Decision Tree Guides Selection of Smoke-Ending Medication for People With HIV

HIV-positive smokers whose provider used a decision tree to pick smoke-ending medications made more quit attempts and cut the daily number of cigarettes smoked more than smokers treated in the usual way in the same clinic.¹ The findings support the idea that smoke-ending strategies pinpointed to individual HIV-positive people could be successful.

Smoking remains the single greatest changeable risk factor for a long list of fatal diseases, including lung cancer and other cancers, heart attacks and stroke, and serious lung diseases like chronic obstructive pulmonary disease and emphysema. In the United States more than 40% of HIV-positive people smoke, a rate twice higher than in HIV-negative people.² In "Smoking Accounts for More Heart Attacks in People With Than Without HIV" in this issue, researchers estimated that, if all HIV-positive smokers quit, 42% of heart attacks might be avoided.³ If nobody with HIV ever started smoking, 72% of heart attacks might be prevented.

Recent research in people with and without HIV shows some success with a proactive approach to helping patients stop smoking. This approach relies on actively identifying smokers in a medical clinic population and offering them structured smoke-ending strategies. But HIV clinicians often report they have little time to help their patients stop smoking and little confidence in their ability to do so.⁴

One way to encourage HIV providers to help patients stop smoking is to give them a decision tree that organizes current knowledge about smoke-ending medications. Such a decision tree could guide providers in picking the best treatment strategy for each individual. A team at the University of Alabama at Birmingham conducted this study to test the value of a decision tree aimed at picking the best smoke-ending medication or medications for individuals with HIV.

How the Study Worked

Researchers invited smokers in care at the University of Alabama at Birmingham HIV clinic to join the study if they were at least 19 years old, smoked at least 5 cigarettes daily for the past month, and tested positive for cotinine, which confirms nicotine use. The investigators gathered relevant clinical information from patients' medical records. Study participants completed questionnaires that evaluated motivation to quit smoking, belief in one's ability to quit, dependence on cigarettes, and nicotine withdrawal.

Then researchers randomly assigned study participants to one of two groups: (1) The standard care group received smoke-ending assistance from their HIV provider when each person was ready to quit. (2) Participants in the decision tree group answered questions* that directed their HIV provider to select the most appropriate smoke-ending medication, including varenicline (Chantix), bupropion, or a nicotine replacement therapy (patch, lozenge, gum, inhaler, or nasal spray). If a person in the decision tree group did not quit smoking 4 weeks after starting a single medication, an additional medication could be added. Everyone in both study groups had one standard 20-minute smoke-ending counseling session that focused on behavioral strategies to reduce smoking. Researchers discussed the importance of medication in quitting with all study participants.

Treatment or standard care continued for 12 weeks. During that time researchers checked participants at weeks 2, 4, 8, and 12. Another evaluation took place 1 month after week 12. The main results assessed were (1) number of cigarettes smoked daily and (2) 24-hour quit attempts. Additional outcomes included motivation to quit, perceived difficulty of quitting, and belief in one's ability to quit. The researchers used standard statistical methods to determine the effect of each intervention (decision tree or standard care) on these outcomes.

What the Study Found

The study involved 100 HIV-positive smokers, 50 randomized to the decision tree group and 50 randomized to standard care. Both groups averaged 46 years in age. The groups did not differ in proportion of men (71% overall), proportion with less than a high school education (30%), or proportion with more than a high school education (40%). Three quarters of participants were black and one quarter white. About two thirds of participants in both groups had received treatment for substance abuse, and 57% had received mental health treatment. The decision tree group smoked an average 17 cigarettes daily and the standard care group an average 15 cigarettes daily. Both groups had been smoking for an average 27 years.

Among people randomized to the decision tree group, the greatest proportion received the nicotine patch (38%), followed by Chantix (36%), nicotine patch plus lozenge (12%), bupropion (10%), or lozenge (4%). After 4 weeks 52% of the people in this group had not tried to quit and were offered the nicotine lozenge to add to their initial medication.

After 4 weeks the decision tree group cut the average number of cigarettes smoked daily significantly more than the standard care group (10 versus 6 cigarettes per day) (Figure 1). The decision tree group maintained this greater decrease in cigarettes smoked daily through week 16, which was 4 weeks after treatment stopped. A significantly higher proportion of people in the decision tree group than in the standard care group reported 24-hour quit attempts (50% versus 38%). And a significantly higher proportion of people in the decision tree group than in the standard care group used medication to try to quit (81% versus 23%). When the researchers report that these differences in results are significant, it means statistical analysis shows the difference cannot be explained by chance.

People randomized to the decision tree group also did significantly better than the standard care group in three measures of attitudes about quitting (Figure 2): (1) a higher level of motivation to quit (8.93 versus 8.61 on a 10-point scale), (2) greater belief in personal ability to quit (8.69 versus 8.14), and (3) lower perception of difficulty in quitting (4.65 versus 5.46).

What the Results Mean for You

This carefully conducted trial is the first to examine the potential benefit of a simple tool to guide HIV clinicians in selecting the best medications to help their patients quit smoking. The study is too small and brief to measure the impact of this approach on long-term success in quitting smoking. But it did show that HIV-positive smokers whose clinicians used this decision tree tool cut the number of cigarettes smoked daily more than smokers treated in the usual way. Smokers whose clinicians used the decision tree also made more attempts to quit smoking, had greater motivation to quit, and perceived less difficulty in quitting than smokers who received standard care.

The findings reinforce previous results showing that several medications can help HIV-positive people stop smoking -- including varenicline (Chantix), bupropion, and nicotine replacement therapy with a patch, lozenge, gum, inhaler, or nasal spray. Knowing that these agents can help HIV-positive people quit smoking should help motivate smokers to find the strategy that works best for them, with the help of their HIV provider.

For HIV providers, the results show that an easy-to-use decision tree can be an effective way to help their patients stop smoking. Many HIV clinicians may feel they do not have the training or the time to counsel their patients effectively about quitting. The simple decision tree tested in this study could be the tool they need to set each smoker on the right path to overcoming nicotine addiction. The complete decision tree appears in the report of this study.1

There is no question that smoking has a huge negative impact on the health of people with and without HIV. Some studies -- like the two reviewed in "Smoking Accounts for More Heart Attacks in People With Than Without HIV" and "Smokers With HIV More Likely to Get Lung Cancer Than Smokers Without HIV" in this issue -- show that smoking has a greater negative impact in HIV-positive people than in people without HIV. The Centers for Disease Control and Prevention (CDC) reports several benefits in people who stop smoking:⁵

• Lower risk of lung cancer and many other types of cancer

• Reduced risk of coronary heart disease within 1 to 2 years of quitting

• Reduced risk of stroke and peripheral blood vessel disease

• Reduced risk of chronic obstructive pulmonary disease, a leading cause of death in the United States

• Reduced risk of infertility in women

For all these reasons, smokers with HIV should talk to their clinicians about finding the best strategy to quit -- perhaps with one of the medications tested in this study.

* Some of the questions were: Do you want to quit smoking today? Are you willing and able to take an oral medication twice daily? Have you tried unsuccessfully to quit smoking?

References

1. Cropsey KL, Jardin BF, Burkholder GA, et al. An algorithm approach to determining smoking cessation treatment for persons living with HIV/AIDS: results of a pilot trial. J Acquir Immune Defic Syndr. 2015;69:291-298.

2. Mdodo R, Frazier EL, Dube SR, et al. Cigarette smoking prevalence among adults with HIV compared with the general adult population in the United States: cross-sectional surveys. Ann Intern Med. 2015;162:335-344.

3. Rasmussen LD, Helleberg M, May MT, et al. Myocardial infarction among Danish HIV-infected individuals: population-attributable fractions associated with smoking. Clin Infect Dis. 2015;60:1415-1423.

4. Shuter J, Bernstein SL, Moadel AB. Cigarette smoking behaviors and beliefs in persons living with HIV/AIDS. Am J Health Behav. 2012;36:75-85.

5. Centers for Disease Control and Prevention. Smoking and tobacco use. Quitting smoking.