Safer Solutions: The Urgent Connection Between Smoking and HIV
People with HIV now lose more years of life to smoking than to HIV itself. About 1.2 million Americans are living with HIV, and while smoking among U.S. adults has fallen below 10 percent for the first time, people with HIV still smoke at up to four times that rate. Although many people with HIV want to quit smoking, their quit rates are much lower compared to the general population.
This picture is driven in part by a public health success story. Advances in antiretroviral therapies for HIV have transformed the diagnosis from a terminal illness into a manageable chronic disease. People with HIV can live long lives, which is cause for celebration. But it’s also a catalyst to put more energy into ensuring people with HIV can avoid or reduce the long-term health harms of smoking. This requires moving beyond a “more of the same” approach to smoking cessation, especially because people with HIV tend to have worse outcomes with traditional quit methods like counseling and medication. People with HIV face unique and complex barriers to quitting, so healthcare providers’ toolkits should offer patients as many evidence-based pathways to cessation as possible.
This summer, we were fortunate to sit down virtually with two researchers who have spent decades working at the intersection of smoking and HIV. In a wide-ranging discussion, Lauren Pacek of Rutgers Health Institute for Nicotine and Tobacco Studies and Patricia Cioe of the University of Rhode Island College of Nursing shared their pragmatic, compassionate perspectives on this urgent public health issue.
What are the barriers to smoking cessation among people with HIV?
Pacek and Cioe described a number of barriers to smoking cessation among people with HIV. First, people with HIV often have multiple, overlapping health concerns including anxiety, depression, diabetes, hypertension, and more, which can make it difficult for healthcare providers to add smoking cessation counseling to time-limited office visits. Further, smoking is more than just a physical dependence on nicotine. HIV diagnosis is often associated with stress, poverty, stigma, and loneliness, and smoking can be a form of stress management. Pacek and Cioe told us that many older people with HIV have been smoking heavily for 25 to 35 years. Some people with HIV also enjoy smoking, which can create resistance to giving it up. People who were diagnosed with HIV when the condition was still terminal might also have a sense of fatalism as a result: A 2004 focus group study found that people with HIV who smoked “discounted health risks … reasoning that they would not live long enough to suffer [smoking’s] consequences.” This complex picture can make giving up the habits, rituals, sensations, and nicotine associated with smoking exceedingly difficult for many people with HIV.
Why don’t traditional quit methods work as well for people with HIV who smoke?
Our panelists noted that traditional cessation methods are more effective when multiple approaches are combined (e.g., using a long-acting nicotine replacement therapy (NRT) patch alongside short-acting gums or lozenges). Medications like bupropion and varenicline can be effective for cessation in the general population, but medication adherence can be an issue for people with HIV. Cioe said that people with HIV often have “complex medical regimens” requiring many pills every day. This may contribute to “treatment fatigue” and reluctance to take yet another medication. Although Cioe noted that behavioral counseling is not “all that effective on its own,” both panelists endorsed the role of counseling when used in conjunction with medication and/or NRT.
How can harm reduction help people with HIV quit smoking?
While there is still more to learn about the long-term health impacts of e-cigarettes and nicotine pouches, we know they are much less harmful than combustible cigarettes. Cioe stressed that never starting to use nicotine is the most helpful thing to do; however, among those who do smoke, a switch to e-cigarettes or nicotine pouches “may be a very viable alternative, and it may be something they’re willing to try.” Cioe was a co-author on recent clinical guidance that advises healthcare providers to include reduced-risk products as part of a “menu of options,” noting that “someone does not have to ‘fail’ traditional smoking cessation medications” in order to switch to a reduced-risk product for help.
Our panelists concurred that a complete switch to reduced-risk products—not the dual use of cigarettes and a reduced-risk product—is the goal. This can be a process over time. “Sometimes dual use can be a step toward complete elimination of combustible tobacco,” Cioe said. She also talked about the beneficial role of flavored vapes in encouraging more people to make the switch, noting that “[w]hen flavors are not offered, you see lower rates of switching” and more people going back to smoking or continuing long-term dual use.
Conclusion
The connection between HIV and smoking deserves a broader approach that includes empathy, breaking down barriers, and risk reduction. Most of all, Pacek and Cioe emphasized the need to “be willing to think out of the box and be creative” for this population, who tend to have a very hard time quitting. Access to wider range of smoking cessation options—and accurate information about them—can help more people with HIV quit smoking and enjoy better health and a longer life as a result.