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.
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.
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."