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Get Your Patients with HIV/AIDS
to Stop Smoking Before it Kills Them
Steven A. Schroeder, MD
Professor of Medicine
University of California San Francisco
San Francisco, California
FORMATTED: 11/03/2015
New Orleans, Louisiana: December 15-17, 2015
Slide 2 of 56
Tobacco’s Deadly Toll
540,000 deaths in the U.S. each year*
 4.8 million deaths world wide each year

--Current trends show >8 million deaths annually by 2030
42,000 deaths in the U.S. due to second-hand smoke exposure
 14 million in U.S. with smoking related diseases
(60% with COPD)
 42.1 million smokers in U.S. (76.9% daily smokers, averaging 14.2
cigarettes/day, 2013)

* Carter et al, NEJM, Feb 12, 2015
Slide 3 of 56
TRENDS in ADULT SMOKING,
by SEX—U.S., 1955–2013
Trends in cigarette current smoking among persons aged 18 or older
60
50
17.8% of adults
are current
smokers
Male
Percent
40
30
Female
20.5%
20
15.3%
10
0
1955
1965
1975
1985
1995
68.8% want to quit
Graph provided by the Centers for Disease Control and Prevention. 1955 Current
Population Survey; 1965–2013 NHIS. Estimates since 1992 include some-day smoking.
2005
Percent/Number of Cigarettes Smoked Daily
Smoking Prevalence and Average
Number of Cigarettes Smoked per Day
per Current Smoker 1965-2010
*January-March 2015: 15.3% prevalence!
Source: Schroeder, JAMA 2012; 308:1586; *CDC/NCHS, National Health Interview Survey, 1997-March 2015, Sample Adult Core
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Health Consequences of Smoking

Cancers
–
–
–
–
–
–
–
–
–
–

Acute myeloid leukemia
Bladder and kidney
Cervical
Colon, liver, pancreas
Esophageal
Gastric
Laryngeal
Lung
Oral cavity and pharyngeal
Prostate (↓survival)

–
–
–
–
–

Abdominal aortic aneurysm
Coronary heart disease
Cerebro-vascular disease
Peripheral arterial disease
Type 2 diabetes mellitus
Reproductive effects
– Reduced fertility in women
– Poor pregnancy outcomes (ectopic
pregnancy, congenital anomalies,
low birth weight, preterm delivery)
– Infant mortality; childhood obesity
Pulmonary diseases
– Acute (e.g., pneumonia)
– Chronic (e.g., COPD)
– Tuberculosis
Cardiovascular diseases

Other effects: cataract; osteoporosis;
Crohn’s; periodontitis; poor surgical
outcomes; Alzheimer’s; rheumatoid
arthritis; less sleep
U.S. Department of Health and Human Services. The Health Consequences of Smoking: A Report of the Surgeon General, 2010.
Causal Associations with
Second-hand Smoke

Developmental

– Low birthweight
– Sudden infant death
syndrome (SIDS)
– Pre-term delivery
-- Childhood depression

Respiratory
– Lung cancer
– Nasal sinus cancer
– Breast cancer? (younger,
premenopausal women)

– Asthma induction and
exacerbation
– Eye and nasal irritation
– Bronchitis, pneumonia, otitis
media, bruxism in children
– Decreased hearing in teens
Carcinogenic
There is no
safe level of
second-hand
smoke.
Cardiovascular
– Heart disease mortality
– Acute and chronic coronary
heart disease morbidity
– Altered vascular properties
USDHHS. (2006). The Health Consequences of Involuntary Exposure to Tobacco Smoke:
Report of the Surgeon General.
Slide 6 of 56
Smoking and Behavioral Health:
The Heavy Burden

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Slide 7 of 56
240,000 annual deaths from smoking occur among patients with Chronic
Mental Illness (CMI) and/or substance abuse
This population consumes 40% of all cigarettes sold in the United States
-- higher prevalence
-- smoke more
-- more likely to smoke down to the butt
People with CMI die earlier than others, and smoking is a large contributor
to that early mortality
Greater risk for nicotine withdrawal
Social isolation from smoking compounds the social stigma
Slide 8 of 56
Smoking Imperils the HIV/AIDS Population
LGBT persons and those with substance use disorders
have higher smoking rates
 HIV/AIDS patients have higher smoking rates
 HIV patients who smoke have greater odds of heart
disease, cancer, CVA, and HIV-related infections than HIV
patients who do not smoke

Dopamine Reward Pathway
Prefrontal
cortex
Dopamine release
Stimulation of
nicotine receptors
Nucleus
accumbens
Ventral
tegmental
area
Nicotine enters
brain
Slide 9 of 56
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Nicotine Addiction


Tobacco users maintain a minimum serum
nicotine concentration in order to
– Prevent withdrawal symptoms
– Maintain pleasure/arousal
– Modulate mood
Users self-titrate nicotine intake by
– Smoking more frequently
– Smoking more intensely
– Obstructing vents on low-nicotine brand cigarettes
Slide 11 of 56
Tools for Smoking Cessation
5As (Ask, Advise, Assess, Assist, Arrange)
 AAR (Ask, Advise, Refer)
 Quitlines
 NRT and other medications
 Counseling and behavioral change strategies
 Peer-to-peer intervention

Slide 12 of 56
Treatment

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Persons with HIV, mental illnesses, and substance use
disorders benefit from same interventions as general
population
Combination of counseling and pharmacotherapy should
be used whenever possible
Duration of treatment might be longer
View failed quit attempt as a practice, not failure
Slide 13 of 56
Cognitive Strategies for Cessation
Review commitment to quit, focus on downsides of
tobacco use
 Reframe the way a patient thinks about smoking
 Distractive thinking
 Positive self-talks, “pep talks”
 Relaxation through imagery
 Mental rehearsal, visualization

Slide 14 of 56
Behavioral Strategies for Cessation
(Avoiding Stimuli that Trigger Smoking)

Stress
– Anticipate future challenges
– Develop substitutes for tobacco

Alcohol
– Limit or abstain during early stages of quitting

Other tobacco users
– Stay away
– Ask for cooperation from family and friends
Slide 15 of 56
Behavioral Strategies for Cessation
(Part 2)

Oral gratification needs
– Use substitutes: water, sugar-free chewing gum or
hard candies

Automatic smoking routines
– Anticipate routines and develop alternative plans,
e.g., with morning coffee

Weight gain after cessation
– Anticipate; use gum or bupropion; exercise

Cravings
– Distractive thinking; change activities
Slide 16 of 56
PHARMACOTHERAPY
“Clinicians should encourage all
patients attempting to quit to use
effective medications for tobacco
dependence treatment, except where
contraindicated or for specific
populations* for which there is
insufficient evidence of effectiveness.”
* Includes pregnant women, smokeless tobacco users, light smokers, and adolescents.
Medications significantly improve success rates.
Fiore et al. (2008). Treating Tobacco Use and Dependence: 2008 Update.
Clinical Practice Guideline. Rockville, MD: USDHHS, PHS, May 2008.
Pharmacologic Methods:
First-line Therapies*
Three general classes of FDA-approved
medications for smoking cessation:
 Nicotine replacement therapy (NRT)
-- nicotine gum, patch, lozenge, nasal spray, inhaler
 Partial nicotine receptor agonist
-- varenicline
--? cytisine in the future
 Psychotropics
-- sustained-release bupropion
* Counseling plus meds better than either alone
Currently, no medications have an FDA indication
for use in spit tobacco cessation.
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Caveats About Cessation Literature

Smoking should be thought of as a chronic condition, yet drug
treatment often short (12 weeks) in contrast to methadone
maintenance

Great spectrum of severity and addiction; treatment should be
tailored accordingly

Volunteers for studies likely to be more motivated to quit

Placebo and drug groups tend to have more intensive
counseling than found in real practice world; and counseling is
not a monolithic black box

Most drug trials exclude patients with mental illness
Slide 19 of 56
LONG-TERM (6 month) QUIT RATES for
AVAILABLE CESSATION MEDICATIONS
30
28.0
Active drug
Placebo
Percent quit
25
20
23.9
18.9
18.9
16.3
17.1
15.9
15
12.0
11.8
10
10.0
9.8
10.6
9.1
8.4
5
0
Nicotine gum
Nicotine
patch
Nicotine
lozenge
Nicotine
nasal spray
Nicotine
inhaler
Bupropion
Varenicline
Data adapted from Cahill et al. (2012). Cochrane Database Syst Rev; Stead et al. (2012).
Cochrane Database Syst Rev; Hughes et al. (2007). Cochrane Database Syst Rev
Slide 20 of 56
Quitlines and Behavioral Health
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Do quitlines work for people with MI and/or SUD? Yes
Are they able to meet the demand? They are
underused
Slide 21 of 56
Tips for Your Office
Referral forms to the quitline (1-800-QUITNOW)
 Carbon monoxide breathalyzer (cost about $500 plus
disposal mouthpieces)
 One key question to ask: “When do you have your first
cigarette of the day?”
 Approach smoking as a chronic illness, just like HIV/AIDS
in 2015

Slide 22 of 56
Contact SCLC for Technical
Assistance
Visit us online

http://smokingcessationleadership.ucsf.edu
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CME/CE webinars
Fact sheets, toolkits, publications
Training resources and presentations
E-newsletter and listserv
Online ordering for 1-800-QUIT NOW cards
Call us toll-free
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1-877-509-3786
Slide 23 of 56
The Electronic Cigarette*
Aerosolizes nicotine in propylene glycol solvent; e-cig
products in evolution
 Cartridges contain about 20 mg nicotine
 Safety unproven, but >cigarette smoke
 Probably deliver < nicotine than promised
 Unclear if help smokers quit
 Not approved by FDA
 My advice: avoid unless patient insists

* Cobb & Abrams. NEJM July 21, 2011; Fiore, Schroeder, Baker, NEJM Jan 23, 2014
Slide 24 of 56
Cigarette and E-Cigarette Use among High School
Students, 2000-2014
Source: Youth Risk Behavior Survey