Author: Jeffery Kwong, MS, MPH, ANP
According to the U.S. Centers for Disease Control and Prevention, smoking prevalence among the general adult population in the United States is approximately 20%. Among HIV-infected persons, the prevalence of cigarette smoking appears to be two to three times greater than in the general population, with estimates ranging from 50% to 70%.
The health effects of cigarette smoking are extensive and have been well documented. There are approximately 400,000 smoking-related deaths annually in the United States. HIV-infected smokers appear to be at higher risk of a variety of tobacco-related conditions than HIV-uninfected smokers. These include lung cancer, head and neck cancers, cervical and anal cancers, oral candidiasis, and oral hairy leukoplakia. HIV-infected smokers who smoke are more likely to develop the conditions listed above, as well as bacterial pneumonia, Pneumocystis jiroveci pneumonia, other pulmonary conditions, and cardiovascular disease. Additionally, HIV-infected smokers have been shown to have a decreased immunologic and virologic response to antiretroviral therapy.
Thus, for HIV-infected persons, even more so than for HIV-uninfected persons, clinicians should consider smoking cessation a health care priority. Although many care providers may feel that they can do little to affect the smoking behaviors of patients, evidence suggests that brief interventions by physicians are quite effective. Studies indicate that smoking cessation interventions as brief as 3 minutes in duration, when delivered by a physician, have a positive impact on abstinence rates of current smokers. Furthermore, studies have found that more than half of current HIV-infected smokers have expressed interest in, or have thought about, smoking cessation.
Cigarettes are highly addictive; the U.S. Surgeon General has equated the addictive potential of cigarettes to that of heroin and cocaine. This is in part because nicotine stimulates the release of several neurotransmitters in the brain, including dopamine. Over time, chronic exposure to nicotine causes physiologic changes in the brain that contribute to the addictive potential of cigarettes.
Cigarette smoking involves dependence on more than a single chemical compound, however. It is a multidimensional behavior that has both physiologic and psychological components. Therefore, smoking cessation efforts often require a combined approach to be successful.
Several behavioral models present a psychological framework for understanding individuals who are attempting to change behaviors. The transtheoretical model of health behavior change is one of the more frequently cited frameworks for understanding the stages of behavior change of smokers. According to this model, there are five phases of behavior change: precontemplation, contemplation, preparation, action, and maintenance. Using this framework, clinicians can devise interventions that are most appropriate for the patient's current stage on the continuum.
Patients may move back and forth among these stages at various points during the process of smoking cessation.
As suggested above, brief smoking cessation interventions delivered by clinicians can significantly increase abstinence rates of current smokers. The U.S. Surgeon General has developed guidelines for clinicians to use during clinic visits to help patients who are interested in smoking cessation. These include use of the Five A's model, which provides a brief and structured framework for addressing smoking cessation in clinical settings (see Table 1).
|ASK every patient about tobacco use||Identify and document tobacco use at every visit.||Incorporate questions about tobacco use when obtaining vital signs or when reviewing a patient's history. |
|ADVISE to quit||Using a clear, strong, and personalized message, urge every tobacco user to quit.|
|ASSESS readiness to make a quit attempt||Determine whether the tobacco user is willing and ready to make a quit attempt within 30 days.|
|ASSIST in the quit attempt||For the patient willing to quit, assist in developing a quit plan.|
Provide practical counseling, support, and supplementary materials.
|ARRANGE for follow-up||Arrange for follow-up contacts beginning within the first week after the quit date.|
For patients who are not ready to quit, techniques such motivational interviewing (MI) can be used in conjunction with the stages-of-change model to explore the smokers' beliefs, feelings, and barriers to successful cessation efforts. Components of MI include: a) expressing empathy; b) developing discrepancy; c) rolling with resistance; and d) supporting self-efficacy. Effective use of MI involves specialized training. Partnering with clinic staff or outside agencies that are familiar with MI techniques can help improve behavior change outcomes, such as smoking cessation. (For further information, see "References," below.)
In addition to counseling, the use of pharmacologic interventions such as nicotine replacement therapy and other adjuvant therapies should be considered. These therapies were developed for the general population, but current clinical guidelines suggest that they should be efficacious for HIV-infected smokers.
Clinicians should be aware of potential medication adverse effects (see Table 2).
During the physical examination, assess for evidence of smoking-related illnesses and the comorbid conditions that may be affected by smoking. At a minimum, measure blood pressure and oxygen saturation measurements and examine for oral lesions, abnormal breath sounds, and decreased peripheral perfusion.
Determine the smoker's readiness to change (see behavioral model for smoking cessation, above). For those smokers in the preparation or action stage, assist with implementing a quit plan. For those who are in the relapse stage, reinforce self-efficacy and encourage them to recommit to cessation. For those in the maintenance stage, congratulate them and reinforce the benefits of smoking cessation.
For patients willing to quit, offer resources and information that will help them to be successful in their quit attempt. Evidence suggests that the combination of counseling and medication is more effective than either intervention alone. Therefore, every effort should be made to combine counseling sessions with pharmacotherapy for patients who are motivated and ready to quit smoking.
Components of effective counseling include problem solving, skills training, and social support. Problem solving and skills training should focus on how to deal with triggers or urges that may lead to relapse. Examples include recognition of situations or events that may prompt a person to smoke (e.g., drinking alcohol, being around other cigarette smokers, situational stress) and means of reducing or coping with these situations. Social support interventions include providing reassurance that the patient has the ability to succeed with smoking cessation, communicating caring and concern, and encouraging the patient to talk about the quit process.
Offer medications, if there are no contraindications to pharmacologic interventions (see Table 2). All currently available over-the-counter and prescription medications have been shown to be effective. However, studies have shown that combination therapy may be more efficacious than monotherapy. The current tobacco cessation guidelines recommend the following combinations, all of which include nicotine preparations: long-term nicotine patch (>14 weeks) with ad lib use of nicotine gum or spray, nicotine patch with nicotine inhaler, and nicotine patch with sustained-release (SR) bupropion.
Both bupropion SR and varenicline may cause sleep disturbance, and varenicline may cause exacerbation of neuropsychiatric symptoms. For HIV-infected patients who take efavirenz as part of their antiretroviral therapy, concomitant use of either bupropion SR or varenicline may increase the possibility of these side effects. Additional research in this area is needed.
|Drug Recommended||Dosing||Common Side Effects||Comments|
Nicotine Patch (available OTC)
Dosage varies by brand:
Nicoderm or Habitrol:
|Dosing recommendations vary based on the number of cigarettes smoked. Individualize treatment.|
Sample treatment recommendation for smokers who smoke ≥10 cigarettes per day:
For smokers who smoke <10 cigarettes per day:
|Local skin reaction, insomnia or vivid dreams|
Nicotine Lozenge (available OTC)
|Nausea, hiccups, heartburn, headache, cough|
Nicotine Inhaler (prescription only)
|Recommended dosage: 6-16 cartridges per day.|
Duration of therapy: up to 6 months, taper dosage in last 3 months.
|Local irritation in the mouth and throat, cough, rhinitis; may cause bronchospasm (<1%)|
Nicotine Nasal Spray (prescription only)
|Nasal irritation, transient changes in sense of smell and taste; may cause bronchospasm (<1%)|
|Non-Nicotine Medications, First Line|
|Bupropion SR||Begin 1-2 weeks before quit date. ||Insomnia, dry mouth|
|Varenicline||Begin 1 week before quit date. ||Nausea; flatulence; headache; sleep disturbance; abnormal, vivid, or strange dreams; depression; agitation; suicidal ideation; and suicide|
FDA Black Box warning regarding neuropsychiatric adverse effects
|Non-Nicotine Medications, Second Line|
|Clonidine||Dry mouth, drowsiness, dizziness, sedation, and constipation|
Rebound hypertension if discontinued abruptly
|Nortriptyline||Sedation, dry mouth, blurred vision, urinary retention, lightheadedness, tremor, cardiac conduction abnormalities|
All patients who are actively quitting should have close follow-up, and they should be offered support. Research has shown that ongoing support during the quit phase results in higher abstinence rates.
Follow-up can include telephone calls or in-person evaluation.
For patients who recently quit or relapsed, continue to provide support and encouragement. Assist individuals who relapsed with the opportunity to continue with cessation plans.
Refer patients to smoking cessation groups, classes, and other resources.