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Cigarette smoking behaviors in persons living with HIV/AIDS (PLWHAs)
Jonathan Shuter, MD
Montefiore Medical Center
111 E 210th St.
Bronx, NY 10467
718-920-7845
[email protected]
Jonathan Shuter, MD1,2, Steven L. Bernstein, MD1,2, Alyson B. Moadel, PhD2
1Montefiore Medical Center, 2Albert Einstein College of Medicine, Bronx, NY
ABSTRACT
RESULTS
RESULTS
Table 2. Perceived risks and benefits of smoking.
Problem/Objective: Over half of PLWHAs in the US smoke. With improved survival, steady increases in tobaccorelated morbidities have been observed. Little is known about smoking behaviors in PLWHAs.
Methods: We conducted standardized interviews on 60 PLWHA smokers in the Montefiore Medical Center
Infectious Diseases Clinic. Interviews included validated measures of smoking behaviors, substance use, and
mental illness.
Results: The mean age of participants was 47 years, and 53% were male. 37% were African American and 50%
Latino. 45% acquired HIV heterosexually, 20% through male-male sex, and 22% through injection drug use. 62%
had CDC-defined AIDS. The mean entry CD4 count and log10 HIV-1 viral load were 520 cells/ul and 2.6. 78%
reported a history of either depression or anxiety, and 58% reported that smoking helped them cope with these
disorders. Mean daily cigarette consumption was 14, and mean cumulative smoking experience was 29 years. 67%
smoked <30 minutes after awakening; 37% were highly nicotine dependent on the Fagerstrom Tolerance
Questionnaire. 67% were in the contemplation stage on the Readiness to Quit Ladder. Mean score on the Reasons
for Quitting Questionnaire was 36.4 (intrinsic motivation: 21.0; extrinsic: 15.4). Mean scores on Smoker and
Abstainer Self-Concept Scales were 20.2 and 25.8. 18% indicated the belief that smoking helped them fight
infections, and 22% that it increased CD4 counts.
Conclusions: Psychiatric comorbidities are extremely prevalent in PLWHA smokers. PLWHA smokers are highly
nicotine dependent, but also exhibit high motivation to quit. Misperceptions about imagined physical benefits of
smoking among PLWHAs are common.
BACKGROUND
More than half of PLWHAs in the United States are current smokers.1-5 Smoking increases the
risk of a number of HIV-related complications, including oral candidiasis,6 hairy leukoplakia,7 and
Pneumocystis jirovecii pneumonia.8 In recent years, there has been an alarming rise in the
incidence of cardiac events in PLWHAs, and cigarette smoking is an independent predictor of
these outcomes.9,10 Increased incidences of tobacco-related cancers11 and increased overall
mortality have also been noted in PLWHA smokers.12,13
Despite the magnitude of this problem, little is known about smoking behaviors in PLWHAs.
An understanding of the behavioral bases of smoking and of the obstacles to quitting is essential to
the development of effective treatment strategies. The National Institutes of Health recently
identified PLWHA smokers as a high priority group for the development and study of tailored
cessation strategies.14 We, therefore, conducted an in-depth study of the social, psychological, and
behavioral characteristics of a sample of smokers in an inner-city HIV-care clinic.
60 subjects completed the interview. Their sociodemographic and clinical characteristics are summarized in Table 1.
Table 1. Characteristics of study sample.
Characteristic
Age (mean±S.D.)
Gender
Male
Female
Subjects were recruited from the patient population of the Montefiore Medical Center’s Center
for Positive Living. A computer-generated randomization scheme was applied to patients
attending regularly scheduled HIV-primary care clinic visits. Individuals who admitted to
smoking a cigarette within the prior 7 days were invited to participate in a face-to-face interview
administered by trained psychology graduate students.
The interview lasted approximately 60 minutes and included questions about demographics,
general, psychiatric, and HIV-related medical history, substance use, and current symptoms of
depression and anxiety using the Brief Symptom Inventory 18 (BSI-18).15 CD4+ lymphocyte and
HIV-1 viral load (VL) measurements were abstracted from the electronic medical record. Various
domains of tobacco use behaviors were explored using the modified Fagerstrom Test for Nicotine
Dependence,16 Abrams and Biener Readiness to Quit Ladder,17 a 12-item Reasons for Quitting
measure,18 a 20-item Self-Efficacy measure,19 a 25-item Locus of Control measure,20 nine-item
Smoker and Abstainer Self-Concept Scale,21 a 20-item Partner Interaction Questionnaire.22 The
authors also developed measures of perceived risks and benefits of smoking, of interactions with
their primary care providers concerning smoking, and of interest in various smoking cessation
interventions.
32 (53.3%)
28 (46.7%)
Race/Ethnicity
Latino/a
African American
White
Other*
30 (50.0%)
22 (36.7%)
2 (3.3%)
6 (10.0%)
Marital status
Single
Married
Widowed
Separated
Divorced
33 (55.0%)
11 (18.3%)
7 (11.7%)
5 (8.3%)
4 (6.7%)
Risk behavior
Injection drug use
Male-male sexual contact
Heterosexual contact
Unknown
13 (21.7%)
12 (20.0%)
27 (45.0%)
8 (13.3%)
Current illicit substance use
Cocaine
Heroin
Marijuana
# of years since HIV
diagnosis (mean±S.D.)
METHODS
N=60
46.8±7.2
CDC-defined AIDS
Yes
No
29 (48.3%)
20 (33.3%)
28 (46.7%)
13.0±5.5
37 (61.7%)
23 (38.3%)
Lowest documented CD4+
lymphocyte count (cells/ul,
mean±S.D.)
215±187
Most recent CD4+
lymphocyte count (cells/ul,
mean±S.D.)
520±404
S.D.=standard deviation
*”Other” included two individuals who identified
themselves as African American/Latino, two Caribbeans,
one White/Latino, and one African American/Native
American.
Tobacco use history and behaviors.
All study subjects, by definition, were cigarette smokers. Fifteen percent also smoked cigars, 6.7%
smoked a pipe, and 3.3% used chewing tobacco. The mean number of cigarettes smoked per day was
14.4±9.6. Mean age of first cigarette was 16.0±5.0 years, and mean total number of years smoking was
29.0±9.8. Thirty percent of participants shared their home with a smoker. The distribution of number of
prior lifetime quit attempts was: none—18.3%, one to five—53.3%, six to ten—16.7%, more than ten—
11.7%. Nineteen subjects (31.7%) reported a history of quitting for a year or more at some point in the
past. Quitting strategies included “cold turkey” in 65%, nicotine replacement therapy in 40%, and
acupuncture in 5%. Only one patient reported trying bupropion, group counseling, or individual
counseling.
Nicotine dependence (modified Fagerstrom Test for Nicotine Dependence).
Median score was 5.0 (IQR: 2—6.8). Twenty-one subjects (35%) exhibited low dependence, 28.3%
exhibited medium dependence, and 36.7% exhibited high dependence on nicotine.
Readiness to quit (Abrams and Biener Readiness to Quit Scale).
The distribution of subjects in the Stages of Change Model was as follows: Precontemplation
(score=1-5)-28.3%, Contemplation-6.7% (score=6), Preparation (score=7-8)-53.3%, and Action (score=910)-13.3%.
Intrinsic and extrinsic motivation to quit (Reasons for Quitting Questionnaire).
Items were scored on a five-point Likert scale: 1=”Not at all true” to 5=”Extremely true.” This
measure separates motivation to quit into intrinsic (i.e. seeking a reward internal to the person) and
extrinsic (i.e. seeking a reward external to the person) components. The mean intrinsic motivation score
was 2.5±1.0, the mean extrinsic motivation score was 1.6±0.9, and the mean difference in scores was
0.9±1.0. Of the intrinsic motivations to quit, 63.3% of subjects rated the reason for quitting, “Because I
feel like smoking is hurting my health” as “Extremely true” (i.e. the highest possible rating), and 61.7% of
subjects rated “Because I am afraid that smoking will shorten my life” as “Extremely true.” Of the
extrinsic motivations, only “To save money that I spend on cigarettes” was endorsed as “Extremely true”
by the majority (60%) of respondents.
Smoker and abstainer self-concept (Smoker and Abstainer Self-Concept Scale).
Items were scored on a ten-point Likert scale: 1=”Strongly disagree” to 10=”Strongly agree.” The
mean total score for abstainer self-concept (27.5±18.0) exceeded that for the smoker self-concept
(20.1±13.3), P=0.02, indicating a greater degree of identification with the abstainer as compared to the
smoker persona.
Social support (Partner Interaction Questionnaire).
Items were scored on a five-point Likert scale: 0=”Never” to 4=”Very often.” Respondents rated the
expected frequency that their social supporter would exhibit positive and negative behaviors relating to
their attempt to quit smoking on a five-point Likert scale: The mean total positive behavior score (10
items) was 26.8±10.2, and the mean total negative behavior score (10 items) was 22.6±9.0. The mean
positive/negative behavior ratio was 1.5±1.7.
Anxiety and depression (BSI-18).
Clinically significant depression was present in 39.0% of subjects and anxiety was present in 37.3%.
Advice from primary care porvider about smoking cessation.
87% of subjects stated that their primary care providers had discussed smoking cessation with them,
72.9% reported that their providers recommended or prescribed pharmacotherapy to assist them to quit,
57.6% reported having received written materials about quitting from their providers, 32.8% reported
having been referred to a quitline, and 5.3% reported having been referred to a smoking cessation
program. 11% expressed the belief that their providers smoked cigarettes.
Interest in smoking cessation interventions.
Asked which cessation strategies they would be interested in using, subjects reported interest in the
following non-mutually exclusive categories: nicotine replacement therapy 64.4%, individual counseling
64.4%, group counseling 55.9%, quitline 52.5%, “buddy” system 49.2%, and oral medications 40.7%.
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This work was supported by a grant from the American Legacy Foundation. The material presented does not necessarily reflect the views of the American Legacy Foundation, its staff, or its Board of Directors.
Perceived risks (“For you, how much do these
things bother you about smoking?”)
Worrying about getting seriously ill
Smelling like smoke
Exposing others to secondary smoke
Expense of smoking
Stigma (i.e. rejection from others)
Inconvenience (e.g. smoke free laws)
Looking older
Feeling tired and/or out of breath
Perceived benefits (“How much do you think
smoking helps you with..?”)
Weight control
Moving your bowels
Enhanced narcotic response (i.e. increases
the “high” from other drugs)
Fighting infection
Increasing your T-cell count
Decreasing your pain
Controlling anxiety
Controlling anger
Controlling depression
Relaxing
Being accepted by other smokers
Increasing social contact
Not at all
N=59*
Somewhat
A lot
20.3%
22.0%
23.7%
10.2%
44.1%
47.5%
42.4%
20.3%
25.4%
22.0%
18.6%
16.9%
23.7%
22.0%
18.6%
23.7%
54.2%
55.9%
57.6%
72.9%
32.2%
30.5%
39.0%
55.9%
55.9%
61.0%
64.4%
22.0%
23.7%
18.6%
22.0%
15.3%
16.9%
81.4%
78.0%
74.6%
40.7%
32.2%
40.7%
25.4%
57.6%
61.0%
6.8%
10.2%
8.5%
40.7%
40.7%
40.7%
54.2%
28.8%
28.8%
11.9%
11.9%
15.3%
18.6%
27.1%
18.6%
20.3%
13.6%
10.2%
*One participant elected not to answer this set of questions, resulting in a sample size
of 59.
CONCLUSIONS
•Persons living with HIV/AIDS (PLWHAs) who smoke are highly dependent on
nicotine, but are also highly motivated to quit. Few have accessed formal
cessation programs.
•Very high rates of psychiatric comorbidity and concurrent illicit substance use
in PLWHA smokers suggest that intensive smoking cessation interventions may
be the preferred treatment strategy for this population.
•Most PLWHA smokers are concerned about the health consequences of their
smoking and about the financial cost of cigarettes.
•PLWHA smokers use cigarettes as a means of coping with depression, anxiety,
and anger. Cessation efforts should offer alternative, healthier approaches for
stress management.
•One-fifth of PLWHA smokers hold mistaken beliefs about the health benefits
of smoking (i.e. “It raises my T-cell count,” or “It helps me fight infections”).
Cessation efforts should work to dispel these myths.
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