Evidence-Based Smoking
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Evidence-Based Smoking Cessation Counseling for HIV-Infected Patients. Julia H. Arnsten, MD, MPH Chief, Division of General Internal Medicine Associate Professor of Medicine, Epidemiology, and Psychiatry Montefiore Medical Center Albert Einstein College of Medicine . Background.

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Evidence-Based Smoking

Cessation Counseling for

HIV-Infected Patients

Julia H. Arnsten, MD, MPH

Chief, Division of General Internal Medicine

Associate Professor of Medicine, Epidemiology, and Psychiatry Montefiore Medical Center

Albert Einstein College of Medicine

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  • More than 50% of HIV-infected patients smoke

  • Smoking poses unique health risks to HIV-infected patients

    • pulmonary infections

    • oropharyngeal lesions

    • AIDS-defining and non-AIDS-defining malignancies.

  • Smoking is a known RF for atherosclerosis and is associated with coronary events in patients on PIs

  • “Graying” of HIV-infected population necessitates screening for and prevention of chronic disease

    • Coronary heart disease

    • Diabetes

    • Obesity

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Prevalence of smoking among HIV-infected patients in New YorkBurkhaler et al, Tobacco use and readiness to quit smoking in low-income HIV-infected persons, Nicotine Tob Res, 2005; 7(4):511-22.

  • 428 HIV+ Medicaid recipients, NYC

    • Age: 22-75

    • 59% males

    • 53% African Americans, 30% Latinos

    • HS education or less : 87%

  • 67% current smokers (mean=16 cig./day)

  • 19% former smokers, 16% never smokers

  • Current smokers

    • Greater use of illicit substances (ever and current)

    • Lower perceived health risk of continued smoking

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Distribution of HIV/AIDS Discharges by Age-group, 1994-2002 York

Source: SPARCS (Statewide Planning and Research Cooperative System)

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Distribution of Medicaid recipients with HIV/AIDS by age group, 1993-2001

Source: NYS Medicaid Claims Database

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Changing Morbidity and Mortality group, 1993-2001CancerLung diseaseCardiovascular disease

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Trends in AIDS-Defining and Non–AIDS-Defining Malignancies: 1989–2002Bedimo, R et al. Trends in AIDS-defining and non-AIDS-defining malignancies among HIV-infected patients: 1989-2002. Clin Inf Dis 2004;39:1380-1384

Cases per 1000 pat-years


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Cancers of the larynx and oropharynx Malignancies: 1989–2002



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Cancers of the lung/trachea Malignancies: 1989–2002

Source: SPARCS

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Lung disease Malignancies: 1989–2002

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Chronic Bronchitis and Emphysema Malignancies: 1989–2002

Source: SPARCS database, NYSDOH

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Cardiovascular disease Malignancies: 1989–2002

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Myocardial infarction Malignancies: 1989–2002

Holmberg et al. Trends in rates of Myocardial infarction among patients with HIV

N Engl J Med 2004; 350:730-731

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Acute Myocardial Infarction Malignancies: 1989–2002

Source: SPARCS database, NYSDOH

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Mean Absolute Risk (%) Malignancies: 1989–2002

Risk Factors Are Additive

The total severity of multiple low-level risk factors often exceeds that of a single severely elevated risk factor.





BP 165/95 mm Hg

BP 165/95 mm Hg

Age 56 years

BP 165/95 mm Hg

Age 56 years

LDL-C 155 mg/dL

BP 165/95 mm Hg

Age 56 years

LDL-C 155 mg/dL


Grundy SM et al. J Am Coll Cardiol 1999;34:1348-1359.

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Are physicians intervening in Malignancies: 1989–2002tobacco use?Ellerbeck, Ahluwalia, et al. Direct observation of smoking cessation activities in primary care practice. J Fam Pract. 2001; 50:688-693

In 38 primary care practices:

Tobacco was discussed in 21% of encounters.

Discussion was:

  • more common in those practices (58%) with standard forms for recording smoking status

  • more common during new patient visits

  • less common with older patients

  • less common with physicians in practice more than 10 years

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Barriers to treating tobacco dependence Malignancies: 1989–2002

“Not enough time.”

“Patients don’t want to hear about it.”

“I can’t help patients stop.”

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“Not enough time” Malignancies: 1989–2002

“Minimal interventions lasting less than 3 minutes increase overall tobacco abstinence rates.”

The PHS Guideline

(Strength of Evidence = A)

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“Patients don’t want to hear Malignancies: 1989–2002about it”

  • In several studies, smoking cessation interventions during physician visits associated with increased patient satisfaction with care among smokers

  • 1,898 patients who reported that they had been asked about tobacco use or advised to quit during the latest visit had 10% greater satisfaction rating and 5% less dissatisfaction than those not reporting such discussions Mayo Clin Proc. 2001;76:138-143

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Positive Changes in Health Promoting Behavior Following Diagnosis with HIVCollins et al, Health Psychology 2001; 20(5):351-360

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Interest in Quitting Smoking Diagnosis with HIVMamary et al, Cigarette smoking and the desire to quit among individuals living with HIV, AIDS Patients Care and STDs 2002; 16(1):39-42

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“I can’t help patients stop” Diagnosis with HIV

Effective clinical interventions exist

The Public Health Service Clinical Practice Guideline Treating Tobacco Use and Dependence was published in June, 2000 and offers effective treatments for tobacco dependence.

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The 5 A’s Diagnosis with HIVFor Patients Willing To Quit

  • ASK about tobacco use at every visit.

  • ADVISE to quit with a clear, strong, personalized message.

  • ASSESS willingness to make a quit attempt within the next 30 days.

  • ASSIST in quit attempt with a brief (3-5 min) counseling intervention.

  • ARRANGE for follow-up (ANTICIPATE relapse).

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ASK Diagnosis with HIV

EVERY patient at EVERY visit

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ADVISE Diagnosis with HIV

  • Once tobacco use status has been identified and documented, advise all tobacco users to quit

  • Even brief advice to quit results in greater quit rates

  • Advice should be:

    • clear

    • strong

    • personalized

“As your health care provider, I must tell you that the most important thing you can do to improve your health is to stop smoking.”

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ASSESS Diagnosis with HIV

After providing a clear, strong, and personalized message to quit, you must determine whether the patient is willing to quit at this time

“Are you willing to try to quit at this time? I can help you.”

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ASSIST Diagnosis with HIV

  • Help develop a quit plan

  • Provide practical counseling

    • Identify events, internal states, or activities that increase the risk of smoking or relapse (e.g. drinking, other smokers).

    • Identify and practice coping or problem-solving skills.

    • Provide basic information about smoking and successful quitting.

  • Provide intra-treatment social support

    • Encourage the patient in the quit attempt.

    • Communicate caring and concern.

    • Encourage the patient to talk about the quitting process

  • Help patient obtain extra-treatment social support

  • Recommend pharmacotherapy (ex. special circumstances)

  • Provide supplementary materials

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Developing a quit plan Diagnosis with HIV

  • Set a quit date

  • Review past quit attempts

  • Anticipate challenges

  • Remove tobacco products

  • Avoid

    • Alcohol use

    • Exposure to tobacco

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Counsel your patients to quit Diagnosis with HIV

“Minimal interventions lasting less than 3 minutes increase overall tobacco abstinence rates”

The PHS Guideline

(Strength of Evidence = A)

“There is a strong dose-response relation between the session length of person-to-person contact and successful treatment outcomes. Intensive interventions are more effective than less intensive interventions and should be used whenever possible”

The PHS Guideline

(Strength of Evidence = A)

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Brief Intervention Diagnosis with HIV

  • 5-15 minute counseling session

  • Four components

    • State your concern about your patient’s behaviors (smoking, use of alcohol/drugs, diet)

    • Make explicit recommendation for change in behavior

    • Discuss patient’s reaction

    • Review treatment options; negotiate plan

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  • Schedule a follow-up contact within one week after the quit date

    • Telephone contact

    • Quit lines

  • The majority of relapse occurs in the first two weeks after quitting

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Relapse Diagnosis with HIV

  • Preventing Relapse

    • Congratulate success

    • Encourage continued abstinence

    • Discuss with your patient:

      • benefits of quitting

      • barriers

  • If your patient has used tobacco, remind him or her that the relapse should be viewed as a learning experience

  • Relapse is consistent with the chronic nature of tobacco dependence; not a sign of failure

“How has stopping tobacco use helped you?.”

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Cell Phone Intervention Pilot Study: Houston, Texas Diagnosis with HIVLazev et al, Increasing access to smoking cessation treatment in a low-income, HIV-positive population: The feasibility of cellular telephones. Nicotine & Tobacco Research, 2004; 6(2):281-286.

  • Pilot study of a proactive cell phone smoking cessation intervention (n=20)

  • Thomas St. Clinic – 4000 medically indigent patients (mostly Black and Hispanic)

  • Six scheduled cell-phone delivered counseling sessions delivered over two weeks (1 d prior to quit date, on quit date, and 2, 4, 7, and 14 d post) – average 5 min

  • 24 hr/7 d/week quit line, patient info also provided

  • Highly successful: 95% made a quit attempt and 75% were abstinent at 1 and 2 weeks post quit date

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Treating patients who are not ready to make a quit attempt with Motivational Interviewing

  • RELEVANCE: Tailor advice and discussion to each patient, avoid argument!

  • RISKS: Outline specific risks of smoking.

  • REWARDS: Outline the benefits of quitting.

  • ROADBLOCKS: Identify barriers to quitting.

  • REPETITION: Reinforce the motivational message at every visit, avoid argument!

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Motivational Interviewing with Motivational InterviewingMotivational interviewing is a directive, client-centered counseling style for eliciting behavior change by helping clients to explore and resolve ambivalence.

Stephen Rollnick, William R. Miller, 1995

Rollnick, S., & Miller, W. R. What is motivational interviewing? Behavioural and Cognitive Psychotherapy. 1995;23:325-334.

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Readiness to Change Model with Motivational Interviewing

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Stages of Change in Two Populations of HIV-infected Smokers with Motivational Interviewing

NY: Burkhaler et al, Tobacco use and readiness to quit smoking in low-income HIV-infected persons, Nicotine Tob Res, 2005; 7(4):511-22.Houston: Gritz et al, Smoking behavior in a low-income multiethnic HIV/AIDS population, Nicotine Tob Res, 2004; 6(1):71-77.

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Precontemplation with Motivational Interviewing

  • Goal is to raise doubt, increase perception/ consciousness of problem

    • express concern

    • state the problem non-judgmentally

    • agree to disagree

    • advise a trial of abstinence or cutting down

    • importance of follow-up (even if still smoking/using drug & alcohol )

    • less intensity is better

Samet, JH, Rollnick S, Barnes H. Arch Intern Med. 1996;156:2287-93.

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Contemplation with Motivational Interviewing

  • Goal is to tip the balance

    • elicit positive and negative aspects of smoking or drug & alcohol use

    • elicit positive and negative aspects of not smoking or using drugs & alcohols

    • summarize (patient could write these down)

    • demonstrate discrepancies between values and actions

    • advise a trial of abstinence or cutting down

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Preparation with Motivational Interviewing

  • Goal is to help determine the best course of action

    • working on motivation is not helpful

    • supporting self-efficacy is (remind of strengths--i.e. previous quits, periods of sobriety, coming to doctor)

    • help decide on achievable goals

    • caution re: difficult road ahead

    • relapse won’t disrupt relationship

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Action with Motivational Interviewing

  • Goal is to help patient take steps to change

    • support and encouragement

    • acknowledge discomfort (losses, withdrawal)

    • reinforce importance of recovery

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Maintenance with Motivational Interviewing

  • Goal is to help prevent relapse

    • anticipate difficult situations (triggers)

    • recognize the ongoing struggle

    • support the patient’s resolve

    • reiterate that relapse won’t disrupt your relationship

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Relapse with Motivational Interviewing

  • Goal is to renew the process of contemplation

    • explore what can be learned from the relapse

    • express concern

    • emphasize the positive aspects of prior abstinence and of current efforts to quit smoking or drug & alcohol use

    • support self-efficacy

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Ingredients of Effective Brief Interventions (FRAMES) with Motivational Interviewing

  • FEEDBACK of personal risk or impairment

    • i.e. CHD, lung disease, state consequences or risks

  • emphasis on personal RESPONSIBILITY for change

    • “…it’s up to you to decide…”

  • clear ADVICE to change

    • identify the problem, explain why change is important, advocate specific change

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Ingredients of Effective Brief Interventions (FRAMES) with Motivational Interviewing

  • a MENU of alternatives

    • a range of options

  • EMPATHIC counseling style

    • understanding and reflective

  • enhancement of SELF-EFFICACY

    • reinforce it, state your belief they can do it

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Physician’s Treatment Goals with Motivational Interviewing

  • Maintain awareness of smoking and other drug & alcohol issues

  • Ask, assess and advise

  • Consider smoking and drug & alcohol problems as a mainstream medical issues

  • Counsel patients about behavior change at every visit

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Parliament ad in Details, Cosmopolitan, Mademoiselle, Penthouse, 1995

Parliament ad in Out magazine, 1995

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Adult smoking rates Penthouse, 1995


2003 21.5%

2004 18.9%


2003 21.6%

2004 20.7%