Smoking and HIV: A Risky Combination

John T. Brooks, MD


December 22, 2014

Editorial Collaboration

Medscape &

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Hello. I am Dr John T. Brooks, leader of the HIV Epidemiology Research Team at the Division of HIV/AIDS Prevention at the Centers for Disease Control and Prevention (CDC) in Atlanta, Georgia. I am happy to be with you as part of the CDC Expert Commentary Series on Medscape. Today I will talk about how smoking adversely affects HIV-infected patients, and what you can do to improve their HIV status and overall health by encouraging them to stop smoking.

Smoking is among the most prevalent problems affecting HIV-infected patients. CDC estimates that in 2009, 42% of HIV-infected Americans in care smoked cigarettes. This is one of the highest rates reported for any subgroup.

Smoking poses a special hazard to persons living with HIV infection for two reasons above and beyond the negative effects that smoking has on the health of anyone. First, tobacco smoking inhibits effective CD4+ T lymphocyte function and thereby increases the risk for certain infections, especially pulmonary infections. Second, evolving science is finding that HIV infection is associated with a chronic state of persistent inflammation—even in persons whose HIV infection is well controlled—and that this inflammation increases the risk for illnesses for which smoking is already a well-established cause. These illnesses include cardiovascular disease (such as heart attack and stroke), chronic obstructive pulmonary disease, low bone mineral density and fragility fractures, and a variety of non-AIDS-defining cancers. In other words, smoking compounds the risk for these conditions for persons already at risk for them as a result of their HIV infection.

The remarkable advances that we have achieved in treating HIV infection make smoking cessation more important than ever before. Today we have good reason to believe that a young person diagnosed early with HIV infection who receives effective treatment has an excellent life expectancy. But the hard-earned years of life gained from effective HIV treatment can be squandered if that patient continues to smoke. Because of this, smoking cessation should be a priority for HIV-infected persons. After treatment for HIV infection, smoking cessation likely produces the next greatest increase in quality and length of life. When HIV-infected patients quit, they experience not only significant reduction in their risk for pulmonary and cardiovascular diseases, but also significant improvement in HIV-related symptoms of fatigue, pain, and physical functioning.

Unfortunately, quit rates are 37% lower for HIV-infected smokers compared with persons in the general population.

The current care model and workforce for HIV infection are well suited to address smoking cessation. The frequency of patient visits required by HIV infection means you have more opportunities to talk about quitting smoking. The good news is that HIV-infected smokers may be more ready and willing to quit than we expect. In various surveys, more than 80% have expressed an interest in quitting, 40%-60% have contemplated quitting, and 70% have made at least one attempt to quit.

The following techniques to help patients stop smoking have been validated in numerous clinic-based trials over decades and can assist you in helping your patients quit:

Ensure that tobacco use status is routinely collected at clinic visits as a "vital sign."

Recommend to smokers that they quit by providing brief advice tailored to their personal circumstances. For instance, some people respond well when shown the cost savings of quitting. Others respond well when shown how quitting can affect their 10-year Framingham cardiovascular risk score. Still others may respond well when told how their secondhand smoke injures their children and other loved ones.

Determine whether your patient is interested in quitting, and if so, provide assistance either in-office or by referral to community resources. Assistance can include brief counseling and prescription of cessation medications. Of note, the pharmacologic interventions available for smoking cessation are generally safe to use with the antiretroviral therapies used to treat HIV infection.

If in-house resources are not available or acceptable to the patient, consider referring them to 1-800-QUIT-NOW, a toll-free service that provides phone counseling in all 50 states as well as community referrals.

If patients don't appear interested in quitting, remind them that smoking adds to the harm caused by HIV, undermines the benefits of antiretroviral treatment, and increases their risks for other smoking-related diseases and conditions.

As with other key aspects of HIV treatment, track smoking or quit status at follow-up visits, and provide support based on individual patient characteristics.

There are many resources for busy clinical practices to help patients quit; some of them can be accessed through the links provided on this page. You can also help your patients quit by becoming involved in broader community efforts to reduce tobacco use and secondhand smoke exposure, including supporting comprehensive tobacco control efforts in your community.

Web Resources

HIV Provider Smoking Cessation Handbook, A Resource for Providers HIV and Smoking Cessation Working Group of the Veterans Affairs Clinical Public Health

HIV & Tobacco Use – Pharmacologic and Behavioral Methods to Help Your Patients Quit . A reference-easy pocket guide produced by the Mountain Plains AIDS Education and Training Center

CDC Tips From Former Smokers:

Brian's Story

Quit Guide

I'm Ready to Quit

John T. Brooks, MD, leads the HIV Epidemiology Research Team within the Division of HIV/AIDS Prevention, CDC. Dr. Brooks also participates in the development of multiple US government guidelines on antiretroviral treatment, prevention and treatment of opportunistic infections, STD prevention and treatment, vaccination, and traveler's health. He is board certified in internal medicine and infectious diseases, has a clinical appointment at Emory University, and cares for HIV-infected patients at the Infectious Diseases Clinic at the Atlanta VA Hospital. He has been actively involved in HIV research and treatment since 1994.