Featuring Jonathan Shuter, M.D.
Positively Smoke Free: An 8-Module Intervention
What's the status of Positively Smoke Free, the smoking-cessation intervention for people with HIV?
Positively Smoke Free is a suite of different options, including an eight-module group therapy intervention led by a counselor and an eight-module self-administered online intervention, PositivelySmokeFreeMe (Figure 1). In New York State a Positively Smoke Free brochure has been disseminated statewide. We offer on-site Positively Smoke Free group therapy in the setting of a clinical trial. But outside the centers participating in the trial, Positively Smoke Free group therapy is not yet available. Positively Smoke Free individual therapy is starting at the University of Maryland in Baltimore, but that is not yet available outside of a clinical trial.
Figure 1. PositivelySmokeFreeMe, accessible to anyone online, offers an eight-module intervention smokers can use on their own to quit. In a clinical trial, PositivelySmokeFreeMe doubled the odds of quitting in a Bronx, New York HIV group that smoked an average half-pack of cigarettes daily.3 (See study details.)
The Positively Smoke Free Web site is an eightmodule program that parallels the eight modules in the Positively Smoke Free live sessions. That is now available in the public domain at www.PositivelySmokeFreeMe. com. HIV specialists, behavioral psychologists, graphic artists, software engineers, and smokers with HIV collaborated to design this 8-session, 7-week program.3 Each session includes 4 to 7 Web pages with interactive features. The sessions aim to educate, motivate, and increase patient self-efficacy to quit.
Have people been using the online PositivelySmokeFreeMe?
We're just beginning to track use because it hasn't been available continuously. Originally it was restricted to clinical trials, but now it's in the public domain. The American Legacy Foundation, which very recently changed its name to The Truth Initiative,4 has taken this up and now maintains PositivelySmokeFreeMe on its server.
The Web site will incorporate a social network with contributions from users on topics of interest to HIV-positive smokers. The social network will be kicking into gear soon and will be fully active by late spring or early summer of 2016. It will be available in the public domain for at least several years. If it's successful, we hope it can sustain itself after that. We're planning a clinical trial to assess the effect of the social network.
What will be the thrust of the social network?
There will be discussion threads pertaining to topics of particular interest to HIV-infected smokers and former smokers -- probably including the impact of stress on smoking and as an impediment to quitting, whether smoking interferes with adherence to medications, whether smoking cessation medications have interactions with HIV medicines, and anything else users want to bring up. The social network will be guided by a professional Web site social network moderator. We plan to design a very modern type of site with the bells and whistles that our patients expect in 2016.
Do you plan other versions of Positively Smoke Free?
Yes. In concert with the University of Michigan Center for Health Communications Research, we're developing another version of Positively Smoke Free specifically for smartphones. Positively Smoke Free Mobile has been alpha- and beta-tested and it's ready to go. This smartphone version is faithful to the original 8-session Positively Smoke Free intervention. But instead of having a live counselor conducting a group therapy session or individual therapy, and instead of the mostly written presentation on the Web site, the smartphone version uses an actor and cartoon characters in video sessions. We distilled the content into 8 bite-size pieces available as video via smartphone.
Positively Smoke Free Mobile includes some innovative and hopefully useful resources not possible in the other formats. For example, the mobile version includes a HELP button. When someone trying to quit craves a cigarette, that craving usually lasts for 3 to 5 minutes. The Positively Smoke Free group therapy counselor can't help you if you're out on the street away from your group therapy. You might be able to apply some of the lessons you learned in group therapy, but there's none of the immediacy you have with your cell phone. You have your cell phone in your pocket, you go to the site, and you hit the HELP button. Doing that will send you to a place where you hear one of your favorite songs, where you play a game, or where you get directed to a quitline. All these things could distract you for 5 or 10 minutes until your craving passes. We're very eager to see how that works.
Another major element of Positively Smoke Free Mobile is a text-messaging intervention. We plan frequent texts with encouragement, motivational messages, and tips to help you quit. All of those things together make up the Positively Smoke Free Mobile intervention.
Picking the Best Cessation Therapy for Your Patient
Do you always recommend medication for HIV-positive smokers who want to quit?
The answer is a qualified yes. You could imagine a scenario where someone has a contraindication to every single medicine out there. That would be extremely rare. Barring that, the answer is yes, I would always recommend pharmacotherapy.
How do you decide which medication to use?
The decision rests on discussion with the patient and review of the medical and psychiatric history. The default medication is usually the nicotine patch or another form of nicotine replacement therapy. There is very little downside with nicotine replacement options, and they do help. Even though we haven't had great success with nicotine patches at our center in the Bronx, other investigators have found them to be effective and predictive of successful cessation in the HIV population. And many patients are familiar with this strategy and not scared of it.
The potential negative aspect of nicotine patches is that many of our patients have used them already, failed with them, and feel they don't help. So we have many patients who just say no to nicotine replacement. For many of those patients, varenicline -- Chantix -- is a terrific choice. Product information cautions about psychiatric morbidities and complications with Chantix, but I believe those risks are exaggerated.
We've used Chantix many, many times in patients with a history of depression or anxiety -- as long as they're psychiatrically stable at the time. They usually tolerate Chantix very well, and I've had good experience with it.
The last major option is bupropion -- Wellbutrin or Zyban -- which we use fairly frequently because it is an antidepressant and many of our patients have depression. In some patients, Wellbutrin can kill two birds with one stone.
Are there any other important issues you would like to stress about smoking cessation in people with HIV?
I would like to give an extra plug to PositivelySmokeFreeMe.com. Clearly, the long-term success of a social network depends on how much people use it and how much they like it. There's nothing that bodes worse for a social network than underutilization. So we encourage HIV-positive smokers and quitters to visit that site (Figure 1). I think it will be a great resource where none exists right now. The site and the social network component are professionally moderated and administered. It's really exciting that anyone with a computer and WiFi who's interested in getting help can use this site to quit and to stay engaged with other HIV-positive people.
Finally, I want to say I appreciate the attention the mainstream media and the public health and medical community are beginning to pay to cigarette smoking in people with HIV infection. I've been taking care of HIV-infected patients since the early 1980s. I certainly remember the day when smoking was completely ignored in the HIV population because they were dying from something else so much sooner than cardiovascular disease or lung cancer. They were dying from direct complications of HIV. Now we live in an era when patients are surviving much longer with HIV. Tobacco use has emerged as one of the most important treatable medical issues in this population. It still doesn't get enough attention, but it's getting more and more. I appreciate the opportunity to speak about this issue, because help is available today for smokers with HIV who want to quit. But more work needs to be done.
- SmokeFree.gov. Have you built a quit plan?; Preparación de un plan para dejar de fumar.
- Shuter J, Salmo LN, Shuter AD, Nivasch EC, Fazzari M, Moadel AB. Provider beliefs and practices relating to tobacco use in patients living with HIV/AIDS: a national survey. AIDS Behav. 2012;16:288-294.
- Shuter J, Morales DA, Considine-Dunn SE, An LC, Stanton CA. Feasibility and preliminary efficacy of a web-based smoking cessation intervention for HIV-infected smokers: a randomized controlled trial. J Acquir Immune Defic Syndr. 2014;67:59-66.
- The Truth Initiative "is dedicated to achieving a culture where all youth and young adults reject tobacco. We speak, seek and spread the truth about tobacco through education, tobacco control research and policy studies, and community activism and engagement."