With studies estimating that an alarming 50% to 70% of HIVers are regular tobacco smokers'a rate that is two to three times higher than that of the general population'health advocates are bewildered about how to go about reversing this trend.
In addition to their obvious concerns about the harms of tobacco use, advocates find such statistics especially troubling because of the myriad additional problems associated with the combination of cigarettes, HIV, and antiretroviral therapy. Smoking can weaken the immune system and increase HIVers' risk of developing thrush, oral candidiasis, hairy leukoplakia, AIDS-related dementia, bacterial pneumonia, emphysema, and pneumocystis pneumonia. Smoking can raise cholesterol levels already elevated by antiretrovirals and multiply the risk of heart disease. Then, of course, there is the potential for developing lung, stomach, and mouth cancer.
Notwithstanding 10 years of access to life-extending therapies, many HIVers still carry the antiquated attitude that they might as well smoke, since, they rationalize, they have nothing to lose. This attitude perplexes Christopher Murray, coordinator of the SmokeFree Project at the Lesbian, Gay, Bisexual, and Transgender Community Center in New York City. 'The time has come,' he says, 'when we should stop saying 'Oh, sure, they can smoke' about people with HIV.'
But Gal Meyer, medical director at Callen-Lorde Community Health Center in New York City, says such efforts might not be easy to execute. He has been unsuccessful at getting his patients to quit smoking because the issue is not so black-and-white. 'Risk is relative,' he says, speaking of a patient population that is often struggling with mental health or substance abuse issues too. 'A lot of people who have bigger, more immediate threats'and are dealing with those'have trouble putting down the security that smoking gives them.'
Because of the pervasive nature of beliefs that keep HIVers from worrying about quitting, any broad-based antismoking movement that would be directed at the HIV-positive population is still in its infancy. There have been only a few ad campaigns geared specifically toward HIV-positive smokers. Perhaps the most successful one was 2003's 'Cigarettes Are My Greatest Enemy,' which ran in local California newspapers with captions such as 'I didn't survive HIV so I could die from lung cancer. I had to stop smoking.'
Meanwhile, the California and New York state health departments have developed informational brochures; and groups like the Latino Commission on AIDS have only recently received grant money to develop antismoking programs.
Murray was one of the key organizers of a first-of-its-kind conference on HIV and smoking in New York City on November 15 that was sponsored by the New York state health department. A group largely composed of AIDS service organization case managers gathered at Rockefeller University to learn about the harms of tobacco, especially those particularly dangerous to HIVers, and how to develop smoking-cessation strategies for clients.
Meanwhile, this year the American Academy of HIV Medicine will add a new chapter about smoking issues to its study guide for HIV treatment physicians. Tony Mills is a West Hollywood, Calif., HIV specialist who argued for smoking's inclusion in the study guide. He said smoking cessation can be successful if physicians have a close relationship with their patients and are persistent about encouraging them to quit.
'I've been amazed over the course of my years in practice how maybe for the first six months, nine months, 12 months, it doesn't really sink in,' Mills says. 'But then they start thinking, Every time I go back there he's going to talk to me about this. Maybe this is important.'
Raymond Niaura is a professor of psychiatry at Brown Medical School in Providence, R.I., whose research has found that 70% of New England HIVers smoke. He says, 'Very often I think physicians will find that their patients are actually motivated to quit'or at least willing to try.' In fact, Murray estimates that 70% of HIVers want to quit, the same rate as in the general population.
Niaura says doctors need to dispel the pervasive belief among HIVers that smoking is the least of their worries. 'In addition to the positive health benefits, what we see when people quit is that they feel a sense of empowerment that allows them to change other aspects of their life in positive ways,' he says.