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HIV. What We Know About HIV+ Smokers Implications for Treatment. Jack Burkhalter, Ph.D. Smoking Cessation Program Memorial Sloan-Kettering Cancer Center. Acknowledgments. HIV.
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HIV What We Know About HIV+ SmokersImplications for Treatment Jack Burkhalter, Ph.D. Smoking Cessation Program Memorial Sloan-Kettering Cancer Center
Acknowledgments HIV 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.
Approach to this talk HIV • Evidence-based, with the state of current knowledge • Clinical researcher’s perspective • Cancer prevention perspective
HIV and Smoking: Why now? HIV • 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
Comparisons of Smoking Rates HIV 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 hyper- responsiveness (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
Two Published Studies HIV • 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
Smoker characteristics 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
Perceived risks of smoking “How much do you believe that there are health risks associated with quitting smoking?” Current smokers 3.8* Former smokers 4.5* *p<.001
What health risks do you believe smoking exposes you to? 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?” Current smokers 3.8* Former smokers 4.5* *p<.001
What health benefits do you believe quitting smoking provides? NOTE: No differences between current and former smokers in percent endorsement of benefit categories
Summary HIV • 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 • Intrinsicmotivation (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