Download What We Know About HIV+ Smokers Implications for Treatment

HIV
What We Know About
HIV+ Smokers
Implications for Treatment
Jack Burkhalter, Ph.D.
Smoking Cessation Program
Memorial Sloan-Kettering Cancer Center
HIV
Acknowledgments
Support: NYS HRI 656-03-FED awarded to The AIDS
Institute, NYS Dept. of Health Resources and Services
Administration under the Special Projects of National
Significance Program
Colleagues:
Carolyn Springer, Ph.D., Adelphi University
Rosy Chhabra, Psy.D., Yeshiva University
Jamie Ostroff, Ph.D., Memorial Sloan-Kettering Cancer Ctr.
Bruce Rapkin, Ph.D., Memorial Sloan-Kettering Cancer Ctr.
HIV
Approach to this talk
 Evidence-based, with the state
of current knowledge
 Clinical researcher’s perspective
 Cancer prevention perspective
HIV
HIV and Smoking: Why now?
 Improved life expectancy in HIV disease
 Increasing interest in health behaviors that
affect length and quality of life
 Growing research that links smoking to
increased health risks for PLWHIV
 Recent studies indicating very high rates of
tobacco use among PLWHIV
HIV
Comparisons of Smoking Rates
Population
Smoking Rate
U.S. General
Females
Males
U.S. Medicaid patients
22.1%
20.3%
24.8%
36.0%
HIV+ National samples
45-51%
HIV+ Outpatient clinics
47-72%
Sources: CDC, 2001; 2004; Collins et al., 2001; Turner et al., 2001; Gritz, et al., 2004;
Mamary, et al., 2002; Niaura et al., 1999
What are the health risks
of smoking for HIV+
persons?
↑ Risk of oral thrush and oral hairy leukoplakia
↑ Risk of community-acquired pneumonia, emphysema,
spontaneous pneumothorax, and bronchial hyperresponsiveness (indicator of asthma)
↑ Risk of cryptococcosis
↑ Incidence of periodontal disease and oral lesions
↑ Lung, lip, and anal cancer, in addition to AIDS-defining
cancers (Kaposi Sarcoma, non-Hodgkin lymphoma, and
invasive cervical cancer)
What we don’t know for sure- Cannot conclude that smoking
promotes progression in HIV disease
 Although smoking negatively affects
SOME aspects of immune system,
this has not been linked with AIDS
onset or mortality
 More research needed
HIV
Two Published Studies
 Gritz et al. (2004). Smoking behavior in a low-income
multiethnic HIV/AIDS population. Nicotine & Tobacco
Research, 6 (1), 71-77.
 N = 348 HIV+, medically indigent persons receiving
outpatient services at Thomas St. Clinic in Houston
 Burkhalter et al. (2005). Tobacco use and readiness to
quit smoking in low-income HIV-infected persons.
Nicotine & Tobacco Research, 7 (4), 511-522.
 N = 428 HIV+ persons on Medicaid in New York State
Sample characteristics
Characteristics
Texas
New York
N
348 (one clinic)
428 (statewide)
Response rate
62%
92%
Age
40 years
40 years
Gender
78% male
59% male
Sexual behavior
identity
46% MSM
40% LGB
Ethnicity
44% Black
29% Hispanic
53% Black
30% Hispanic
Education
58% < high school
87% < high school
% with AIDS
52%
38%
Smoking status
47% current
17% former
36% never
66% current
19% former
16% never
TX: daily/some days
NY: within past 3 mos.
Smoker characteristics
Measures
Texas
New York
Mean # cigarettes/day
15.4
15.7
Nicotine dependence1
62%
67%
Readiness to quit:
Precontemplator
Contemplator
Preparation
38%
29%
34%
42%
40%
18%
Excessive alcohol use2
66%
16%
Current illicit drug use3
64%
31%
1Percent
smoking within 5 minutes of waking
2Texas
assessed by asking if drank > 5 drinks at one time in past 30 days. NY assessed by asking if they had used
too much alcohol in past 3 months
3Texas assessed for any illicit drug use in last 30 days; NY assessed for any illicit drug use in past 3 months
Texas Findings
 Current smokers vs. nonsmokers (former +
never) more likely to be:
–
–
–
–
White non-Hispanic
Older (vs. 20-29 years)
Have lower education (< high school)
Heavy drinkers of alcohol
 Quitters (vs. current smokers) more likely to:
– Be White (vs. Black, p<.06)
– Have higher education
– Not be heavy drinkers of alcohol
New York Findings
 Current smokers vs. nonsmokers (vs. former
+ never) more likely to report:
– Greater lifetime illicit drug use
– Greater current illicit drug use
– Less bodily pain
 Quitters (vs. current smokers) more likely to:
– Perceive greater health risks of smoking
– Not currently use illicit drugs
– Report more bodily pain (p<.10)
NY Study
What affects readiness to quit smoking?
 Lower readiness to quit smoking
associated with:
– Greater current illicit drug use
– Greater emotional distress
– Lower number of quit attempts since
HIV diagnosis
Other Indicators of Readiness
to Quit Smoking
Advised by a healthcare provider to
quit smoking
Would use a “low cost or free”
smoking cessation program
Smokers who had not attempted to
quit since HIV diagnosis
Former smokers who quit after HIV
diagnosis
Former smokers who quit within 1
year of diagnosis
81%
46%
35%
77%
14%
Perceived risks of smoking
“How much do you believe that there are health
risks associated with quitting smoking?”
Not at all
A little bit
Somewhat
Quite a bit
Very much
1
2
3
4
5
Current
smokers
3.8*
*p<.001
Former
smokers
4.5*
What health risks do you believe
smoking exposes you to?
Smokers’ responses and % endorsing this risk
Percent
Respiratory problems, e.g., “breathing problems”1
38
Cancer of any type
20
Impact on immune system, e.g. “lowers T-cells”1
8
Non-specific health risks, e.g., “definitely no good”
8
Cardiovascular diseases, e.g., “heart attack”
6
1Former
smokers, compared to current smokers, more frequently endorsed risks to respiratory
(84% vs. 71%; p < .05) and immune system functioning (28% vs. 12%; p < .05).
Perceived benefits of quitting
“How much do you believe that there are health benefits
associated with quitting smoking?”
Not at all
A little bit
Somewhat
Quite a bit
Very much
1
2
3
4
5
Current
smokers
3.8*
*p<.001
Former
smokers
4.5*
What health benefits do you
believe quitting smoking provides?
Smokers’ responses and % endorsing this risk
Percent
Improved respiration, e.g. “better sense of breathing”
32
Non-specific health benefits, e.g. “feel better”
14
Improved energy level, e.g., “would not have fatigue”
9
Better immune function, e.g., “healthy immune system”
5
“Do not know” or unsure
5
NOTE: No differences between current and former smokers in percent endorsement of benefit
categories
HIV
Summary
 High prevalence of smoking and low readiness to quit
 HIV diagnosis a weak “teachable moment” for quitting
 Continued smoking despite medical advice to quit
 Lower readiness to quit: Emotional distress, illicit
substance use, fewer quit attempts
 Barriers to quitting: Alcohol abuse, illicit substance use
 Motivational boosters: Perceived risks of smoking for
lung health, cancer, and immune system
 Motivational boosters: Perceived benefits of quitting
need more emphasis
What do research findings mean for
designing treatment programs?
Enhancing Motivation to Quit:
The “5 R’s”
Relevance: Why quitting is personally
relevant. Be specific.
Risks: Identify acute (shortness of breath),
long-term (emphysema), and environmental
risks (increased heart disease for family)
•Rewards: Identify benefits (e.g., lower risk of oral thrush, improved
breathing)
•Roadblocks: Identify barriers to quitting (e.g.,substance use)
•Repetition: Repeat motivational intervention every time client visits
Source: USDHHS Clinical Practice Guidelines: Treating Tobacco Use and Dependence, 2000
“Teachable Moments”
 HIV diagnosis
 Respiratory events, symptoms,
diagnoses
– PCP or bacterial pneumonia
– Symptoms such as shortness of breath,
chronic cough
– Bronchitis
• Oral conditions, such as thrush, OHL
• Any concerns about health or well-being
Personalizing Risks & Benefits
 Intrinsic motivation (health concerns) is
related to quitting success
 Extrinsic motivation (social pressure to quit)
is not as powerful as intrinsic motivation
 Identify each person’s specific benefits in
cessation and educate them about benefits
unknown to them
– “You complain of shortness of breath; giving up cigarettes will
improve your breathing and stamina.”
 Do the same for risks of continued smoking:
– “Your risk for oral thrush and bacterial pneumonia are higher.”
Systems Level Interventions
 Regular contact with healthcare providers
offers many opportunities to:





Ask
Advise
Assess willingness to quit
Assist
Arrange for follow-up
 Discuss NYS Medicaid coverage for
treatment of tobacco dependence, cost
Comprehensive Care

Comprehensive treatment needed for
prevalence of substance abuse, depression,
and smoking among PLWHIV

Integrate services for maximum uptake,
reinforcement of adherence, and continuity
of care

Tobacco use should be treated seriously as
a significant health threat
What to treat first?
So many problems, so few resources
 Treating depression, anxiety, alcohol or
substance abuse, nonadherence to HIV
meds—where to begin?
 Can PLWHIV change more than one health
behavior at a time?
 What about motivation to change?
 Tobacco use assessment and treatment may
be an opening to address other problems as
well
Queens Quits!
• Our mission is to promote tobacco prevention
and cessation among the residents of Queens
County.
To
provide training and technical assistance to
enhance readiness and capacity of Queens-based
physicians, dentists and other health care providers to
deliver brief tobacco cessation interventions in clinical
practice.
To
increase the number of Queens residents who are
referred for intensive cessation counseling, cessation
pharmacotherapy and use the services of the NYS
QuitLine.
Funded by a Tobacco Cessation Center Grant from the
NYS DOH Tobacco Control Program.
Let’s work together!
 Health care clinicians, advocates, service
providers, researchers, policy makers
 Reduce smoking prevalence among HIV+
persons through education, research, and
HIV care that targets tobacco use
 Improve the quality and length of life of
those living with HIV
For more HIV-related resources,
please visit www.hivguidelines.org