Makers of e-cigarettes (electronic nicotine delivery systems, conveniently shortened to ENDS) promote their ability to ease nicotine addiction and thus put smokers on the road to quitting. A few studies (none of them in people with HIV) found that e-cigarettes can help people reduce nicotine intake,35 perhaps on a level equivalent to nicotine patches.36 But the potential value -- and risks -- of e-cigarettes remain largely unknown.
E-cigarettes have three parts: a cartridge containing a liquid solution of nicotine and other chemicals, a heating element that vaporizes the liquid, and a power source, usually a battery (Figure 4).37 Proponents of e-cigarettes say they are safer than cigarettes because don't produce tar and other chemicals that come from burning tobacco. But e-cigarette vapors do contain substances other than nicotine, including some carcinogens and toxic substances such as formaldehyde, acetaldehyde, and derivatives of benzene and benzodiazepine.18,37
Figure 4. The three parts of a standard e-cigarette (fitted together at top to resemble an actual cigarette) are the mouthpiece cartridge containing liquid nicotine solution, a heating element, and a power source. (Source: FDA, public domain.)
The FDA does not regulate e-cigarettes but the agency has begun to study them. Quality-control of processes used to make e-cigarettes, the FDA found, "are substandard or non-existent."38 Cartridges labeled as containing no nicotine did contain nicotine, and three cartridges with the same label produced markedly different nicotine levels. The FDA sent warning letters to three e-cigarette makers accusing them of unsubstantiated claims and poor manufacturing processes.
The National Institute on Drug Abuse cautions that "very little data exists on the safety of e-cigarettes, and consumers have no way of knowing whether there are any therapeutic benefits or how the health effects compare to conventional cigarettes."37 Calvo-Sánchez and Martínez say "reasons for skepticism about the potential benefits of ENDSs" include "paradoxical hindering of tobacco smoking cessation, inhalation of propylene glycol, unexpectedly high plasma nicotine levels, and inadequate information about the contents of ENDSs and the chemical environmental contamination they may produce."18
As HIV smoking maven Jonathan Shuter observes in the interview in this issue, writing a prescription for smokers and wishing them good luck are not enough. Medication-based smoking cessation attempts must be backed by counseling and some form of structured support. The most basic non-drug support may be provider follow-up within the first week of a scheduled quit attempt, as called for in the 5As approach to smoking cessation (Figure 2),7 or referral to a smoke-ending support line. A national quit line (1-800-QUIT-NOW) routes callers to state smoke-ending call lines (see Quit by Phone box below). Nondrug support can be considerably more extensive than that. Most of the drug intervention trials reviewed above included at least one nondrug element. This article reviews four nondrug strategies that complement pharmacotherapy and have been studied in people with HIV: an Internet-based approach smokers can start today, a cell-phone reminder strategy, a physician-training program, and a one-session counseling strategy.
|Quit by Phone: 1-800-QUIT-NOW|
A national quit line, 1-800-784-8669, refers callers to state phone lines that may provide an array of services:
The CDC offers online quitting tips at
SmokeFree.gov guides smokers through designing their own quit plan at
Reproduced from: Centers for Disease Control and Prevention. Smoking & tobacco use.
PositivelySmokeFreeMe (PSFM) is an 8-session 7-week interactive program that any smoker with Internet access can start today.39 In the pilot trial described here, 18% of HIV-positive smokers who completed all 8 sessions stopped smoking. Almost one third of women who viewed all 8 sessions quit. All participants were offered the nicotine patch and could use other cessation-aiding drugs.
The study took place at Montefiore Medical Center in the Bronx, which serves more than 2800 HIV-positive people in a poor to middle-class part of New York City. Between March 2012 and April 2013, the Montefiore team recruited HIV-positive smokers who said they wanted to quit and had access to an Internet-linked computer. They excluded pregnant women and people with low English or Spanish literacy. Participants got randomized to standard care (under 5 minutes of counseling and a self-help brochure) or to PSFM. Everyone got a prescription for a 3-month supply of nicotine patches, and everyone had full insurance for patch therapy. PSFM includes 8 separate sessions of 4 to 7 interactive Web pages that become available over 7 weeks. These pages aim to educate, motivate, and increase self-efficacy to quit smoking. The primary efficacy endpoint was carbon monoxide-verified 7-day abstinence 3 months after participants were supposed to complete the 8 sessions.
Among 138 people who entered the study, 134 completed follow-up, including 68 of 69 in the PSFM group. Age averaged 46, about 40% of participants were women, three quarters black, and almost half Hispanic. Although 90% had stable housing, 86% were unemployed. These people smoked an average 11 cigarettes daily. None of these factors differed significantly between study groups.
Of the 51 study participants who used any smokeending drug, 24 were in the PSFM group and 27 in the control group. Two thirds of people randomized to PSFM visited six or more online sessions, 41% visited all eight, and one third viewed all 41 Web pages. Almost everyone in the PSFM group, 94%, needed phone calls reminding them to view their next Web session.
In an intention-to-treat analysis, the 3-month 7-day quit rate measured 10.1% in the PSFM arm versus 4.3% in the control arm, a nonsignificant difference (Figure 5). But among 28 Internet users who logged into all 8 sessions, the quit rate came to 17.9%. Quit rates were higher for women overall than men (11.7% versus 2.7%, P = 0.08) and higher still for women who logged into all 8 sessions (30.8%) and women who viewed all 41 Web pages (40%) (Figure 5).
Figure 5. An Internetbased smoking-cessation program helped up to 40% of HIV-positive people prescribed the nicotine patch to quit smoking 3 months after the online program ended.39
Although adherence in this trial required frequent phone-call reminders, adherence might be better in a population that spends more time online and enjoys interactive programs. Because PositivelySmokeFreeMe is free and immediately available, HIV providers may consider recommending it to motivated smokers. A new and enhanced version of PositivelySmokeFreeMe, including a moderated social network, will be online in the first half of 2016. (See the interview with Jonathan Shuter in this issue for more details about PositivelySmokeFreeMe.)
Three months of counseling via cell phone improved 3-month quit rates compared with usual care in a randomized trial of HIV-positive smokers in Houston.40 But that advantage waned over the next 9 months and overall quit rates were low, perhaps because few study participants used nicotine replacement therapy, as recommended.
The study involved 474 adult smokers willing to set a quit date within 7 days. Researchers randomized 238 people to standard care (written smoke-ending materials and instructions on how to get nicotine patches at the study clinic) and 236 to the cell-phone intervention (standard care plus a prepaid cell phone, proactive smoking counseling calls for 3 months, and access to a support hotline).
The cell-phone group was significantly younger than the control group (43.9 versus 45.7 years), but the groups were balanced in proportion of women (about 30%), blacks (about 75%), whites (about 12%), Hispanics (about 10%) and in years of education (about 11), employment (about 20%), not working because of illness (about 63%), cigarettes smoked daily (about 19), illicit drug use in the past 30 days (40%), and major depressive symptoms (67%). Three quarters of participants in both groups completed 12 months of follow-up.
In an intention-to-treat analysis about 12% in the cell-phone group and 4% in the control group quit at 3 months.40 Among people who completed all 12 months, respective quit rates at 3 months were about 15% and 5%. Quit rates remained stable through 6 and 12 months in the control group while dropping in the cell-phone group to levels equivalent to control participants. Multivariate analysis determined that people randomized to get cell-phone reminders had quadrupled odds of quitting at 3 months (OR 4.3, 95% CI 1.9 to 9.8, P < 0.001). Through 12 months chances of quitting remained significantly higher in the cell-phone arm (OR 2.41, 95% CI 1.01 to 5.76, P = 0.049).
The researchers suggested high nicotine dependence coupled with low nicotine patch use could explain the low quit rates in both study arms. Trial investigators did not give participants nicotine patches but instead told them how to get patches through the clinic. But county requirements that people getting patches take smoke-ending classes may have discouraged patch use in this study group. The waning impact of cellphone counseling after 3 months, the authors suggest, could mean a longer intervention may be needed for smokers like these.
Instead of making smokers the initial target of cessation efforts, Swiss HIV Cohort Study (SHCS) researchers in Zurich aimed at HIV providers in a half-day session on patient smoking counseling and drug therapy.41 This nonrandomized study comparing Zurich smokers with smokers at other SHCS sites found that those cared for in Zurich were about 25% more likely to stop smoking and 25% less likely to relapse.
All physicians at the University Hospital Zurich HIV outpatient clinic took a half-day smoking-cessation course between November 2007 and December 2009. The course included information on identifying smokers, rating nicotine dependence and motivation, counseling, and prescribing drugs to help smokers quit. During the study period these physicians completed a checklist documenting the smoking status of each patient and physician support offered (counseling, explaining medications available, arranging followup appointments, and if appropriate setting a quit date). The SHCS investigators defined quitting as a study visit in which a patient smoked followed by at least two consecutive visits without smoking. Relapse meant consecutive study visits in which a patient had quit followed by a visit with smoking.
The analysis involved 11,056 SHCS cohort members across the country, including 1689 seen at the Zurich clinic during the intervention period. The smoking cessation analysis considered 5805 smokers with at least three follow-up visits, while the relapse analysis involved 1953 smokers who quit. Zurich cohort members were older than SHCS members at other centers (median 44 versus 38), and Zurich had a lower proportion of women (25% versus 34%). Zurich and other cohort members smoked a median of 20 pack-years. Except for Zurich, none of the other SHCS centers offered structured smoke-ending programs for clinicians. About 80% of Zurich clinicians counseled smokers during the intervention period, a result indicating that such counseling can fit into routine care.
Overall smoking prevalence in SHCS members plunged from 60% in 2000 to 43% in 2010. The overall drop was greater in Zurich (-22.5%) than in other SHCS centers (-16.5%) or private practices (-14.5%). Logistic regression analysis determined that during the provider training period Zurich smokers were almost 25% more likely to quit smoking than SHCS smokers at other centers (OR 1.23, 95% CI 1.07 to 1.42, P = 0.004), and Zurich quitters were 25% less likely to relapse (OR 0.75, 95% CI 0.61 to 0.92, P = 0.007). The effect of the intervention was stronger than the effect of calendar time (OR 1.19 versus 1.04 per year).
The Zurich team proposed that "our approach of an institution-wide training programme for infectious diseases physicians to improve smoking cessation counselling can be well integrated into routine HIV care, was well accepted by patients and physicians, and can support patients' efforts to stop smoking."41 A 2008 survey of 363 HIV clinicians across the United States found that only 23% ever had formal tobacco treatment training.19 Only 29% of these US clinicians said they would be interested in attending a brief smoking cessation session, another 29% said they might be interested, and 40% claimed no interest. The Zurich HIV group now provides clinicians a yearly 1-hour smoking cessation class. Other SHCS centers around the country have not adopted that practice.42
A 1-hour individualized smoke-ending session with a physician, other health professional, or peer helped 16% of HIV-positive smokers in Newark quit through 6 months, a rate similar to results reported in other studies of more complex and time-consuming strategies.43
The Infectious Disease Practice in Newark, New Jersey43 cares for a largely minority, low-income HIV population similar to those in the Bronx39 and Houston40 studies. The Newark analysis involved HIV-positive adult smokers interested in quitting. Prospective participants were referred to the smoking program by their clinic provider, by clinic staff, or by themselves in response to fliers in waiting rooms and exam rooms. The hour-long counseling session with a physician, case manager, peer navigator, or mental health counseler (all trained in smoking cessation) focused on practical problem solving, withdrawal symptoms, and coping strategies. Clinicians prescribed smoke-ending therapy either at the counseling session or at a follow-up visit. Participants self-reported smoking cessation at 6 months at a follow-up visit or by phone.
Among 1545 adults cared for at the HIV clinic, 774 (50%) smoked. Of these 744 people, 123 (16%) had counseling and 651 did not. Age averaged 50 years in counseled smokers and 47 in uncounseled smokers (P = 0.01). Respective proportions of women were 47% and 43%, blacks 85% and 85%, and uninsured 29% and 40% (P = 0.03). Among all patients analyzed, 52% had a history of mental illness, 58% had used cocaine, and 41% had used heroin. The study group smoked 11 cigarettes daily and had tried to quit an average of 2 times.
Among the 123 counseled smokers, 101 (82%) got prescribed a smoke-ending drug, usually nicotine replacement therapy (96% of 101), though 54% got a combination prescription. Most people with a prescription (83%) reported nonadherence at least once during follow-up, and 48% said insurance did not fully cover their prescription.
Twenty of 123 people (16%) who received counseling reported quitting at 6 months. (The study did not confirm quitting biochemically.) Multivariate analysis determined that past or current heroin or cocaine use lowered chances of quitting 80% (aOR 0.20, 95% CI 0.07 to 0.56, P = 0.002). Being in the preparation stage to quit rather than the precontemplation stage or the contemplation stage boosted odds of quitting more than 8 times (aOR 8.26, 95% CI 1.02 to 66.67, P = 0.048). Factors that did not influence quitting in this analysis were age, gender, race, mental illness history, and nicotine dependence level.
Each of the four just-reviewed nondrug interventions has its pluses and minuses (Table 3). PositivelySmokeFreeMe is free and immediately available to all smokers with Internet access.39 This 8-session Web-based program may be particularly well-suited to people who enjoy interactive online programs. But unless clinicians or staff can check patient progress through the eight online segments, many smokers may not have the motivation needed to complete the program. The inner-city study group in a randomized trial39 required regular prodding to access each new session that came online. So PositivelySmokeFreeMe will probably work best for more highly motivated individuals. Clinicians will have to work with motivated patients to select and prescribe an appropriate medication and to promote adherence.
|Table 3. Four Nondrug Interventions* Tested in People With HIV|
|Strategy||Population||Trial, Smoking Level||Advantages||Disadvantages||Quit Rate|
|8-Session Internet program for smokers39||Bronx, NY, n = 138,† age 46, 40% women, 75% black, 47% Hispanic, 86% unemployed||Randomized, 11 cig/day||Ready-to-use, free online program developed for HIV+ smokers||Text reminders and calls needed to ensure adherence||10% at 6 m, up to 40% with good adh|
|Cell-phone reminder calls40||Houston, n = 474,† age 43-46, 30% women, 75% black, 9% Hispanic, 80% unemployed||Randomized, 19 cig/day||Cell-phone use simplifies counseling, follow-up||Staff time required for regular cell-phone follow-up||12%-15% at 3 m|
|Half-day clinician training41||Zurich SHCS, n = 1689, age 44, 25% women, 22% IDU history||Prospective cohort, 20 pack-years||Ensures provider training in half-day session; uses simple patient checklist||Assumes provider adherence (80% in this study)||23% higher odds of quitting with provider training|
|One-time 1-hour, 1-on-1 smoker counseling43||Newark, NJ, n = 123,† age 50, 47% women, 85% black, 52% mental illness history, 58% cocaine history||Prospective cohort, 11 cig/day||Time efficient, focused on individual smoker, can be done by trained nonphysicians, including patient peers||Ensures only 1 counseling session, therapy may have to be prescribed at separate visit||16% at 6 m|
* All interventions coupled with drug therapy prescription, offer, or advice.
† All participants said they wanted to quit smoking.
adh, adherence; cig, cigarettes; IDU, injection drug use; SHCS, Swiss HIV Cohort Study.
Cell-phone counseling calls offer a reliable platform to bolster patient commitment to quitting, to remind patients to use their antismoking medication, and to address concerns that arise.40 But such a program requires some planning at the clinic level, commitment of time from capable staff or perhaps trained peer volunteers, and occasional interaction with the clinician. Houston researchers who tested this approach found that quit rates waned when the calls stopped.
The half-day clinician training program designed by the Zurich unit of the Swiss HIV Cohort Study (SHCS) provides the foundation for any successful smoking cessation program by ensuring that providers understand the principles of nicotine addiction, counseling, and treatment.41 After the Zurich researchers launched this program, which included a smoking checklist for each patient, they recorded higher quit rates and lower relapse rates than other SHCS units across Switzerland. Program success clearly depends on clinicians implementing what they learn in the session, as a large majority of clinicians in the Zurich study did. After publishing their report, the Zurich group began providing a 1-hour smoking cessation course for HIV clinicians once a year. Other SHCS centers have not adopted such a program. Updated numbers show that smoking prevalence in HIV-positive people remains lower in Zurich than at other centers.42
The primary advantage of the one-time, 1-hour, one-on-one smoke-ending session is its focus on individual smokers in a single session that can be performed by a nonphysician health professional or even a peer counselor.43 The Newark researchers who ran this study observe that this "low-intensity" approach yielded a 6-month quit rate similar to rates recorded in studies of more complicated and lengthy interventions. Yet the authors note that prior or current illicit drug use cut chances of success, a finding suggesting some smokers "may benefit from more intensive cessation approaches or strategies that incorporate substance use counseling and mental health services into cessation interventions."43
The three US studies all involved low-income heavy smokers with high rates of alcohol and drug abuse and psychiatric comorbidities.39,40,43 All achieved similar short-term quit rates around 15%. Although that rate may sound low, it is comparable to rates in some general population studies, which often include people with fewer addiction and dependence risk factors. And getting 3 of every 20 HIV-positive people to quit will certainly have a profound impact on the health of those quitters -- an impact that easily justifies the health worker effort.
* Quit ratio equals former smokers divided by former plus current smokers.
|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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