Smoking Cessation Interventions: Smoking Cessation Interventions: A Selected Review of the A Selected Review of the Research Literature.Research Literature.

Jeanne EllardJeanne Ellard

PLHIV and SmokingPLHIV and Smoking

The availability in many western countries of effective The availability in many western countries of effective treatments has greatly reduced mortality due to AIDS –treatments has greatly reduced mortality due to AIDS –related causes and it is now possible for PLHIV to live related causes and it is now possible for PLHIV to live longer and healthier liveslonger and healthier lives

The proportion of deaths due to non-AIDS defining The proportion of deaths due to non-AIDS defining illnesses has increasedillnesses has increased

Cigarette smoking in HIV-infected people has been Cigarette smoking in HIV-infected people has been identified with a number of diseases and health risks: identified with a number of diseases and health risks:

PLHIV and SmokingPLHIV and Smoking

Increased risk of lung infectionIncreased risk of lung infection Doubled risk of PCPDoubled risk of PCP Developing TBDeveloping TB Developing non-AIDS related Cancers Developing non-AIDS related Cancers Cardiovascular diseaseCardiovascular disease

PLHIV and Smoking PLHIV and Smoking

HIV-positive people have significantly higher rates of HIV-positive people have significantly higher rates of cigarette smoking compared to the general populationcigarette smoking compared to the general population

HIV Futures 5 Study shows that 47.6% of PLHIV smoke HIV Futures 5 Study shows that 47.6% of PLHIV smoke compared to 23% of the general population compared to 23% of the general population

PLHIV and SmokingPLHIV and Smoking

In treated HIV-infected patients, mortality is now In treated HIV-infected patients, mortality is now dominated by non-AIDS related causes in which tobacco dominated by non-AIDS related causes in which tobacco smoking is a predominant risk factor.smoking is a predominant risk factor.

Smoking cessation interventions are recommended as a Smoking cessation interventions are recommended as a central part of contemporary HIV/AIDS ???central part of contemporary HIV/AIDS ???

Effective smoking cessation interventions have the Effective smoking cessation interventions have the potential to greatly reduce the disease burden and improve potential to greatly reduce the disease burden and improve the quality of life of PLHIVthe quality of life of PLHIV

AIM: AIM: Review published research on smoking in Review published research on smoking in relation to the following areas:relation to the following areas: Successful and cost effective smoking cessation Successful and cost effective smoking cessation

interventionsinterventions Barriers to smoking cessation among HIV-positive smokersBarriers to smoking cessation among HIV-positive smokers Comparison of peer-based interventions, clinic based Comparison of peer-based interventions, clinic based

interventions, pharmacotherapy and mass general interventions, pharmacotherapy and mass general population intervention population intervention

Optimal target population for smoking cessation Optimal target population for smoking cessation interventions i.e., PLHIV smokers only, GLBT communityinterventions i.e., PLHIV smokers only, GLBT community

Role of social networks Role of social networks Effectiveness of combined cessation strategies i.e., Effectiveness of combined cessation strategies i.e.,

pharmacotherapy and counsellingpharmacotherapy and counselling

Method: conducted search for relevant published research Method: conducted search for relevant published research from key sociological, psychological and medical databasesfrom key sociological, psychological and medical databases

Literature specifically addressing HIV-positive people and Literature specifically addressing HIV-positive people and smoking cessation was collected and reviewed with a focus smoking cessation was collected and reviewed with a focus Literature about smoking and GLBT communities was also Literature about smoking and GLBT communities was also included in the review included in the review A selection of literature addressing smoking cessation A selection of literature addressing smoking cessation interventions in the general population was also included interventions in the general population was also included to gain an overview of recognised effective smoking to gain an overview of recognised effective smoking interventions interventions

Factors Associated With Smoking and Smoking Factors Associated With Smoking and Smoking Cessation Among PLHIVCessation Among PLHIV

Benefits of smoking include: pleasure, facilitating and Benefits of smoking include: pleasure, facilitating and sustaining social engagement and reducing stress related sustaining social engagement and reducing stress related to having HIV.to having HIV.Disadvantages of smoking: expense of smoking, addiction Disadvantages of smoking: expense of smoking, addiction was sometimes inconvenient and controlling and harmful was sometimes inconvenient and controlling and harmful to health for example, coughing and sinus troubleto health for example, coughing and sinus troublePLHIV had limited knowledge of the ‘unique threats’ PLHIV had limited knowledge of the ‘unique threats’ associated with HIV and Smokingassociated with HIV and SmokingMany smokers desired to quit, but were concerned about Many smokers desired to quit, but were concerned about intensification of stress, anxiety and depressionintensification of stress, anxiety and depressionThese factors need to be addressed in any programs These factors need to be addressed in any programs including offering counselling for anxiety and depression including offering counselling for anxiety and depression and medication where indicated and medication where indicated

Factors Associated With Smoking and Smoking Factors Associated With Smoking and Smoking Cessation Among PLHIVCessation Among PLHIV

Smoking cessation offers significant health benefits, with Smoking cessation offers significant health benefits, with observable benefits apparent as early as 3 monthsobservable benefits apparent as early as 3 months

Despite a range of barriers to quitting many PLHIV are Despite a range of barriers to quitting many PLHIV are interested in quittinginterested in quitting

Clinicians and Health Care ProvidersClinicians and Health Care Providers

Clinicians and other health care providers are known to Clinicians and other health care providers are known to play a significant role in smoking cessation. play a significant role in smoking cessation. Brief clinical interventions offer an effective and low cost Brief clinical interventions offer an effective and low cost approach to smoking cessation: ask about smoking a every approach to smoking cessation: ask about smoking a every opportunity, advise all to quit, assess willingness to quit, opportunity, advise all to quit, assess willingness to quit, assist in quitting and arrange follow-up.assist in quitting and arrange follow-up.However, both Australian and international research However, both Australian and international research indicates that health care professional are not routinely indicates that health care professional are not routinely discussing smoking cessation with clients/patients.discussing smoking cessation with clients/patients.Surveys of Australian health care providers found only Surveys of Australian health care providers found only 34% of GPs reported giving smoking cessation advice 34% of GPs reported giving smoking cessation advice during every routine consultation with patients who during every routine consultation with patients who smokedsmoked

Clinicians and Health Care ProvidersClinicians and Health Care Providers

The nature of HIV means the majority of PLHIV have The nature of HIV means the majority of PLHIV have regular and ongoing interactions providing numerous regular and ongoing interactions providing numerous occasions for intervention.occasions for intervention.PLHIV make efforts to improve their health in receiving PLHIV make efforts to improve their health in receiving diagnosis, and therefore diagnosis may be ‘an important diagnosis, and therefore diagnosis may be ‘an important teachable moment’teachable moment’

Diagnosis is an optimal time for intervention, given HIV-Diagnosis is an optimal time for intervention, given HIV-positive people are more likely to be receptive to lifestyle positive people are more likely to be receptive to lifestyle and health behaviour changes in the the early phasee of and health behaviour changes in the the early phasee of HIV diagnosisHIV diagnosis

Approaches to Smoking Cessation and evidence of Approaches to Smoking Cessation and evidence of effectivenesseffectiveness Behavioural: self-help, minimal clinical interventions and Behavioural: self-help, minimal clinical interventions and

intensive clinical interventionsintensive clinical interventions Pharmacotherapy: Nicotine Replacement TherapyPharmacotherapy: Nicotine Replacement Therapy Mass media campaignsMass media campaigns

Self-help materials alone are not effective in sustaining Self-help materials alone are not effective in sustaining cessationcessationQuitlines are effective particularly when promoted in Quitlines are effective particularly when promoted in conjunction with advertising campaignsconjunction with advertising campaignsProactive phone counselling has been found to be effectiveProactive phone counselling has been found to be effectiveIntensive counselling is more effective that brief Intensive counselling is more effective that brief interventions but the cost is much greaterinterventions but the cost is much greater

Approaches to Smoking Cessation and evidence of Approaches to Smoking Cessation and evidence of effectivenesseffectiveness

Little evidence of difference between group and individual Little evidence of difference between group and individual therapy provided content is similartherapy provided content is similar

Types of behavioural therapy that have been shown to be Types of behavioural therapy that have been shown to be effective are problem-solving, skills training, social support effective are problem-solving, skills training, social support as part of treatment (group support) and social support as part of treatment (group support) and social support outside of treatment (buddy system)outside of treatment (buddy system)

Pharmacotherapy combined with behavioural support Pharmacotherapy combined with behavioural support significantly increased the success of quit attemptssignificantly increased the success of quit attempts

Effective interventionsEffective interventions

Recommendation that NRT and some anti-depressant Recommendation that NRT and some anti-depressant pharmacotherapies should be offered to all smokers pharmacotherapies should be offered to all smokers wishing to quit unless contra-indicated as they increase wishing to quit unless contra-indicated as they increase cessation rates by 75 – 150 % and enhance the quit rates cessation rates by 75 – 150 % and enhance the quit rates of most cessation methods.of most cessation methods.

Targeted interventionsTargeted interventions

There is good evidence that tailoring interventions to There is good evidence that tailoring interventions to individuals and specific group needs is a more effective individuals and specific group needs is a more effective approach to health behaviour change than untailored approach to health behaviour change than untailored messages and interventionsmessages and interventions

Research indicates that PLHIV are interested in Research indicates that PLHIV are interested in interventions that are to some degree tailored to HIV interventions that are to some degree tailored to HIV specificallyspecifically

Likewise some research indicates that gay men have a Likewise some research indicates that gay men have a preference for smoking interventions that are tailored to preference for smoking interventions that are tailored to gay mengay men

Targeted interventionsTargeted interventions

Based on these findings researchers call for interventions Based on these findings researchers call for interventions that resonate with gay men’s social contexts and that resonate with gay men’s social contexts and specifically develop strategies that support non-smoking in specifically develop strategies that support non-smoking in gay social and recreational activities and for gay health gay social and recreational activities and for gay health care organisations to become involved in the global anti-care organisations to become involved in the global anti-smoking movementssmoking movements

Social Networks, Contexts and Smoking CessationSocial Networks, Contexts and Smoking Cessation

Increasingly research indicates that long-term and Increasingly research indicates that long-term and sustained health behaviour change involves the sustained health behaviour change involves the development of policy, education and prevention strategies development of policy, education and prevention strategies that target not only individuals, but also social networks that target not only individuals, but also social networks communities and physical environments in which people communities and physical environments in which people live, work and socialiselive, work and socialise

Smoking prevalence among GLBT communities is higher Smoking prevalence among GLBT communities is higher than in the general populationthan in the general population

Smoking Cessation Intervention Targeting Gay MenSmoking Cessation Intervention Targeting Gay Men

Very little research on effective smoking cessation Very little research on effective smoking cessation interventions for gay meninterventions for gay men

London based community charity adapted a cessation London based community charity adapted a cessation intervention from an existing NHS programmeintervention from an existing NHS programme

Programme combined group work, nicotine replacement Programme combined group work, nicotine replacement and ongoing peer support throughoutand ongoing peer support throughout

The programme aimed to provide a non-judgemental The programme aimed to provide a non-judgemental context where gay men could discuss socialising and gay context where gay men could discuss socialising and gay social spaces, recreational drug use, sexuality, HIV and the social spaces, recreational drug use, sexuality, HIV and the impact of these on capacity to quitimpact of these on capacity to quit

Smoking Cessation Intervention Targeting Gay MenSmoking Cessation Intervention Targeting Gay Men

A deliberate strategy to substitute ‘quit buddies’ with ‘quit A deliberate strategy to substitute ‘quit buddies’ with ‘quit cells’ made up of 3-4 participants – based on experience cells’ made up of 3-4 participants – based on experience that support from more than one person was more reliablethat support from more than one person was more reliableThe groups were facilitated by gay men and focussed on The groups were facilitated by gay men and focussed on culturally specific contexts to gay men.culturally specific contexts to gay men.

98 men registered, 76 started programme and 69 did the 98 men registered, 76 started programme and 69 did the whole programmewhole programme44 (64%) men quit, this is a high success rate compared 44 (64%) men quit, this is a high success rate compared to national rate of 53%to national rate of 53%

ConclusionConclusion

Currently the published research on smoking cessation Currently the published research on smoking cessation interventions focussed on PLHIV is small and often based interventions focussed on PLHIV is small and often based on pilot studieson pilot studiesThis research and the general literature on smoking This research and the general literature on smoking cessation suggest a number of potential approaches to cessation suggest a number of potential approaches to smoking cessation relevant to HIV-positive smokers in the smoking cessation relevant to HIV-positive smokers in the Australian contextAustralian contextThere is good evidence that brief smoking cessation There is good evidence that brief smoking cessation interventions delivered by clinicians as a routine part of interventions delivered by clinicians as a routine part of any clinical interaction is an effective and low cost any clinical interaction is an effective and low cost approach to smoking cessationapproach to smoking cessation

ConclusionConclusion

The literature indicates that all PLHIV who smoke would The literature indicates that all PLHIV who smoke would benefit from smoking cessation interventions, regardless of benefit from smoking cessation interventions, regardless of whether they are experiencing poor health or have for whether they are experiencing poor health or have for example a low CD4example a low CD4

However there is evidence that people newly diagnosed However there is evidence that people newly diagnosed with HIV are more likely to be interested in health with HIV are more likely to be interested in health behaviour changebehaviour change

Both general literature on smoking and research on HIV Both general literature on smoking and research on HIV indicate that successful smoking cessation is best acheived indicate that successful smoking cessation is best acheived when pharmacotherapy is combined with some sort of when pharmacotherapy is combined with some sort of behavioural interventionbehavioural intervention

ConclusionConclusion

The research suggests that targeting interventions to The research suggests that targeting interventions to particular groups increases acceptability and effectiveness particular groups increases acceptability and effectiveness of interventions.of interventions.

To date limited research on smoking cessation that use To date limited research on smoking cessation that use new technologies such as mobile phones and internet.new technologies such as mobile phones and internet.

The available literature suggest internet-based and mobile The available literature suggest internet-based and mobile phone interventions offer a potential low-cost way to phone interventions offer a potential low-cost way to delivered tailored smoking cessation programmes delivered tailored smoking cessation programmes

ConclusionConclusion

There is increasing evidence that social networks and There is increasing evidence that social networks and contexts play a significant role in people’s health contexts play a significant role in people’s health behaviours and therefore it is important to target the GLBT behaviours and therefore it is important to target the GLBT community more broadly, in order to effectively support community more broadly, in order to effectively support HIV-positive smokers who wish to quit. Utilising social HIV-positive smokers who wish to quit. Utilising social contexts and community spaces such as bars, gay social contexts and community spaces such as bars, gay social groups and special events for example, Mardi Gras and groups and special events for example, Mardi Gras and Queer Screen may provide potential sites for intervention.Queer Screen may provide potential sites for intervention.The movement toward GLBT health occurring in some HIV/The movement toward GLBT health occurring in some HIV/AIDS organisations in Australia may also provide an AIDS organisations in Australia may also provide an opportunity for smoking cessation programmes that target opportunity for smoking cessation programmes that target gay men generally with specific strategies and gay men generally with specific strategies and interventions incorporated for HIV-positive gay men who interventions incorporated for HIV-positive gay men who smokesmoke