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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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What we know about hiv smokers implications for treatment

HIV

What We Know About HIV+ SmokersImplications for Treatment

Jack Burkhalter, Ph.D.

Smoking Cessation Program

Memorial Sloan-Kettering Cancer Center


Acknowledgments
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
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 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
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
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
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
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
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
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
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
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
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
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
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
What health benefits do you believe quitting smoking provides?

NOTE: No differences between current and former smokers in percent endorsement of benefit categories


Summary
Summary provides?

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



Enhancing Motivation to Quit: The “5 R’s” programs?

  • 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
“Teachable Moments” programs?

  • 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
Personalizing Risks & Benefits programs?

  • 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
Systems Level Interventions programs?

  • 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 Care programs?

  • 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
What to treat first? programs?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! programs?

  • 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
Let’s work together! programs?

  • 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



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