartphone applications, efficacy of text messaging interventions, acceptance and effectiveness of smartphone applications, and interventions targeting young adults and students using mobile phone and social media platforms. The top 10 cited articles demonstrated effectiveness of digital interventions in promoting smoking cessation rates and reducing relapse rates. Emerging research topics included the use of virtual reality interventions, interventions for specific populations through personalized tools, and technology-based interventions in non-Western countries.

CONCLUSIONS

The findings of the current study highlight the potential of technology to address the challenges associated with tobacco smoking. Further future research in this area is warranted to continue advancing the field and developing effective and evidence-based interventions to combat tobacco smoking.

The Role of Seed Users in Nurturing an Online Health Community for Smoking Cessation Among People With HIV/AIDS

BACKGROUND

To nurture a new online community for health behavior change, a fruitful strategy is to recruit "seed users" to create content and encourage participation.

PURPOSE

This study evaluated the impact of support from seed users in an online community for smoking cessation among people living with HIV/AIDS and explored the linguistic characteristics of their interactions.

METHODS

These secondary analyses examined data from a randomized trial of a smoking cessation intervention for HIV+ smokers delivered via an online health community (OHC). The analytic sample comprised n = 188 participants randomized to the intervention arm who participated in the community. Independent variables were OHC interactions categorized by participant interlocutor type (study participant, seed user) and interaction type (active, passive). The primary outcome was biochemically verified 7-day abstinence from cigarettes measured 3 months post-randomization; 30-day abstinence was examined for robustness.

RESULTS

Logistic regression models showed that participants' interactions with seed users were a positive predictor of abstinence but interactions with other study participants were not. Specifically, the odds of abstinence increased as the number of posts received from seed users increased. Exploratory linguistic analyses revealed that seed users wrote longer comments which included more frequent use of "we" and "you" pronouns and that study participants users used more first-person singular pronouns ("I").

CONCLUSIONS

Seeding a community at its inception and nurturing its growth through seed users may be a scalable way to foster behavior change among OHC members. These findings have implications for the design and management of an OHC capable of promoting smoking cessation.

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.

Co-use of cigarettes and cannabis among people with HIV: Results from a randomized controlled smoking cessation trial

Significance

People with HIV (PWH) who smoke cigarettes have lower cessation rates than the general population. This study investigated whether changes in cannabis use frequency impedes cigarette cessation among PWH who are motivated to quit.

Methods

Between 2016-2020, PWH who smoked cigarettes were enrolled in a randomized controlled trial for cigarette cessation. Analyses were limited to PWH who reported on their past 30-day (P30D) cannabis use during four study visits (baseline, 1-month, 3-month, and 6-month) (N=374). Descriptive statistics and multivariable logistic regression were used to evaluate changes in cannabis use frequency from baseline to 6 months and associations with cigarette abstinence at 6 months among PWH who reported no use during all four visits (n=176), as well as those who reported use during at least one visit and who increased (n=39), decreased (n=78), or had no change (n=81) in use frequency.

Results

Among those who reported cannabis use during at least one visit (n=198), at baseline, 18.2% reported no use. At 6 months, 34.3% reported no use. Controlling for covariates, increased cannabis use frequency from baseline was associated with reduced odds of cigarette abstinence at 6 months versus decreased use frequency (aOR=0.22, 95% CI=0.03, 0.90) or no use at either time-point (aOR=0.25, 95% CI=0.04, 0.93).

Conclusions

Increased cannabis use over 6 months was associated with reduced odds of cigarette smoking abstinence among PWH who were motivated to quit. Additional factors that influence cannabis use and cigarette cessation simultaneously are in need of further study.

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).