HIV and Smoking: HIV and Smoking: The Time to Quit is Now The Time to Quit is Now
Dec 23, 2015
HIV and Smoking:HIV and Smoking:The Time to Quit is NowThe Time to Quit is Now
HIV and Smoking:HIV and Smoking:The Time to Quit is NowThe Time to Quit is Now
HIV Disease: New ParadigmHIV Disease: New Paradigm Decreased mortalityDecreased mortality
Increases in non-HIV related deathsIncreases in non-HIV related deaths
Chronic diseaseChronic disease PLWH/AIDS living longer, healthier and more PLWH/AIDS living longer, healthier and more
productive livesproductive lives Changing picture of mortality/morbidityChanging picture of mortality/morbidity
Cancer, CVD, diabetes, liver disease, etc.Cancer, CVD, diabetes, liver disease, etc.
Changing MortalityChanging Mortality
55615561 pats., HOPS, 1996-2002pats., HOPS, 1996-2002
19961996 20022002 DeathsDeaths
6.3 /100 person-yrs 6.3 /100 person-yrs 2.2 2.2
OI rates: OI rates: 23 /100 person-yrs 23 /100 person-yrs 6 6
HAART use:HAART use: 48% 48% 80% 80%
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. Abstract 872
Changes in MortalityChanges in Mortality
Use of HAARTUse of HAART
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. Abstract 872
0
20
40
60
80
100
1996 2002
HAART No HAART
% o
f pa
tient
s
.. and Change in Causes of .. and Change in Causes of DeathDeath
0102030405060708090
100
1996 2002
Non-HIV related HIV-related
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. Abstract 872
% o
f de
aths
Non-AIDS Related Causes of DeathNon-AIDS Related Causes of DeathSouthern Alberta, Canada, 1984-2003Southern Alberta, Canada, 1984-2003
0
5
10
15
20
25
30
35
Pre-HAART HAART
7%
32%
Cohort: 1987 patients Total # of deaths= 560
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
% o
f de
aths
, no
n-A
IDS
rel
ated
cau
ses
Increases in non-AIDS Increases in non-AIDS Related Causes of Death Related Causes of Death
Southern Alberta, Canada, 1984-2003Southern Alberta, Canada, 1984-2003
Causes of DeathCauses of Death 1984-961984-96 1997-031997-03
Accidental deathsAccidental deaths 2.2%2.2% 17%17%(drug overdose)(drug overdose)
Liver diseaseLiver disease <1<1 8.48.4
Non-HIV CancersNon-HIV Cancers <1<1 77
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 HIV-related and Non-HIV related deaths in PLWHArelated deaths in PLWHA
NYC 1988-2003 NYC 1988-2003
0%
20%
40%
60%
80%
100%
Perc
ent of
dea
ths
Non-HIV related deaths HIV-related deaths
Source: HIV Epidemiology Program 1st Quarter Report (Jan 2005), NYC Dept. of Health and Mental Hygiene
HAART
Living LongerLiving Longer
PLWHA Cohort, Southern PLWHA Cohort, Southern AlbertaAlberta
PLWHA, 40 years of age or olderPLWHA, 40 years of age or older
Pre-HAART period (1984-96)Pre-HAART period (1984-96)
28%28%
HAART period (1997-2003)HAART period (1997-2003)
51%51%
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
PLWHA Are Getting PLWHA Are Getting Older…Older…
HIV/AIDS Discharges among PLWHA, 50 HIV/AIDS Discharges among PLWHA, 50 years of age or olderyears of age or older
19941994 10%10%20032003 23%23%
Medicaid Recipients with HIV/AIDS, Age Medicaid Recipients with HIV/AIDS, Age 50+50+
19931993 6% 6%20022002 18% 18%
Source: SPARCS database, NYSDOH
Source: Medicaid Claims database
Changing MorbidityChanging Morbidity
“..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?”
James Cadenhead
Infected with HIV for 18 years. Has had Hep B, C, toxoplasmosis.
New York Times, Aug. 17, 2004
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
The D:A:D Study Group. Combination antiretroviral therapy and the risk of myocardial infarction. N Engl J Med 2003; 349:1993–2003
Myocardial Infarction: Incidence and Risk Myocardial Infarction: Incidence and Risk Factors Among Persons Receiving ARTFactors Among Persons Receiving ART
Total cholesterol (per 1-mmol/liter
increase)
Age (per additional 5
yr)
Tryglicerides (per doubling)
Exposure to combination antiretroviral therapy (per
additional year)
Current or former smoker
Hypertension Diabetes Male sex Prior cardiovascular
disease
Greenspoon, S. Carr, A. Cardiovascular risk and body-fat abnormalities in HIV-infected adults. N Engl J Med 2005; 352:48–62
The Writing Committee of the D:A:D Study Group. Cardio- and cerebrovascular events in HIV-infected persons. AIDS 2004; 18:1811–1817
Myocardial infarctionMyocardial infarction
0
0.5
1
1.5
2
2.5
3
3.5
1993 1994 1995 1996 1997 1998 1999 2000 2001 2002
Ra
te p
er
10
00
pa
tien
t-yr
s
Holmberg et al. Trends in rates of Myocardial infarction among patients with HIVN Engl J Med 2004; 350:730-731
0
100
200
300
400
500
600
700
800
1994 1995 1996 1997 1998 1999 2000 2001 2002
per 1
00,0
00 H
IV/A
IDS
disc
harg
es
Acute Myocardial Infarction
Source: SPARCS database, NYSDOH
Chronic Bronchitis and Chronic Bronchitis and EmphysemaEmphysema
0
200
400
600
800
1000
1200
1400
1994 1995 1996 1997 1998 1999 2000 2001 2002
per 1
00,0
00 H
IV/A
IDS
dis
char
ges
Chronic Bronchitis Emphysema
Source: SPARCS database, NYSDOH
“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
“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.”
HIV and CancerHIV and Cancer
Trends in AIDS-Defining and Non–AIDS-Defining Malignancies among HIV-Infected
Patients: 1989–2002
0
5
10
15
20
25
30
35
40
89-96 97-02
ADM non-ADM
Ca s
es p
er 1
000
p at-
year
s
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
0
25
50
75
100
125
150
1994 1995 1996 1997 1998 1999 2000 2001 2002
Pe
r 1
00
,00
0 H
IV/A
IDS
dis
cha
rge
s
HAART
Cancers of the larynx and oropharynx
0
20
40
60
80
100
120
140
160
1993 1994 1995 1996 1997 1998 1999 2000 2001
Pe
r 1
00
,00
0 r
ecip
ien
ts w
ith H
IV/A
IDS
Oropharynx Larynx
HAART
0
100
200
300
400
500
600
700
800
1994 1995 1996 1997 1998 1999 2000 2001 2002
Per
100
,000
HIV
/AID
S d
isch
arge
s
Lung, Trachea
Source: SPARCS
Cancer of the lung/tracheaCancer of the lung/tracheaper 100,000 HIV/AIDS discharges, 1994-2002per 100,000 HIV/AIDS discharges, 1994-2002
Cancer of the lung/tracheaCancer of the lung/tracheaper 100,000 HIV/AIDS discharges, 1994-2002per 100,000 HIV/AIDS discharges, 1994-2002
Cancer of the lung/tracheaCancer of the lung/tracheaper 100,000 Medicaid recipients with HIV/AIDS, 1993-2001per 100,000 Medicaid recipients with HIV/AIDS, 1993-2001
0
100
200
300
400
500
600
1993 1994 1995 1996 1997 1998 1999 2000 2001
Per
100,
000
reci
pien
ts w
ith H
IV/A
IDS
Lung&Trachea
Source: Medicaid Claims database
0
50
100
150
200
250
300
350
400
1994 1995 1996 1997 1998 1999 2000 2001 2002
Pe
r 1
00
,00
0 H
IV/A
IDS
dis
ch
arg
es
HAART
Cancers of the colon, anus, liver & pancreas
0
50
100
150
200
250
1993 1994 1995 1996 1997 1998 1999 2000 2001Per
100
,000
reci
pien
ts w
ith H
IV/A
IDS
Colon Anus Liver Pancreas
HAART
Cancer among People with Cancer among People with HIVHIV
Switzerland, 1985-2002Switzerland, 1985-2002
05
10152025303540
An
us
Ho
dg
kin
lym
ph
om
a
Liv
er
Mu
ltip
le m
yelo
ma
Lip
, m
ou
th,
ph
ary
nx
Tra
che
a,
lun
g,
bro
nch
us
Ski
n,
no
n-m
el.
Bra
in
Th
yro
id
Sta
ndar d
i zed Inci
denc e
Rat i
os
( SIR
s )
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
All cancers of lip, mouth and pharynx, All cancers of lip, mouth and pharynx, trachea, bronchus and lung (8) occurred trachea, bronchus and lung (8) occurred among smokersamong smokers
Cancer among People with Cancer among People with HIVHIV
Switzerland, 1985-2002Switzerland, 1985-2002
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
How Big is the Problem?How Big is the Problem?
New England clinics: More than 70% of HIV+ New England clinics: More than 70% of HIV+ smokesmoke
Swiss HIV Cohort StudySwiss HIV Cohort Study 72% are current/former smokers72% are current/former smokers 96% among IDUs96% 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
Low Income HIV+ in NYCLow Income HIV+ in NYC
428 HIV+ Medicaid recipients, NYC428 HIV+ Medicaid recipients, NYC Age: 22-75 Age: 22-75 59% males59% males 53% African Americans53% African Americans
30% Latinos30% Latinos HS education or less : 87%HS education or less : 87%
66% current smokers (mean=16 cig./day)66% current smokers (mean=16 cig./day) 19% former smokers19% former smokers Current smokersCurrent smokers
Greater use of illicit substancesGreater use of illicit substances Lower state of healthLower state of health Lower perceived health risk of continued smokingLower 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
Tobacco Use Survey 2005Tobacco Use Survey 2005 Preliminary ResultsPreliminary Results
(August 31, 2005)(August 31, 2005)
NYS DOH AIDS InstituteNYS DOH AIDS InstituteOffice of the Medical DirectorOffice of the Medical Director
Office of Program Evaluation and ResearchOffice of Program Evaluation and Research
Purpose:Purpose:
To ascertain To ascertain smoking prevalence among PLHWA in care in New York State.
2 Sampling StrataDesignated AIDS Care CentersAdult Day Health Centers
Target sample size for each facility/program related to caseload.
Methodology:Methodology:
NYS DOH AIDS Institute, OMD/OPERNYS DOH AIDS Institute, OMD/OPER
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
Methodology:Methodology:
NYS DOH AIDS Institute, OMD/OPERNYS DOH AIDS Institute, OMD/OPER
Survey Administered in 15 Survey Administered in 15 Facilities/Programs, March 2005Facilities/Programs, March 2005
Upstate NY RegionUpstate NY Region Erie County Medical Center*Erie County Medical Center* Nassau University*Nassau University* Strong Memorial Hospital*Strong Memorial Hospital* SUNY Syracuse*SUNY Syracuse* United Health Services*United Health Services* Westchester County Medical Westchester County Medical
Center*Center*
* Designated AIDS Care Center* Designated AIDS Care Center
**Adult Day Health Center**Adult Day Health Center
NYC RegionNYC Region Bronx Lebanon*Bronx Lebanon* Harlem United**Harlem United** Housing Works 13Housing Works 13thth Street** Street** Housing Works 98Housing Works 98thth Street** Street** NY Hospital of Queens*NY Hospital of Queens* PROMESA**PROMESA** Saint Vincent Medical Center*Saint Vincent Medical Center* SUNY Brooklyn*SUNY Brooklyn* Village Center**Village Center**
NYS DOH AIDS Institute, OMD/OPERNYS DOH AIDS Institute, OMD/OPER
Table 1: Survey Return RateTable 1: Survey Return Rate
TotalTotal
NYCNYC
UpstateUpstate
AreaArea
87%87%695695802802
94%94%399399426426
89%89%1094109412281228
Percent of Percent of TargetTarget
Returned*Returned*
NumberNumber
ReturnedReturned
Target Target SampleSample
SizeSize
*Just 41 subjects (3.4%) refused to completed the survey.
NYS DOH AIDS Institute, OMD/OPERNYS DOH AIDS Institute, OMD/OPER
Table 2: Race/Ethnicity Table 2: Race/Ethnicity (N=(N=1045)1045)
*Other includes: Albanian (2) American Indian – Alaska Native (19) Asian (3) Australian (1) Canadian (1) French *Other includes: Albanian (2) American Indian – Alaska Native (19) Asian (3) Australian (1) Canadian (1) French (1) Guyana (1) Haitian (6) Indian (2) Iranian (1)(1) Guyana (1) Haitian (6) Indian (2) Iranian (1) Native Hawaiian or Pacific (9) Native Hawaiian or Pacific (9)
10010010451045TotalTotal
4.44.44646OtherOther
53.653.6560560African AmericanAfrican American
15.115.1158158WhiteWhite
26.926.9281281HispanicHispanic
%%(N)(N)Race/EthnicityRace/Ethnicity
NYS DOH AIDS Institute, OMD/OPERNYS DOH AIDS Institute, OMD/OPER
Table 3: Tobacco UseTable 3: Tobacco Use (N=1077) (N=1077)
Includes Cigarettes, Cigars, Pipes and Chewing Tobacco*Includes Cigarettes, Cigars, Pipes and Chewing Tobacco*
10010010771077TotalTotal
16.316.3175175Never UsedNever Used
24.524.5264264Used in the PastUsed in the Past
59.259.2638638Currently UseCurrently Use
%%NNUse StatusUse Status
*631 cases in the “Currently Use” category are cigarette smokers. 255 cases in the “Used in the Past” category were cigarette smokers.
NYS DOH AIDS Institute, OMD/OPERNYS DOH AIDS Institute, OMD/OPER
Table 8: Percentage Correct on Smoking Table 8: Percentage Correct on Smoking Knowledge StatementsKnowledge Statements
64%64%Smoking isn’t any more dangerous for HIV positive Smoking isn’t any more dangerous for HIV positive individuals than it is to people without HIV. individuals than it is to people without HIV. N=1027 N=1027
63%63%
Because it takes many years for the effects of smoking to Because it takes many years for the effects of smoking to occur, smoking isn’t a serious health concern for HIV positive occur, smoking isn’t a serious health concern for HIV positive people. people. N=1027 N=1027
86%86%The risk of getting lung cancer is higher among people who The risk of getting lung cancer is higher among people who smoke. smoke. N=1017N=1017
84%84%The risk of having a heart attack is higher among people who The risk of having a heart attack is higher among people who smoke. smoke. N=1022N=1022
14%14%Nicotine is a cause of cancerNicotine is a cause of cancer. . N=1023N=1023
56%56%
If a person has smoked a pack of cigarettes a day for more If a person has smoked a pack of cigarettes a day for more than 20 years, there is little benefit to quitting smoking.than 20 years, there is little benefit to quitting smoking.
N=1039N=1039
% Correct% CorrectSmoking Knowledge StatementsSmoking Knowledge Statements
NYS DOH AIDS Institute, OMD/OPERNYS DOH AIDS Institute, OMD/OPER
During the past 12 months, have you stopped During the past 12 months, have you stopped smoking for one day or longer because you were smoking for one day or longer because you were
trying to quit? trying to quit? (N=584)(N=584)
100100584584TotalTotal
36.336.3212212NoNo
63.763.7372372YesYes
%%NN
by Race/ Ethnicity(N=582)
48
66 68 6852
34 32 32
0
20
40
60
80
100
White African American Hispanic Other
Perc
enta
ge
Yes
No
P=<.05NYS DOH AIDS Institute, OMD/OPERNYS DOH AIDS Institute, OMD/OPER
Table 13: Are you currently Table 13: Are you currently interested in stopping smoking? interested in stopping smoking?
(N=572)(N=572)
100100572572TotalTotal
25.525.5146146NoNo
74.574.5426426YesYes
%%NN
NYS DOH AIDS Institute, OMD/OPERNYS DOH AIDS Institute, OMD/OPER
Smoking CessationSmoking CessationAre PLWHA Interested?Are PLWHA Interested?
Survey of patients (n=228), San Francisco Survey of patients (n=228), San Francisco General HospitalGeneral Hospital
Smokers=123 (54%)Smokers=123 (54%)
Smokers interested in quitting = 77 (63%)Smokers interested in quitting = 77 (63%)
Mamary EM et al. Cigarette smoking and the desire to quit among individuals living with HIV. AIDS Patient.Care STDS. 2002;16:39-42.
Table 14: If you decided to give up smoking Table 14: If you decided to give up smoking altogether during the next year, how likely altogether during the next year, how likely
do you think you would be to succeed?do you think you would be to succeed? (N=562)(N=562)
7.37.3417417Very UnlikelyVery Unlikely
100100562562TotalTotal
17.317.39797Somewhat unlikelySomewhat unlikely
40.740.7229229Somewhat likelySomewhat likely
34.734.7195195Very likelyVery likely
%%NN
NYS DOH AIDS Institute, OMD/OPERNYS DOH AIDS Institute, OMD/OPER
How Big is the Problem?How Big is the Problem?
BIGBIG
HIV+ populations include the following HIV+ populations include the following overlapping conditionsoverlapping conditions Substance useSubstance use Mental healthMental health Poverty, low educational attainmentPoverty, low educational attainment
Niaura R et al. Smoking among HIV-positive persons. Ann Behav Med 1999; 21(Suppl):S116
Smoking------Risk Factor Smoking------Risk Factor for…for…
Cardiovascular diseasesCardiovascular diseases CancersCancers Lung diseasesLung diseases GI tractGI tract Age-related disordersAge-related disorders …….. Single most preventable cause of Single most preventable cause of
deathdeath
HIV Disease: New ParadigmHIV Disease: New Paradigm
Lifestyle-related risk factorsLifestyle-related risk factors SmokingSmoking Physical activityPhysical activity Healthy dietHealthy diet Alcohol, recreational drugsAlcohol, recreational drugs Sexual activitySexual activity
ConclusionsConclusions Significant changes in mortality and morbidity Significant changes in mortality and morbidity
among people with HIVamong people with HIV
As people with HIV live longer, they are As people with HIV live longer, they are increasingly becoming ill or dying of increasingly becoming ill or dying of non-HIV/AIDS related conditionsnon-HIV/AIDS related conditions
Smoking is highly prevalent among PLWHASmoking is highly prevalent among PLWHA
Smoking is the single most preventable cause of Smoking is the single most preventable cause of death and disease … even for people with HIVdeath and disease … even for people with HIV
ConclusionsConclusions Treating tobacco dependence should be a Treating tobacco dependence should be a
priority for HIV clinicianspriority for HIV clinicians Clinicians should
Use evidence-based interventions to promote smoking cessation in HIV-infected patients
Routinely assess HIV-infected patients’ smoking status and readiness to quit.
Identify and discuss barriers to quitting smoking for HIV-infected smokers who are not interested in stopping in the immediate future, but may consider it at a later time
(www.hivguidelines.org)
For more HIV-related resources, please visit www.hivguidelines.org