Smoking is among the most prevalent problems affecting HIV-infected patients. CDC estimates that in 2009, 42 percent of HIV-infected Americans in care smoked cigarettes1
one of the highest rates reported for any subgroup. Smoking poses a special hazard to persons living with HIV infection. It inhibits effective CD4+ T lymphocyte function2,3
increasing susceptibility to infectious diseases, especially pulmonary infections4,5
. Additionally, emerging science finds that even in persons with well-controlled HIV infection, HIV also stimulates chronic immune activation6
. This inflammatory state increases risk for a set of illnesses for which smoking is a well-established risk and that appear to be on the rise.
These illnesses include cardiovascular disease, chronic obstructive pulmonary disease, low bone mineral density and associated fragility fracture, and a variety of non-AIDS-defining cancers of infectious etiology, notably of the lung, liver, anus, and oropharynx7-11
. In other words, HIV infection adds to the risk for smoking-related illnesses while smoking adds to the injury caused by HIV infection.
For HIV-infected smokers, antiretroviral therapy shifts the risk of death dramatically away from HIV and towards smoking-related causes12-14
. The hard-earned life-years gained from effective HIV treatment are squandered on cigarettes at great personal and societal cost. In this context, smoking cessation should be a priority for HIV-infected persons; in addition to achieving effective antiretroviral therapy, smoking cessation could likely produce the greatest increase in quality and length of life.
With the increased life expectancy now afforded by remarkable advances in care, the need and opportunity to address smoking cessation have grown. Smoking cessation has become a cornerstone of primary care practice. We can take this extensive experience and build on it by tailoring interventions to the unique needs of HIV-infected smokers. Progress has been mostly modest15
but recent success with novel strategies16-18
promises effective cessation programs for HIV-infected smokers are possible.
The current care model and work force for HIV infection are well suited to address smoking cessation. The frequency of care-related visits necessitated by HIV infection creates repeated opportunities to address smoking status, which benefits from repeated interventions and quit attempts. HIV specialists have experience administering behavioral interventions such as adherence and risk-reduction counseling, which is directly applicable to smoking cessation. For primary care practitioners, who in the changing healthcare landscape are expected to take on more of routine management of HIV infection, smoking cessation is already part of basic good clinical practice. Reassuringly, the pharmacologic interventions available for smoking cessation are generally safe to use with antiretrovirals.
HIV-infected smokers may be more ready and willing to quit than we expect. In various surveys, 84 percent have expressed an interest in quitting, 40-60 percent have contemplated quitting, and 70percent have made at least one quit attempt 19, 20
. After quitting, HIV-infected smokers experience not only significant reduction in risk for pulmonary and cardiovascular diseases21-23
but significant improvement in HIV-related symptoms24
There are multiple resources to help busy clinical practices help their patients quit, including a dedicated webpage
for health care providers from CDC's Tips from Former Smokers campaign and a specific handbook
for HIV-infected smokers produced by the Veterans Administration.
The counseling fundamentals we know work in clinical settings is straightforward, and validated in numerous clinic-based trials over decades: