Featuring Jonathan Shuter, M.D.
Jonathan Shuter, M.D., is a professor in the Department of Medicine, Division of Infectious Diseases, Montefiore Medical Center and the Albert Einstein College of Medicine, Bronx, New York
Dr. Shuter ranks among the top researchers on smoking in people with HIV infection. Together with several collaborative teams, he developed Positively Smoke Free, a smoking cessation program designed for people with HIV for use in group therapy, individual therapy, and online computer and smartphone applications. Dr. Shuter is a clinician who has been caring for people with HIV since 1985 and a researcher with multiple NIH grants to study tobacco treatment strategies for HIV-positive smokers. Working with low- to middle-income minority populations in the Bronx, he has conducted and published research on conditions that affect inner-city HIV populations, including tuberculosis, overweight, and poor antiretroviral adherence. Dr. Shuter reviews articles for The Lancet, PLoS One, JAIDS, Clinical Infectious Diseases, and a half-dozen other leading journals.
Motivating the Unmotivated, Then Closing the Deal
Why does smoking have a greater negative impact in people with HIV?
There are a few answers to that question. Much recent attention is focused on the additive impact of the direct damage of tobacco use plus the inflammatory state that is part of living with HIV. These two factors have additive effects on the cardiovascular damage that we associate with cigarette smoking. Tobacco use also compromises lung function by impairing mucociliary function of the respiratory epithelium, and patients with HIV are at uniquely high risk for pulmonary infection because of their compromised immunity. All these factors plus the infectious disease component of HIV infection pose additive risks for tobacco use in patients with HIV.
Research shows that high motivation to quit smoking predicts success in quitting. How should HIV clinicians start with people who have low motivation?
Clinicians can start by trying to get them to understand the damage that tobacco use is doing to them and the prospect that they can quit if they really try. Patients with low motivation should understand that long-time smokers can be successful in quitting and it's not hopeless to try. It's also useful to emphasize how much better they'll feel both in the short term and the long term if they're able to quit.
What do you tell people with HIV about their chances of success in quitting?
Here statistics are probably not your friend. At best, studies are getting 15% or 20% quit rates. I certainly wouldn't stress that. But I do tell smokers that I've had many patients successfully quit and that they can too.
When an HIV-positive person is highly motivated to quit, how should clinicians close the deal?
We're not trying to reinvent the wheel here. There's an awful lot of data available on the best strategies to promote cessation. [See "Helping People With HIV Quit Smoking: What Works For Whom?" in this issue.] One thing I've learned over time as a clinician is that patients with HIV often have such complicated and stressful lives that simply prescribing a medication -- whether it's nicotine patches or varenicline -- generally is not enough. You have to remember that many patients live in a medical world where they believe the solution to a problem comes in a bottle. These patients may have a mindset that says, "I'm ready to quit now, I'll get some nicotine patches or Chantix, and that'll do it for me." I certainly support medication as part of the attempt to quit. The medications we have really do help, and they're necessary for many patients.
But I try very hard to convince patients that they need a multipronged approach. Besides pharmacotherapy, social support is very important. Patients should try to find someone who's going to support them though this, and they should stay away from people who are going to discourage the cessation process. A roommate or housemate who smokes can pose a particular challenge. If someone lives with another smoker, try to get them motivated to quit together because it's really hard to quit if you live with another smoker.
The support person may be a family member or friend, or someone at the end of a telephone, like a quitline counselor. There are online resources too. More and more patients like to go online and seek support that way. There are social networks one can go to as well. [See box "Quitlines and online: Tools to help smokers stop."]
|Quitlines and Online: Tools to Help Smokers Stop|
US National Quitlines
Calling one of the following three toll-free numbers will connect you to your state quitline, where trained coaches can provide information and help with quitting. Specific services and hours vary by state.
TTY (text telephone)
US National Cancer Institute Quitline (English or Espagñol):
Trained counselors from the National Cancer Institute can provide information and help with quitting in English or Spanish, Monday through Friday, 8:00 AM to 8:00 PM eastern time.
Centers for Disease Control and Prevention. Smoking & tobacco use.
The comprehensive CDC site for tobacco use includes links to the TipsCampaign to help people quit, FactSheets, and state and community resources.
Centers for Disease Control and Prevention. How to quit.
The CDC "How to quit" site includes five basic tips all quitters should know, tips from former smokers, and information on the short- and long-term benefits of quitting smoking.
In English and Spanish, SmokeFree.gov helps smokers build a quit plan, provides a quitSTART app to get support via your phone, and offers a sign-up for SmokeFreeTXT messages.
American Cancer Society Guide to Quitting Smoking
The American Cancer Society answers 20 basic questions about why to quit, how to quit, and how to stay smoke-free, including getting help with the mental and physical parts of nicotine addiction.
This 7-week 8-part program, detailed in this interview, is designed specifically for HIV-positive smokers who want to quit. A new and improved version, which will incorporate a social network, will be available in late spring or early summer 2016.
Someone who's really serious about quitting should also pick a quit day and get ready for that quit day.1 A patient who decides impulsively, "I'm quitting today," is probably not going to succeed. Planning a quit day means getting a support person, getting your pharmacotherapy in order, getting rid of all your cigarettes and getting secret stashes of cigarettes out of the house, throwing all ashtrays away -- and doing all this in a thoughtful and methodical way. Patients who are willing to take those steps have a higher chance of succeeding.
Do you see certain mistakes that many HIV clinicians make when addressing smoking in their patients?
I think the biggest problem is that time is limited. The typical patient in my clinic has multiple medical problems; he might be on 5, 10, 15 medications. When you're seeing patients like that and writing their notes, you realize you're dealing with 7 or 8 problems, and tobacco use can fall to the bottom of the list. I think that's the biggest challenge.
An additional challenge is that HIV providers don't have a lot of training in tobacco cessation. A survey we did showed that only one quarter of HIV providers in a national US sample reported ever receiving formal teaching in tobacco treatment.2 That means many HIV clinicians don't really know how to treat tobacco use, and they don't often get to it during smokers' visits.
Personally I think this is a very destructive scenario. It means if you're a smoker you can walk into your provider's office and deal with your HIV and your high blood pressure and your diabetes and asthma. So tobacco use falls off the list. It's never even addressed. Subliminally, that patient can walk out of that office after 15 minutes with a net-neutral view of smoking. But an HIV provider should be communicating a negative view toward tobacco use at every visit.