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TOBACCO USE AND HIV

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Epidemiology of Tobacco Use

• Prevalence of Tobacco use in USA 20.6%1

• Prevalence among HIV positives 45 – 74%2,3,4

• Prevalence in Swiss Cohort – 72%5

• Among HIV patients who used IV drugs – 96%5

• A comparative analysis within the NHIS Survey suggests that MSMs are 2.3X more likely to smoke compared to general male population6

• Tobacco use data CDC 2010

1. Vital Signs: Current Cigarette Smoking Among Adults Aged ≥18 Years - United States, 2009 - Morbidity and Mortality Weekly Report 2010;59(35):1135–40 [accessed 2011 Aug. 11].

2. Burkhalter, JE et al, 2005; Nicotine and Tobacco Research, 7(4), 511–5223. Gritz, ER et al, 2004; Nicotine and Tobacco Research, 6(1), 71–774. Webb, MS et al, Journal of Behavior Medicine, 30(5), 371–3835. Clifford GM , Polesel J, Rickenbach M, et al, JNCI J Natl Cancer Inst (2005) 97 (6): 425-4326. McKirnan D et al, 2006, Substance Use & Misuse, 41:1197–1208

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Tobacco use and HIV patient

• Tobacco use reduces effectiveness of HAART therapy1

• High rates of lung and bronchial cancers in HIV patients is associated with high prevalence of smoking among HIV patients2,3

• HIV patients who smoke have an increased risk of bacterial pneumonia4

• HIV positive smokers have 56% increased risk of PCP compared to non-smokers4

• Long term Tobacco use is associated with increased risk of Pulmonary Tuberculosis about 3x among HIV patients 4

• HIV patients with COPD who smoke progress faster.5

1. Feldman JG, Minkoff H, Schneider MF et al, Am J Public Health 2006, 96: 1060 – 10652. Clifford GM , Polesel J, Rickenbach M, et al, JNCI J Natl Cancer Inst (2005) 97 (6): 425-4323. Frisch M, Biggar RJ, Engels EA, Goedert JJ. JAMA 2001;285:1736 –17454. Miguez-Burbano MJ et al, Addiction Biology 2003: 8 , 39 - 425. Diaz PT, King MA, Pacht ER, et al. Ann Intern Med 2000;132:369–372..

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Tobacco use and incidence of PCP

Miguez-Burbano MJ et al, Addiction Biology 2003: 8 (1) 39 - 42

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Health Effects of Smoking in HIV Patients (I)

• In the Monica database in France risk of MI is 1.52 per 1000 person years1

• Among HIV patients MI incidence was 5.0 – 5.5 per 1000 person years suggestive of at least 3-3.5 fold increase1

• HIV infected smokers have a 2.8 times increased risk of lung cancer2

• The risk of lung cancer in HIV positive IV drug users is 12.6 times according to data from the Swiss Cohort2

1. Vittecoq D, Escaut L, Chironi G, et al; AIDS 2003; 17 (suppl. 1): S70 – S762. Clifford GM , Polesel J, Rickenbach M, et al, JNCI J Natl Cancer Inst (2005) 97 (6): 425-432

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Health Effects of Smoking in HIV Patients (II)

• Smoking is associated with a 33% increased risk of HPV infection in women1

• HIV positive smokers are 33% more likely to have persistence of HPV infection2

• Analysis of data from the MACS Cohort shows a R.R. of 3.9 for Anal Squamous cell cancers in HIV positive smokers vrs non-smokers3

1. Minkoff, H., Feldman JG et al, 2004, J Infect Dis. 189 (10): 1821-1828.2. Rowhani-Rabar, A, Hawes SE et al, 2007, J Infect Dis. 196:887–943. D’Souza, G, Wiley D.J. et al, 2008, J Acquir Immune Defic Syndr;48:491–499

Relationship between Smoking and other Cardiovascular Risk Factors and the Rate of Myocardial Infarction

The DAD Study Group. N Engl J Med 2007;356:1723-1735

Cardiovascular Risk Factor

Relative Risk of Heart Attack

p-value

Protease Inhibitor use per additional year

1.10 (1.04 – 1.18) 0.002

Age per additional 5 yrs 1.32 ( 1.23 – 1.41) < 0.001

BMI > 30 1.34 (0.86 – 2.09) 0.19

Family History of Heart Dx 1.40 (0.92 – 1.91) 0.08

Current Smoker 2.92 (2.04 – 4.18) < 0.001

Former Smoker 1.63 (1.07 – 2.48) 0.02

Previous CVS event 4.64 (3.22 – 6.69) < 0.001

Diabetes 1.86 (1.31 – 2.65) < 0.001

Hypertension 1.30 (0.99 – 1.72) 0.06

Total Cholesterol per mmol 1.26 (1.19 – 1.35) < 0.001

HDL per mmol 0.65 (0.48 -0.88) 0.05

HIV Viral Replication

Immune activation

Inflammation

Macrophage Recruitment

Endothelial Dysfunction

Hypertension

SmokingGenetics

Anti-retroviral Therapy

Insulin Resistance &

Diabetes

Atherosclerosis

Dyslipidemia

Modified from: Currier J.S., Topics in HIV Medicine, 2009, 17(3); 98-103

CARDIOVASCULAR DISEASE IN HIV

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Estimated Relative Risk of Myocardial Infarction after Quitting Smoking.

Rosenberg L et al. N Engl J Med 1985;313:1511-1514.

© 2003 Lippincott Williams & Wilkins, Inc. Published by Lippincott Williams & Wilkins, Inc. 6

Cardiovascular disease risk factors in HIV patients - association with antiretroviral therapy. Results from the

DAD study.Friis-Moller, Nina; Weber, Rainer; Reiss, Peter; Thiebaut,

Rodolphe; Kirk, Ole; Monforte, Antonella; Pradier, Christian; Morfeldt, Linda; Mateu, Silvia; Law, Matthew;

El-Sadr, Wafaa; De Wit, Stephan; Sabin, Caroline; Phillips, Andrew; Lundgren, Jens

AIDS. 17(8):1179-1193, May 23, 2003.

Fig. 1. Prevalence of elevated total cholesterol (>= 6.2 mmol/l) according to current antiretroviral therapy (ART),

CD4 cell count (a) and HIV RNA (b) at baseline. The six ART categories are: naive (ART naive), no ART

(treatment-experienced, but not currently receiving antiretroviral therapy), NRTI (currently receiving only

NRTI), NNRTI (currently receiving NNRTI and NRTI but not PI), PI (currently receiving PI and NRTI but not NNRTI), and PI/NNRTI (currently receiving PI, NNRTI and NRTI).

Cardiovascular disease risk factors in HIV patients - association with antiretroviral therapy. Results from the DAD study.

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Psychosocial Aspects of Smoking and HIV

• HIV positive patients are 2 times more likely to be smokers1

• MSMs are more likely to be smokers compared with heterosexuals2, 3

• In the US HIV patients tend to be socio-economically disadvantaged and are more likely to have social networks with more smokers4, 5

• High rates of depression and drug use among HIV patients4

• Individual self efficacy is one of the strongest predictors of successful quit attempt5

1. Gritz ER, Vidrine DJ, et al, 2004; Nicotine and Tobacco Research, 6(1), 71–772. Greenwood GL, Paul JP, et a, 2005; Am J Public Health;95:145-151

3. Ryan H, Wortley PM, et al, 2001 Amer. Jour. Prev. Med. 21(1), 142 – 1494. Reynolds N. 2009, AIDS Educ. Prev. 21, Suppl. A, 106 – 121

5. Lloyd-Richardson, E. E. et al, 2008; Amer. Jour. Health Beh, J2(1). 3 -15

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SMOKING CESSATION

• 70% of the 45million smokers in the US report they wish to quit1

• 44% of all smokers attempt to quit each year1

• HIV positive smokers are just as willing to quit as other smokers2, 3

1. Morbidity and Mortality Weekly Report 2002;51(29):642–5 [accessed 2011 Aug 11].2. Burkhalter, JE, Springer CM et al, 2005; Nicotine and Tobacco Research, 7(4), 511–5223. Mamary EM, Bahrs D, Martnez S, AIDS PATIENT CARE and STDs, 2002 16 (1) 39 - 42

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Tobacco Use History

• Introduction to Healthy Tobacco Free Life• Onset of habit• Longest periods of abstinence and circumstance• Current smoking habits – Intensity and Frequency• Determination of Nicotine dependence• Living situation and smokers and non-smokers in the home • Prior quit attempts and results

The Fagerstrom Nicotine Dependent Test

Heatherton TF, Kozlowski LT, et al; A Revision of the Fagerstrom Tolerance Questionnaire; British Journal of Addiction 1991; 86: 1119 - 27

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The Financial Costs of Smoking

Cost $6.65 per pack

At 1 pack per day,Weekly cost = $46.55Monthly cost = $205Annual cost = $2,427

Half a pack per dayWeekly cost = $23.27Monthly Cost = $102

Annual cost = $1,213

6 cigarettes a dayWeekly cost = $13.30

Monthly cost = $60.00Annual cost = $720

Potential Gains of QuittingFor a 1 pack per day smoker

• Save enough for a full tank of gas in a week

• In one month one could buy a Nintendo Wii or similar high

end video game• In two months you could buy

a 40inch flat screen TV

• In a year enough money for a vacation package for two

• In 5yrs enough money for to pay for a fairly nice car

• In 15 yrs enough for a down payment on a houseSource: Wikipedia, the free encyclopedia

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Individualized Motivational Speech

5 A’s1.Ask- Ask about Tobacco use at every visit2.Advise – Strongly urge all smokers to quit3.Assess– Determine willingness to make a quit attempt4.Assist – Aid client in quitting5.Arrange – Schedule follow-up contact

Source: US Food and Drug Administration; 2011

Proposed Tobacco Warning Labels

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Behavior Therapy

Can Fam Physician 2008;54:994-999

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What Happens When People Quit Smoking

• Irritability• Anxiety• Difficulty concentrating • Increased appetite• Cravings to smoke • Insomnia • Fatigue • Headache • Cough • Sore throat • Constipation, gas, stomach pain • Dry mouth • Sore tongue and/or gums • Postnasal drip • Tightness in the chest

The Five D's Delay until the urge passes - usually within 3 to 5 minutes.Distract yourself. Call a friend or go for a walk.Drink water to fight off cravings.Deep Breaths - Relax! Close your eyes and take 10 slow, deep breaths.Discuss your feelings with someone close to you or at the support group

How to Handle Withdrawal SymptomsNicotine withdrawal symptoms

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Drug Therapy

Nicotine patches• What is it?• Why must I use a patch if I am

trying to quit nicotine in cigarettes?

• How long I am going to use this medication for?

• What if I want to smoke whilst having the patch on?

• How must I apply the patch?• Does the patch have side-effects?• Can I add a second patch if I have

cravings with a single patch?

• What if I am unable to quit after completing a full course of treatment ?

• What if the patch falls off?• Can I take a bath with the patch?• What if I get redness at the site of application of the patch?

Source: Sunday Mirror UK

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Zyban

• What is Zyban?• How does it work to help me quit?• When must I start this medication?• How long will I need to take this

medication?• Are there any side-effects of this

medication?• What if I forget to take my medication in

the morning?• Would this medication interact with my

HIV medications?• Would this medication interact with other

medications that I take?

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Chantix• What is Chantix?• How does it work to help me quit?• When must I start this medication?• How long will I need to take this

medication?• Are there any side-effects of this

medication?• Will this medication change my behavior• I have heard that you can get a heart

attack if you take Chantix, is this true?• What if I forget to take my medication in

the morning?• Would this medication interact with my

HIV medications?• Would this medication interact with other

medications that I take?

Source: OnThePharm

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Pharmacotherapy

Can Fam Physician 2008;54:994-999

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Summary

• Health Impact of Tobacco use appears to be accelerated in HIV patients

• HIV patients by virtue of certain socio-cultural characteristics are more likely to be smokers

• Smoking cessation interventions have proven more challenging in HIV patients

• HIV patients are however just as willing to quit as all other smokers• Use of combined behavioral intervention and pharmacotherapy has

shown some success in this population

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Online Resources

• http://mdquit.org/quitline

• http://www.smokefree.gov/

• http://www.lungusa.org/stop-smoking/

• http://www.cancer.org/Healthy/StayAwayfromTobacco/index

• http://apps.nccd.cdc.gov/StateSystem/Default/Default.aspx

• 1-800-QUIT-NOW OR 1-800-784-8669