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Why Smoking Cessation Should Be a Priority in HIV Care Today…. Alvaro Carrascal, MD, MPH Office of the Medical Director AIDS Institute AI is a Local Performance Site of the NY/NJ AETC. Objectives. Review the changing paradigm of HIV disease Review the association between smoking and HIV

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why smoking cessation should be a priority in hiv care today

Why Smoking Cessation Should Be a Priority in HIV Care Today…

Alvaro Carrascal, MD, MPH

Office of the Medical Director

AIDS Institute

AI is a Local Performance Site of the NY/NJ AETC

objectives
Objectives
  • Review the changing paradigm of HIV disease
  • Review the association between smoking and HIV
  • Describe the importance of addressing tobacco use among PLWHA
hiv disease changing paradigm
HIV Disease: Changing Paradigm
  • Reduced mortality
  • Chronic disease
    • PLWH/AIDS living longer, healthier and more productive lives
  • Changing morbidity/mortality
    • Cancer, CVD, diabetes, liver disease, etc.
reductions in mortality
Reductions in Mortality
  • 5561pats., HOPS, 1996-2002

1996 2002

  • Deaths
    • 6.3 /100 person-yrs 2.2
  • OI rates:
    • 23 /100 person-yrs 6

Palella FJ et al. Mortality and morbidity in the HAART era: Changing causes of death and disease in the HIV Outpatient study. 11th CROI; San Francisco, CA 2004. Abs. 872

use of haart
Use of HAART

% of patients

Palella FJ et al. Mortality and morbidity in the HAART era: Changing causes of death and disease in the HIV Outpatient study. 11th CROI; San Francisco, CA 2004. Abs. 872

and change in causes of death
.. and Change in Causes of Death

% of deaths

Palella FJ et al. Mortality and morbidity in the HAART era: Changing causes of death and disease in the HIV Outpatient study. 11th CROI; San Francisco, CA 2004. Abs. 872

changes in causes of death southern alberta canada 1984 2003
Changes in Causes of DeathSouthern Alberta, Canada, 1984-2003

Cohort: 1987 patients Total # of deaths= 560

% of deaths, non-AIDS related causes

32%

7%

Krents, HB et al. Changing mortality rates and causes of death for HIV-infected individuals living in Southern Alberta, Canada, from 1984 to 2003. HIV Medicine 2005; 6:99–106

increases in non aids related causes of death southern alberta canada 1984 2003
Increases in Non-AIDS Related Causes of Death Southern Alberta, Canada, 1984-2003

Causes of Death 1984-961997-03

  • Accidental deaths 2.2% 17%

(drug overdose)

  • Liver disease <1 8.4
  • Non-HIV Cancers <1 7

Krents, HB et al. Changing mortality rates and causes of death for HIV-infected individuals living in Southern Alberta, Canada, from 1984 to 2003. HIV Medicine 2005; 6:99–106

hiv related and non hiv related deaths among plwha nyc 1988 2003
HIV-related and Non-HIV related deaths among PLWHANYC 1988-2003

HAART

Source: HIV Epidemiology Program 1st Quarter Report (Jan 2005), NYC Dept. of Health and Mental Hygiene

plwha are getting older
PLWHA Are Getting Older…

NY: HIV/AIDS hospital discharges among PLWHA 50 years of age or older

% of HIV/AIDS discharges

Source: SPARCS database, NYSDOH

plwha are getting older13
PLWHA Are Getting Older…

NY: Medicaid Recipients with HIV/AIDS, Age 50+

% of HIV/AIDS recipients

Source: Medicaid Claims database

slide18

Prospective observational cohort

23,468 HIV+ pats,

Incidence of myocardial infarction (MI) increased by an average of 26% per year of exposure to CART, over the first 6 years of exposure

Incidence of MI according to the duration of exposure to CART

The D:A:D Study Group. Combination antiretroviral therapy and the risk of myocardial infarction. N Engl J Med 2003; 349:1993–2003

slide19

The Writing Committee of the D:A:D Study Group. Cardio- and cerebrovascular events in HIV-infected persons. AIDS 2004; 18:1811–1817

myocardial infarction among patients with hiv infection
Myocardial infarction Among Patients with HIV Infection

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

N Engl J Med 2004; 350:730-731

slide21

Acute Myocardial Infarction

NY: Discharges among PLWHA

Source: SPARCS database, NYSDOH

slide22

“Cigarette smoking is the most important modifiable cardiovascular risk factor among HIV-infected patients.”

Greenspoon, S. Carr, A. Cardiovascular risk and body-fat abnormalities in HIV-infected adults. N Engl J Med 2005; 352:48–62

slide23

“Cessation of smoking is more likely to reduce cardiovascular risk than either the choice of antiretroviral therapy or the use of any lipid-lowering therapy.”

Greenspoon, S. Carr, A. Cardiovascular risk and body-fat abnormalities in HIV-infected adults. N Engl J Med 2005; 352:48–62

slide24

James Cadenhead

Infected with HIV for 18 years. Has had Hep B, C, toxoplasmosis.

“..I’m doing pretty well. I think my chances are better of going of a heart attack than of AIDS. My biggest problem now is , What do I do when I retire?”

New York Times, Aug. 17, 2004

trends in aids defining and non aids defining malignancies among hiv infected patients 1989 2002
Trends in AIDS-Defining and Non–AIDS-Defining Malignancies among HIV-Infected Patients1989–2002

Cases per 1000 pat-years

Years

Bedimo, 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

slide28

Cancers of the larynx and oropharynx

among PLWHA discharged from hospitals in NY, 1994-2002

Discharges from hospitals

Source: NY SPARCS

slide29

Cancers of the larynx and oropharynx

among PLWHA, Medicaid recipients, NY, 1993-2001

Source: NY Medicaid

slide30

Cancers of the lung and trachea among PLWHA discharged from hospitals in NY, 1994-2002

Source: NY SPARCS

slide31

Cancers of the lung and trachea

among PLWHA, Medicaid recipients, NY, 1993-2001

Source: NY Medicaid Claims database

causes of death among hiv infected adults in france 2000
Causes of death among HIV-infected adults in France, 2000

N=964

% of all deaths

Lewden C et al. Causes of death among HIV-infected adults in the era of potent antiretroviral therapy: emerging role of hepatitis and cancers, persistent role of AIDS. Int J Epidemiol 2005;34:121-130

causes of death among hiv infected adults in france 200033
Causes of death among HIV-infected adults in France, 2000
  • Prevention, screening, and management of non-Hodgkin’s lymphoma and of non-AIDS related cancers, especially lung cancer, prevention of CVDs, and management of viral hepatitis should be considered public health priorities
  • Specific programs for smoking cessation should be developed for the HIV-infected

Lewden C et al. Causes of death among HIV-infected adults in the era of potent antiretroviral therapy: emerging role of hepatitis and cancers, persistent role of AIDS. Int J Epidemiol 2005;34:121-130

slide34
“Now that HAART-regimens have considerably improved the life expectancy in HIV-infected populations in industrialized countries, efforts to reduce smoking and alcohol consumption must be a priority in HIV medicine.”

Zwahlen M, Lundgren, JD. Commentary: Death in the era of potent antiretroviral therapy: shifting causes, new challenges. Int J Epidemiol 2005;34:130-131

slide35

Incidence Rate Ratios of Non-AIDS Defining Malignancies1992-2002

Incidence rate ratio Standardized HIV: Observed SEER

Patel P et al. Incidence of AIDS-defining and non-AIDS defining malignancies among HIV infected persons. CROI 2006

slide36

Incidence Rate Ratios of Non-AIDS Defining Malignancies1992-2002

  • “The incidence of many non-ADM were significantly higher … suggesting that HIV-infected persons are at higher risk of developing certain cancers
  • In addition to encouraging tobacco cessation, health care providers should consider enhanced monitoring for these malignancies in their HIV-infected patients.”

Patel P et al. Incidence of AIDS-defining and non-AIDS defining malignancies among HIV infected persons. CROI 2006

lung cancer in plwha
Lung Cancer in PLWHA
  • 5,238 pats., Moore Clinic, 1989-2003
  • 19,061 person-years of follow up
  • 33 cases identified (85% current smokers 12% former smokers)
  • SIR Detroit gen. pop. = 4.7

US pop. = 6.9

Engels, EA et al. Elevated incidence of lung cancer among HIV-infected individuals. J Clin Oncol 2006; 24: 1383–88

lung cancer in plwha38
Lung Cancer in PLWHA
  • “Elevated incidence of lung cancer
  • As people with HIV live longer and age, clinicians should be alert to the possible diagnosis of lung cancer in HIV-inf. patients
  • Need to develop effective interventions to assist individuals in their attempts to quit smoking
  • Smoking might not entirely explain the excess of lung ca. among HIV-inf. persons, hence the need for research regarding pathogenesis”

Engels, EA et al. Elevated incidence of lung cancer among HIV-infected individuals. J Clin Oncol 2006; 24: 1383–88

chronic bronchitis and emphysema among plwha discharged from hospitals in ny
Chronic Bronchitis and Emphysemaamong PLWHA Discharged from Hospitals in NY

Source: SPARCS database, NYSDOH

oral health
Oral Health
  • HIV+ smokers are more likely to develop
    • Oral candidiasis
    • Periodontitis
    • Oral hairy leukoplakia
    • Cancers
oral health42
Oral Health
  • HIV Cost and Services Utilization Study. National probability sample of HIV inf. Adults in the US
  • Self-reported, 3 sets of interviews
  • Smokers were 62% more likely to report “oral white patches” than non-smokers

Marcus, M. et al. Oral white patches in a national sample of medical HIV patients in the era of HAART. Community Dent Oral Epidemiol 2005; 33: 99–106

slide43

Minkoff H et al. Relationship between smoking and Human Papillomavirus infections in HIV-infected and -uninfected women. J Infect Dis 2004;189:1821-8

women cigarrette smoking and hiv prognosis in the haart era
Women: Cigarrette Smoking and HIV Prognosis in the HAART Era

Feldman JG, Minkoff H et al. The association of cigarette smoking with HIV prognosis among women in the HAART era—A report from the Women’s Interagency HIV Study. Am J Public Health 2006;96(6):1-6

women cigarrette smoking and hiv prognosis in the haart era46
Women: Cigarrette Smoking and HIV Prognosis in the HAART Era

Cumulative percentage remaining free from an AIDS-defining condition, by smoking status before HAART initiation

Feldman JG, Minkoff H et al. The association of cigarette smoking with HIV prognosis among women in the HAART era—A report from the Women’s Interagency HIV Study. Am J Public Health 2006;96(6):1-6

impact of cigarette smoking on mortality and qol among plwha
Impact of Cigarette Smoking on Mortality and QOL Among PLWHA
  • 867 HIV+ from Veterans Aging Cohort 3 Site Study
  • 63% current smokers, 22% former smokers
  • Current smokers had highest VL (compared to form. or never smokers. p=.001)
  • Smoking was strongly associated with increased respiratory symptoms (cough, dyspnea), noninfectious pulmonary disease (COPD &/or asthma), and bacterial pneumonia

Crothers, K et al. The impact of cigarette smoking on mortality, quality of life, and comorbid illness among HIV-positive veterans. J Gen Intern Med 2005;20:1142-45

impact of cigarette smoking on mortality
Impact of Cigarette Smoking on Mortality

After adjusting for age, race/ethnicity, baseline CD4 cell count, VL, hemoglobin, illegal drug/alcohol use, mortality was significantly increased in current smokers compared with never smokers (hazard ratio [HR] 1.99, 95% CI

1.03 to 3.86).

Unadjusted mortality rate per 100 person-years

Smokers

Never smokers

Crothers, K et al. The impact of cigarette smoking on mortality, quality of life, and comorbid illness among HIV-positive veterans. J Gen Intern Med 2005;20:1142-45

cigarette smoking and qol
Cigarette Smoking and QOL

N=129

QOL

N=189

N=549

Crothers, K et al. The impact of cigarette smoking on mortality, quality of life, and comorbid illness among HIV-positive veterans. J Gen Intern Med 2005;20:1142-45

how serious is the problem
How Serious is the Problem?
  • Prevalence of smoking among people with HIV --- estimated to be higher than among the general population
  • New England clinics: More than 70% of HIV+ smoke
  • Swiss HIV Cohort Study
    • 72% are current/former smokers
    • 96% among IDUs

Niaura R et al. Smoking among HIV-positive persons. Ann Behav Med 1999; 21(Suppl):S116

Clifford, GM et al. Cancer risk in the Swiss HIV Cohort Study: Associations with immunodeficiency, smoking and Highly Active Antiretroviral Therapy. J Natl Cancer Inst 2005;97:425-432

new york
New York
  • 482 HIV+ Medicaid recipients, NYC
    • Age: 22-75 59% males 53% African Americans 30% Latinos
    • HS education or less : 87%
  • 66% current smokers (mean=16 cig./day)
  • 18% former smokers
  • Current smokers
    • Greater use of illicit substances
    • Lower state of health
    • Lower perceived health risk of continued smoking

Burkhalter, JE et al. Tobacco use and readiness to quit smoking in low-income HIV-infected persons. Nicotine Tob Res 2005; 7(4):511-522

slide53

Smoking Prevalence among PLWHA Receiving Care in NYS

2005

  • 3-page self-administered survey
  • Input from NYSDOH Tobacco Control Program
    • Instruments used to measure tobacco use
  • Survey collected:
    • Demographics
    • Current and past tobacco use. Frequency.
    • Perceptions regarding tobacco use
    • Cessation history. Intentions/readiness to quit

NYS DOH AIDS Institute

slide54
Upstate NY Region

Erie County Medical Center*

Nassau University*

Strong Memorial Hospital*

SUNY Syracuse*

United Health Services*

Westchester County Medical Center*

* Designated AIDS Care Center

**Adult Day Health Center

NYC Region

Bronx Lebanon*

Harlem United**

Housing Works 13th Street**

Housing Works 98th Street**

NY Hospital of Queens*

PROMESA**

Saint Vincent Medical Center*

SUNY Brooklyn*

Village Center**

Smoking Prevalence among PLWHA Receiving Care in NYS

2005

NYS DOH AIDS Institute

slide55

Smoking Prevalence among PLWHA Receiving Care in NYS

2005

  • Target Sample: 1228
  • Surveys completed: 1094
  • Return rate: 89%

NYS DOH AIDS Institute

slide56

Use Status

N

%

Currently Use

638

59.2

Used in the Past

264

24.5

Never Used

175

16.3

Total

1077

100

Smoking Prevalence among PLWHA Receiving Care in NYS

2005

NYS DOH AIDS Institute, OMD/OPER

percentage correct on smoking knowledge statements

Smoking Knowledge Statements

% Correct

If a person has smoked a pack of cigarettes a day for more than 20 years, there is little benefit to quitting smoking.

N=1039

56%

Nicotine is a cause of cancer. N=1023

14%

Because it takes many years for the effects of smoking to occur, smoking isn’t a serious health concern for HIV positive people. N=1027

63%

Smoking isn’t any more dangerous for HIV positive individuals than it is to people without HIV. N=1027

64%

Percentage Correct on Smoking Knowledge Statements

NYS DOH AIDS Institute, OMD/OPER

willingness to quit
Willingness to Quit
  • Stopped smoking for one day or longer during the past 12 months:
  • Currently interested in quitting:

64%

74%

NYS DOH AIDS Institute, OMD/OPER

how big is the problem
How Big is the Problem?
  • HUGE!
    • In NY, smoking is 3 times higher among PLWHA than among the general pop.
  • HIV+ populations include the following overlapping conditions
    • Substance use
    • Mental health
    • Poverty, low educational attainment
2004 surgeon general report on smoking
2004 Surgeon General Report on Smoking
  • Updates the health effects of smoking
  • Identifies substantial number of diseases that were not previously associated with smoking
    • Cancer of the stomach, uterine cervix, pancreas, kidney
    • Acute myeloid leukemia
    • Pneumonia
    • Abdominal aortic aneurysm
    • Cataracts
    • Periodontitis
  • Single most preventable cause of death and illness
conclusions
Conclusions
  • Significant changes in mortality and morbidity among people with HIV
  • PLWHA are living longer and increasingly becoming ill or dying of non HIV- related conditions
  • Smoking is highly prevalent among PLWHA
  • Smoking cessation should be a priority in the medical management of PLWHA
conclusions65
Conclusions
  • Significant, and immediate, benefits for HIV+ individuals can be achieved by quitting
  • Significant public health benefits can be derived from reducing smoking among PLWHA
  • To further improve survival and quality of life for PLWHA, we MUST promote smoking cessation
acknowledgements
Acknowledgements
  • Kumara Singaravelu, MD, MPH
  • James Tesoriero, Ph.D.
  • Susan Gyeric
  • The AIDS Institute’s HIV and Smoking Workgroup
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