Interview conducted by April Cashin-Garbutt, BA Hons (Cantab)
How does the prevalence of smoking in individuals living with HIV/AIDS compare to the general population?
In the general population, current smoking prevalence is 18%. Persons living with HIV/AIDS smoke at a rate 2 to 3 times higher, up to almost 70% in some studies.
What do you think is the reason behind the high prevalence of smoking in HIV-positive individuals?
Many persons living with HIV/AIDS come from lower socioeconomic groups (lower levels of education and income) which are associated with high smoking rates in the general population.
Others have problems with substance use (alcohol and other drugs), also very strongly associated with high smoking rates.
Finally, depression is common in this population, which is also linked to a higher prevalence of smoking.
Why is it particularly important for individuals living with HIV/AIDS to stop smoking?
The use of tobacco can increase susceptibility to a variety of diseases in people with suppressed immune systems, such as those living HIV/AIDS. Some of these diseases include several different cancers, heart disease, and pulmonary diseases such as bacterial pneumonia.
It was shocking to learn from a recent study of a large cohort of individuals living with HIV/AIDS that over 60% of deaths in this group were due to smoking related conditions.
Have any interventions previously been attempted to help this population stop smoking?
There have not been a lot of studies conducted with this vulnerable population. Some of the smaller, pilot studies have been promising but the few, larger scale and well-conducted studies have not shown significant differences between the special intervention and usual care groups.
Our study is the first to show a significant positive effect on smoking cessation for the intervention group.
Please can you outline the recent smoking-cessation intervention that was trialled on individuals living with HIV/AIDS? How does this compare to previous interventions?
In our study (my two prinicpal collaborators are Damon Vidrine, DrPH and Roberto Arduino, MD), which was a two group randomized controlled trial, a usual care approach was compared to an innovative cell phone counseling-based smoking cessation intervention; 474 low-income, multiethnic, HIV-positive smokers were enrolled.
To our knowledge, this was the largest smoking cessation intervention exclusively targeting persons living with HIV/AIDS conducted to date, and the first to use a mobile-delivered intervention.
All study participants, who were patients at a large, county operated HIV clinic, serving a predominantly low income population, received brief advice to quit smoking from a health care provider, written self-help materials and information on how to obtain nicotine patches at their clinic.
In addition, those participants randomized to the cell phone intervention condition were provided with prepaid cell phones to address any practical and economic barriers to receiving the counseling intervention.
The proactive counseling calls were designed to provide intensive support for smoking cessation, and were targeted to the special needs of persons living with HIV/AIDS. Other elements of the calls included cognitive and behavioral techniques to facilitate cessation and staying off cigarettes. Motivational messages are aimed at maintaining the intention to quit and increasing self-confidence.
A total of 11 calls were scheduled over the 3 month intervention period. The intervention group also had access to a supportive telephone hotline.
How successful was this mobile-delivered intervention?
The overall treatment effect (not smoking for the past 7 days at 3-, 6-, and 12-month follow-ups) showed that participants in the cell phone intervention group were significantly more likely to be abstinent (2.41 times, P=0.049) than those in the usual care group.
At the 3 month follow-up, the treatment effect was strongest (OR=4.3, P<.001), but it fell off at the later follow-ups (6 and 12 months, not significant).
Did this trial highlight any particular hurdles specific to HIV-positive individuals maintaining abstinence from smoking?
Yes, we found that while the cell phone intervention was statistically superior over the entire year of follow-up, the effect was strongest at the 3-month follow-up, after treatment ended, and then diminished over time.
So, remaining abstinent after quitting is a big hurdle for our participants, who were moderately to highly nicotine dependent and smoked almost a pack of cigarettes per day, on average.
In addition, our participants faced a number of mental health and social hurdles, including high levels of depressive symptoms (67.3%), poor mental and physical functional status on a measure of quality of life, harmful/hazardous level of alcohol use (31%) and recent illicit drug use (40%).
Thus, our participants would likely benefit from longer treatment, nicotine replacement therapy, relapse prevention strategies, and more assistance with other social and addictive problems in their lives.
What first prompted your research into HIV-positive smokers and what impact do you hope your work will have?
About 10 years ago, a colleague (Roberto Arduino, MD) and I were discussing his work as an infectious disease specialist in the treatment of persons living with HIV/AIDS. I asked him whether these persons had high rates of smoking and he responded that the rates were very high.
Further, he told me that smoking had serious adverse consequences on the health of his patients, both related to HIV treatment as well as other diseases, such as heart disease, cancer and other conditions.
At that point, we resolved to collaborate on tobacco cessation interventions in this very high risk and underserved population, and have continued to work together to this day.
What further research is needed to improve smoking-cessation rates in individuals living with HIV/AIDS?
There are several major research questions that remain to be addressed to improve smoking cessation rates in individuals living with HIV/AIDS. First of all, we need to find ways to boost the absolute quit rates; pharmacotherapy (nicotine replacement or other approved agents) in combination with counseling will likely be more effective than counseling alone.
Second, we need to be able to prevent relapse after a successful quit effort; referrals and help with some of the social and substance abuse problems faced by our population are being built into future research strategies.
Finally, we need to broaden our reach to all smokers in this population, including light and non-daily smokers; the study we just completed included those who smoked a minimum of 5 cigarettes/day and there are likely many more individuals who will benefit from a smoking cessation intervention who are lighter smokers.
Where can readers find more information?
Gritz ER, Danysh HE, Fletcher FE, Tami-Maury I, Fingeret MC, King RM, Arduino RC, Vidrine DJ. Long-term outcomes of a cell-phone delivered intervention for smokers living with HIV/AIDS. Clinical Infectious Diseases, 57:608-615, 2013.
Vidrine DJ, Marks RM, Arduino RC, Gritz ER. Efficacy of cell phone-delivered smoking cessation counseling for persons living with HIV/AIDS : 3-month outcomes. Nicotine and Tobacco Research, 14: 106-110, 2012.
Humfleet GL, Hall SM, Delucchi KL, Dilley JW. A randomized clinical trial of smoking cessation treatments provided in HIV clinical care settings. Nicotine and Tobacco Research, 15: 1436-1445, 2013.
About Dr Ellen R. Gritz
Ellen R. Gritz, Ph.D., is Professor and Chair of the Department of Behavioral Science and Olla S. Stribling Distinguished Chair for Cancer Research at The University of Texas MD Anderson Cancer Center. She is an established leader in cancer prevention and control research and internationally known investigator. Dr. Gritz has published extensively on cigarette smoking behavior: prevention, cessation, pharmacologic mechanisms, and special issues of concern to women and high-risk groups, including ethnic minorities, youth, cancer patients and persons living with HIV/AIDS. Other research includes skin cancer prevention in children and high-risk individuals, genetic testing and counseling for hereditary cancers, and cancer survivorship.
Dr. Gritz has served on advisory boards of numerous agencies, organizations, and comprehensive cancer centers, and is a member of the American Association for Cancer Research Task Force on Tobacco and Cancer. She is a member of the Institute of Medicine (IOM) and The Academy of Medicine, Engineering, and Science of Texas (TAMEST). Dr. Gritz was a member of the IOM’s National Cancer Policy Board (1997-1999) and the Board on Population Health and Public Health Practice (1995-2005). From 2002-2008, Dr. Gritz served on the Board of Directors of the American Legacy Foundation, the large, non-profit public health foundation established in 1998 as part of the Master Settlement Agreement, and was Vice-Chair of the Board from 2005-2008. Dr. Gritz was President of the Society for Research in Nicotine and Tobacco, 2006-2007. She was President of the American Society of Preventive Oncology (ASPO) from 1993-1995.
Dr. Gritz has received numerous awards, including ASPO’s Joseph W. Cullen Memorial Award (1992) for outstanding research in smoking, ASPO’s Distinguished Achievement Award (2001), MD Anderson’s Margaret and James A. Elkins, Jr. Faculty Achievement Award in Cancer Prevention (2002), and the Business and Professional Women’s Clubs (BPW) Texas Award (2006). She was the 2008 recipient of both the Alma Dea Morani, M.D. Renaissance Woman Award, an award that honors an outstanding physician or scientist, and the Society of Behavioral Medicine, Cancer Special Interest Group’s Outstanding Biobehavioral Oncology Award. Dr. Gritz was the recipient of the 2009 Distinguished Professional Woman’s Award, presented by the Committee on the Status of Women at The University of Texas Health Science Center at Houston. Most recently, Dr. Gritz was honored as an inductee of the 2013 Greater Houston Women’s Chamber of Commerce Hall of Fame. She is a fellow of the Society of Behavioral Medicine and the American Psychological Association, and is Senior Editor for Behavioral Sciences of the journal, Cancer Epidemiology, Biomarkers, and Prevention. Dr. Gritz's bibliography lists over 286 journal publications, books, book chapters, teaching aids and other publications. She holds a Ph.D. in psychology from the University of California at San Diego and is a licensed clinical psychologist.