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Positively Smoke Free: Targeting the Quiet Killer in the HIV/ AIDS Population

Numerous studies have indicated that persons living with HIV/AIDS (PLWHAs) in the U.S. smoke at much higher rates than the general population,  with rates between 35% and  70% in that population. ^(1-9) This astronomical prevalence rate of tobacco use undercuts the advanced longevity and improved health enabled by antiretroviral therapy. Since the mid nineties, morbidity and mortality statistics show a striking rise of cardiac disease and tobacco related illnesses as causes of hospitalizations and deaths among PLWHAs. Before the era of antiretroviral therapy, AIDS patients were not dying of heart attacks and lung cancer, but from pneumonias and central nervous system infections.  ^(10-12)

Dr. Jonathan Shuter, Director of Clinical Research in the AIDS Center at Montefiore Medical Center in New York City, one of the nation’s largest comprehensive HIV-care centers, saw that he was spending less time counseling his patients on getting their HIV under control than addressing a battery of other health concerns with tobacco use at the top of the list. He realized that this community desperately needed a culturally-tailored smoking cessation intervention.

“I have had too many of my patients manage to get through and survive with their HIV and rescue them from the abyss only to find a spot on their lung,” said Dr. Shuter. “I’ve seen too many people die that way or die from heart attacks. These are preventable illnesses.”     

With the help of a grant from the American Legacy Foundation, Dr. Shuter conducted an in depth study of the social and psychobehavioral underpinnings of smoking among PLWHAs. He found that his patients, like many smokers, turn to tobacco to control stress. PLWHAs live under a constant barrage of stress: stress of living with the illness, financial stresses, stigmatization, depression, and anxiety. He also found that at least 25 percent of his patients had internally calculated a net benefit from their smoking as a stress reliever, making it a health benefit in their minds.

In response to these findings, Doctor Shuter developed Positively Smoke Free, an intensive cessation program specifically tailored with a motivational behavioral model for the PLWHA community. “The HIV infected smoker is a much more complicated patient for achieving smoking cessation than your run of the mill smoker,” said Dr. Shuter. “There are tremendously high rates of psychiatric illness, very high rates of illicit substance use, and these myths [about perceived health benefits of smoking] that need to be dispelled. As a collection of factors, these tend to make it very difficult for smokers living with HIV to quit.”

The onsite Positively Smoke Free eight-week pilot program was a measured success, helping a number of heavily addicted smokers to quit or cut down on their tobacco usage. Like many smoking cessation counseling programs, attrition became an issue for the facilitators, but some of Dr. Shuter’s most challenging smokers cut back or quit smoking entirely.

Dr. Shuter believes his patients need a broad menu of options for successful intervention and has recently partnered with the University of Michigan’s Center for Health Communications Research to design a distilled, Web-based, version of Positively Smoke Free. This will be the first tobacco control intervention for PLWHAs designed for the Internet, opening up cessation support to potentially thousands of isolated individuals. “There are so many smokers out there who aren’t going to have group sessions available to them, or wouldn’t choose to show up week after week,” he said. “An intensive, well thought out, smoking cessation intervention on the Web makes sense for them.”

Social support is critical in the PLWHA community, and an intensive intervention that is built on a psychological model and teaches patients how to stop smoking and maintain their quit is most likely to be successful, whether in group sessions or Web-based support. There is no magic pill for the smoking problem in the PLWHA community, and the problem was long overlooked by the medical community. Dr. Shuter and his team at Montefiore Medical Center are at the frontlines of innovation and implementation in the fight against smoking related diseases in PLWHAs.