hiv and smoking: the time to quit is now

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


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


% 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


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%


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


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


“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


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


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:


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**


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.


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


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*


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.


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


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)


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)


25.525.5146146NoNo

74.574.5426426YesYes

%%NN


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


17.317.39797Somewhat unlikelySomewhat unlikely

40.740.7229229Somewhat likelySomewhat likely

34.734.7195195Very likelyVery likely

%%NN


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

hiv and smoking: the time to quit is now

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