Improving tobacco cessation care for people living with HIV

People living with HIV who smoke are currently more likely to die from lung cancer than from HIV-related causes. Two cancer control researchers at the Medical University of South Carolina's Hollings Cancer Center are setting out to change that.

With more than $3 million from the National Heart, Lung and Blood Institute over five years, Alana Rojewski, Ph.D., and Katherine Sterba, Ph.D., both of the department of Public Health Sciences at MUSC, will build and sustain ENHANCE-TTS (ENgaging pHarmacists to AdvANCE Tobacco Treatment Service) delivery programs that promote smoking cessation for people living with HIV. They will study whether training pharmacists as tobacco treatment specialists and helping them to create manageable workflows can improve and sustain access to tobacco cessation treatments for people living with HIV who smoke. The hope is that improved access to evidence-based care will help more people living with HIV to quit smoking successfully.

The trainings will be offered at six Ryan White clinics throughout the state. These clinics are federally funded and provide HIV/AIDS care to people living with HIV who have limited to no insurance.

People living with HIV are more prone to developing various medical conditions, such as cardiovascular disease and pulmonary complications. Added tobacco use exacerbates these ailments. There are also much higher rates of tobacco-related cancers among people with HIV.

Rojewski is an expert in tobacco cessation treatments, while Sterba specializes in helping clinics to integrate evidence-based practices into their treatment workflows. Sterba co-directs the Dissemination and Implementation Science Collaborative through the South Carolina Clinical & Translational Research Institute. For this project, Sterba and Rojewski have partnered to train pharmacists in improving tobacco cessation care for people living with HIV and to tailor-design programs for each of their partner clinics. All the clinics have pharmacy involvement in some capacity, but each treatment plan is customized, taking into consideration the needs and context of the local population.

The ENHANCE-TTS program will partner with each clinic in a very collaborative way to design best practices for its setting, patient population and location. The one-size-fits-all approach won't work because all the clinics have different characteristics. We want to work with clinics to come up with the best fit for each of them."

Katherine Sterba, Ph.D., Department of Public Health Sciences at MUSC

The ENHANCE-TTS program was partially inspired and predated by a tobacco treatment specialist training offered through Hollings Cancer Center's Cancer Research Education and Training branch. Relying on this existing training, ENHANCE-TTS will teach pharmacists how to assess tobacco use, develop individualized treatment plans and introduce counseling strategies to promote the highest likelihood of success for a quit attempt. Pharmacists will also learn skills that can help patients to cope, manage cravings and navigate other real-life obstacles and situations they might face when trying to quit smoking.

Additional training materials geared toward pharmacists will be incorporated into a new training module by Emily Ware, Pharm.D., a clinical pharmacy specialist in the Tobacco Treatment Program and a co-investigator on the grant. "With Emily's expertise, we are going to create a module that is specific to clinical pharmacists for how they can set up clinical practice agreements, workflow scheduling and some of these aspects of offering care," explained Rojewski.

Sterba and Rojewski have identified three main goals for their study. First, they want to look at whether providers at these HIV clinics will be more likely to ask their patients about their smoking habits and provide counseling and medication as needed once they know that that pharmacists serving their clinics have been trained as tobacco cessation specialists.

Second, they will assess patient, provider and administrator attitudes toward the program. "Is ENHANCE-TTS acceptable to patients who receive the counseling and clinic administrators whose clinics take on the program?" asked Sterba. "Is it something that we can deliver with fidelity according to protocol, or do we hit roadblocks in the process?"

Finally, the study will follow up with a subset of patients from each clinic who received tobacco treatment intervention from a clinical pharmacist to see if their quit attempts were more successful. This feedback will help Sterba and Rojewski to optimize this approach for delivering tobacco treatment to people living with HIV.

The duo has high hopes for the results of the study and beyond. "This is an area where I think that we have room not only to expand the reach of tobacco treatment but also to make an impact in the lives of people who have those high rates of smoking and would have significant cancer-related morbidity from it," said Rojewski.

"We want to help people living with HIV to quit smoking," added Sterba. "We're going to learn how best to do that for various clinical settings, and our goal would be to take those lessons learned and share them more widely throughout South Carolina and then further across the country."