Abstract: In the United States more than half of everyone who ever smoked has quit. Most people addicted to nicotine require several quit attempts to stop, but in some people with HIV a failed quit attempt predicts future success. People with HIV appear to have a harder time quitting than people without HIV. CDC analysis of nationally representative samples figured a quit ratio of 52% in the general population versus 32% in HIV-positive people. Studies in HIV populations indicate that those most likely to quit smoking include older people, pregnant women, and people with a high motivation to quit, a previous quit attempt, or recent pulmonary disease. US health authorities recommend that clinicians adopt the 5As approach to smoking cessation: ask, advise, assess, assist, and arrange. But only a little more than half of US clinicians assist smokers in picking a smoke-ending strategy, and only 10% arrange follow-up within the first week after a quit date. Smoking-cessation medications recommended and tested in people with HIV are varenicline, bupropion, and nicotine replacement in various forms. Success with these strategies generally ranges from 10% to 20% in HIV-positive people, with higher success rates in some subgroups. Successful nondrug strategies to support drug therapy in people with HIV include an Internet-based interactive program, cell-phone reminder calls, one-time 1-hour one-on-one counseling, and formal clinician education.
More people have quit smoking in the United States than still smoke.1 And more than half of everyone who ever smoked has stopped.1 Those eye-opening statistics from the Surgeon General may be the best way to challenge hardcore smokers -- and reluctant clinicians -- who say quitting is just too tough. The Surgeon General's findings make it clear that many can -- and do -- break their dependence on nicotine.
Research reviewed in this article suggests that several standard strategies -- and perhaps a few novel approaches -- have helped HIV-positive people quit smoking. A steadfast few can stub out their last butt, resolve never to light up again, and free themselves for life. But most face a sterner challenge. And that challenge may prove greater for people with HIV. Analysis of a nationally representative sample of US residents with HIV ranked 42.4% as current smokers, 20.3% as former smokers, and 37.3% as never smokers.2 In the general-population National Health Interview survey, only 20.6% were current smokers, while 21.9% smoked in the past and 57.5% never smoked. Centers for Disease Control and Prevention (CDC) researchers calculated that the generalpopulation group had a quit ratio* of 51.7%, compared with 32.4% in the HIV group.
And quitters can become relapsers. A 1994-2011 study of 2961 HIV-positive and 981 HIV-negative women in the Women's Interagency HIV Study (WIHS) found that smoking prevalence in this largely black and Hispanic cohort waned from a high of 57% in 1996 to a low of 39% in 2011.3 Among 1622 women who smoked at their first study visit, 316 (19.5%) quit for a hefty median of 16.5 years. But among 273 sustained quitters with follow-up data, 145 (53%) resumed smoking after an average 7.2 years without cigarettes.
Quitting and relapsing rates proved similar in a Swiss HIV Cohort Study (SHCS) analysis that included 4833 HIV-positive smokers, about one quarter of them women. Through 2012, 1261 smokers (26%) quit at least temporarily.4 Among 1167 quitters with follow-up data, 557 (48%) resumed smoking. CDC researchers turned up several clues to which HIV-positive smokers are more or less likely to quit by analyzing quit ratios in a nationally representative sample of people in care for HIV infection in 20092 (Table 1). Quitting rates track with age, as people 50 or older -- more concerned about mortality -- had the highest quit ratio (42.6%) while 18- to 29-yearolds had the lowest (16.3%). Women with HIV had a substantially lower quit ratio than HIV-positive men (27.0% versus 34.2%), and blacks had a lower quit ratio (26.2%) than Hispanics (35.4%) or whites (38.2%). Quitting proved significantly more likely in HIV-positive people with more than a high school education (quit ratio 39.6%) than in those who only completed high school (26.8%) or didn't finish high school (25.1%). HIV-positive people at or above the poverty level were significantly more likely to quit than people below the poverty levels (quit ratio 39.9% versus 24.3%). For every category listed, people with HIV had quit ratios significantly below those of smokers in the general population comparison group.
|Table 1. HIV-Positive People Likely to Quit Smoking or Relapse After Quitting|
|More Likely to Quit||Less Likely to Quit||More Likely to Relapse|
|Older age2||Younger age2||Younger age3|
|Pregnancy3||On cART3||Not on cART3|
|Previous quit attempt4||CD4 count <200 cells/mm3 (vs >500)||Smoked more daily before quitting4|
|High motivation to quit4||Women vs men2||Poor motivation to quit4|
|Recent pulmonary disease5||Blacks vs Hispanics or whites2||Not living in one's own home3|
|Lower income2,3||Marijuana use3|
|Less education2,3||Crack, cocaine, or heroin use3|
|Having health insurance3|
|Poor self-reported health3|
|Recent hospital admission4|
Nationally representative US sample,2 Women's Interagency HIV Study,3 Swiss HIV Cohort Study,4 Veterans Aging Cohort Study.5
cART, combination antiretroviral therapy.
Analysis of 2961 HIV-positive women and 981 demographically similar HIV-negative women in WIHS identified several factors independently linked to longer time to quit smoking: less than high school education, only high school education (versus more), having health insurance, smoking for more than 10 years, 1 to 6 alcoholic drinks weekly or more (versus none), fair to poor self-reported health (versus good to excellent), and hypertension (Table 1).3 Limiting the analysis to women with HIV, the WIHS team pinpointed four additional risk factors for longer time to quitting smoking: household income at or below $12,000 yearly, use of combination antiretroviral therapy (cART), CD4 count below 200 cells/mm3 (versus 500 or higher), and use of crack, cocaine, or heroin. Pregnant women were more likely to quit smoking sooner.
To single out predictors of quitting and relapse, SHCS investigators built two models.4 The smoking cessation model classified smokers into highly, poorly, and typically motivated people based on common-sense predictors of high motivation (like a previous quit attempt or a recent cardiovascular diagnosis) (Figure 1). The relapse model incorporated nicotine dependence level (maximum cigarettes smoked daily before quitting), the three motivational groups, age, and gender.
Figure 1. Simple models for high or low motivation to quit smoking provided bases for more complex models to predict quitting and relapse from abstention in the Swiss HIV Cohort Study.4 The analysis found that "simple prediction models are nearly as discriminatory as complex models." CVD, cardiovascular disease.
The Swiss team found that smokers who stopped were more likely to be highly motivated and to have tried stopping before.4 Smokers were less likely to stop if they were poorly motivated, had a recent hospital admission, had psychiatric comorbidities, or had a history of alcohol or drug dependence.
A Veterans Aging Cohort Study (VACS) team probed for predictors of quitting in 1027 HIV-positive and 794 HIV-negative veterans in care between 2005 and 2007.5 More than half of both groups, 56%, had tried to quit before, and two thirds of both groups were contemplating another attempt to quit. Among HIV-positive smokers, those with recent pulmonary disease proved almost 5 times more likely to have tried quitting recently (adjusted odds ratio [aOR] 4.93, 95% confidence interval [CI] 1.41 to 17.17). Unhealthy alcohol use cut odds that HIV-positive or negative veterans were contemplating quitting (aOR 0.66, 95% CI 0.49 to 0.90 for HIV positive).
Certainly, clinicians should not refrain from encouraging patients to stop smoking because they have one or more predictors of lower quitting likelihood. For example, the SHCS study found people with psychiatric comorbidity less likely to stop smoking.4 But the WIHS study of mostly black and Hispanic US women found no evidence that depression made women less likely to quit or more likely to relapse.3 People who inject drugs may seem poor candidates for smoke-ending interventions, but some are readier than others. A study of 267 HIV-positive current or former injection drug users who smoked found that older age and having a supporter who used medication to quit smoking doubled the odds of using smoke-ending medication.6
Among HIV-positive and negative WIHS women who stopped smoking for more than 12 months, marijuana use and not living in one's own home independently predicted a shorter time to resumed smoking (Table 1).3 Limiting the analysis to HIV-positive women identified two more predictors of a shorter time to relapse -- enrollment in 2001-2002 (versus 1994-1995) and use of crack, cocaine, or heroin. Older age and cART use predicted a longer time to relapse. In the SHCS study, relapsers smoked more in the three follow-up visits before quitting and had poor motivation to quit (Figure 1).4
Clinicians should tell smokers who quit and relapse that many people try to quit several times before succeeding, so they shouldn't give up if the first few tries fail. Previous quit attempts predicted later success in the Swiss HIV Cohort Study.4
The WIHS team speculates that HIV-positive women with a CD4 count below 200 cells/mm3 may be less likely to stop smoking because their more advanced HIV disease presents more immediate health challenges and robs them of motivation.3 That may also explain why women taking cART (who probably had more advanced disease) were less likely to quit in that analysis. But this WIHS study also linked taking cART to a longer time to relapse among women who quit at least 12 months. That could mean women doing well on cART have more motivation to improve their overall health, the authors propose. The surprising finding that women with health insurance took a longer time to quit, the WIHS team suggests, may mean women without insurance worry more about behaviors that threaten their health. But the insurance finding seems to be at odds with the link between lower income and lower probability of quitting.
The SHCS investigators found that their complex statistical models did no better than simple models (Figure 1) in picking HIV patients more likely to quit. "As a rough rule of thumb for clinicians," they suggest, "patients in our highly motivated group, especially those with a history of attempting to stop, and those known to have stopped recently are the best candidates for an intervention."4
|Smoking Lowers Life Expectancy More Than HIV Itself|
|Decision Tree Guides Selection of Smoke-Ending Medication for People With HIV|
|Varenicline (Chantix) Helps HIV-Positive Individuals Quit Smoking but Overall Success Rates Low|
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