Why Smoking Cessation Should Be a Priority in HIV Care Today

1
Why Smoking Cessation Should Be a Priority in HIV
Care Today
Alvaro Carrascal, MD, MPH Office of the Medical
Director AIDS Institute AI is a Local Performance
Site of the NY/NJ AETC
2
Objectives

• Review the changing paradigm of HIV disease
• Review the association between smoking and HIV
• Describe the importance of addressing tobacco use
  among PLWHA

3
HIV Disease Changing Paradigm

• Reduced mortality
• Chronic disease
• PLWH/AIDS living longer, healthier and more
  productive lives
• Changing morbidity/mortality
• Cancer, CVD, diabetes, liver disease, etc.

4
Mortality
5
Reductions in Mortality

• 5561 pats., HOPS, 1996-2002
• 1996 2002
• Deaths
• 6.3 /100 person-yrs 2.2
• OI rates
• 23 /100 person-yrs 6

Palella FJ et al. Mortality and morbidity in the
HAART era Changing causes of death and disease
in the HIV Outpatient study. 11th CROI San
Francisco, CA 2004. Abs. 872
6
Use of HAART
of patients
Palella FJ et al. Mortality and morbidity in the
HAART era Changing causes of death and disease
in the HIV Outpatient study. 11th CROI San
Francisco, CA 2004. Abs. 872
7
.. and Change in Causes of Death
of deaths
Palella FJ et al. Mortality and morbidity in the
HAART era Changing causes of death and disease
in the HIV Outpatient study. 11th CROI San
Francisco, CA 2004. Abs. 872
8
Changes in Causes of DeathSouthern Alberta,
Canada, 1984-2003
Cohort 1987 patients Total of deaths 560
of deaths, non-AIDS related causes
32
7
Krents, HB et al. Changing mortality rates and
causes of death for HIV-infected individuals
living in Southern Alberta, Canada, from 1984 to
2003. HIV Medicine 2005 699106
9
Increases in Non-AIDS Related Causes of Death
Southern Alberta, Canada, 1984-2003

• Causes of Death 1984-96 1997-03
• Accidental deaths 2.2 17
• (drug overdose)
• Liver disease lt1 8.4
• Non-HIV Cancers lt1 7

Krents, HB et al. Changing mortality rates and
causes of death for HIV-infected individuals
living in Southern Alberta, Canada, from 1984 to
2003. HIV Medicine 2005 699106
10
HIV-related and Non-HIV related deaths among
PLWHA NYC 1988-2003
HAART
Source HIV Epidemiology Program 1st Quarter
Report (Jan 2005), NYC Dept. of Health and Mental
Hygiene
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Living Longer
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PLWHA Are Getting Older

• NY HIV/AIDS hospital discharges among PLWHA 50
  years of age or older

of HIV/AIDS discharges
Source SPARCS database, NYSDOH
13
PLWHA Are Getting Older

• NY Medicaid Recipients with HIV/AIDS, Age 50

of HIV/AIDS recipients
Source Medicaid Claims database
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Changing Morbidity
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Changing MorbidityCardiovascular Diseases
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Prospective observational cohort 23,468 HIV
pats, Incidence of myocardial infarction (MI)
increased by an average of 26 per year of
exposure to CART, over the first 6 years of
exposure
Incidence of MI according to the duration of
exposure to CART
The DAD Study Group. Combination antiretroviral
therapy and the risk of myocardial infarction. N
Engl J Med 2003 34919932003
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The Writing Committee of the DAD Study Group.
Cardio- and cerebrovascular events in
HIV-infected persons. AIDS 2004 1818111817
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Myocardial infarction Among Patients with HIV
Infection
Holmberg et al. Trends in rates of myocardial
infarction among patients with HIV N Engl J Med
2004 350730-731
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Acute Myocardial Infarction NY Discharges among
PLWHA
Source SPARCS database, NYSDOH
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Cigarette smoking is the most important
modifiable cardiovascular risk factor among
HIV-infected patients.
Greenspoon, S. Carr, A. Cardiovascular risk and
body-fat abnormalities in HIV-infected adults. N
Engl J Med 2005 3524862
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Cessation of smoking is more likely to reduce
cardiovascular risk than either the choice of
antiretroviral therapy or the use of any
lipid-lowering therapy.
Greenspoon, S. Carr, A. Cardiovascular risk and
body-fat abnormalities in HIV-infected adults. N
Engl J Med 2005 3524862
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James Cadenhead Infected with HIV for 18 years.
Has had Hep B, C, toxoplasmosis.
..Im doing pretty well. I think my chances are
better of going of a heart attack than of AIDS.
My biggest problem now is , What do I do when I
retire?
New York Times, Aug. 17, 2004
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Changing MorbidityCancer
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Trends in AIDS-Defining and NonAIDS-Defining
Malignancies among HIV-Infected Patients
19892002
Cases per 1000 pat-years
Years
Bedimo, R et al. Trends in AIDS-defining and
non-AIDS-defining malignancies among HIV-infected
patients 1989-2002. Clin Inf Dis
2004391380-1384
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Cancers of the larynx and oropharynx among PLWHA
discharged from hospitals in NY, 1994-2002
Discharges from hospitals
Source NY SPARCS
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Cancers of the larynx and oropharynx among PLWHA,
Medicaid recipients, NY, 1993-2001
Source NY Medicaid
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Cancers of the lung and trachea among PLWHA
discharged from hospitals in NY, 1994-2002
Source NY SPARCS
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Cancers of the lung and trachea among PLWHA,
Medicaid recipients, NY, 1993-2001
Source NY Medicaid Claims database
32
Causes of death among HIV-infected adults in
France, 2000
N964
of all deaths
Lewden C et al. Causes of death among
HIV-infected adults in the era of potent
antiretroviral therapy emerging role of
hepatitis and cancers, persistent role of AIDS.
Int J Epidemiol 200534121-130
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Causes of death among HIV-infected adults in
France, 2000

• Prevention, screening, and management of
  non-Hodgkins lymphoma and of non-AIDS related
  cancers, especially lung cancer, prevention of
  CVDs, and management of viral hepatitis should be
  considered public health priorities
• Specific programs for smoking cessation should be
  developed for the HIV-infected

Lewden C et al. Causes of death among
HIV-infected adults in the era of potent
antiretroviral therapy emerging role of
hepatitis and cancers, persistent role of AIDS.
Int J Epidemiol 200534121-130
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• Now that HAART-regimens have considerably
  improved the life expectancy in HIV-infected
  populations in industrialized countries, efforts
  to reduce smoking and alcohol consumption must be
  a priority in HIV medicine.

Zwahlen M, Lundgren, JD. Commentary Death in the
era of potent antiretroviral therapy shifting
causes, new challenges. Int J Epidemiol
200534130-131
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Incidence Rate Ratios of Non-AIDS Defining
Malignancies1992-2002
Incidence rate ratio Standardized HIV Observed
SEER
Patel P et al. Incidence of AIDS-defining and
non-AIDS defining malignancies among HIV infected
persons. CROI 2006
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Incidence Rate Ratios of Non-AIDS Defining
Malignancies1992-2002

• The incidence of many non-ADM were significantly
  higher suggesting that HIV-infected persons are
  at higher risk of developing certain cancers
• In addition to encouraging tobacco cessation,
  health care providers should consider enhanced
  monitoring for these malignancies in their
  HIV-infected patients.

Patel P et al. Incidence of AIDS-defining and
non-AIDS defining malignancies among HIV infected
persons. CROI 2006
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Lung Cancer in PLWHA

• 5,238 pats., Moore Clinic, 1989-2003
• 19,061 person-years of follow up
• 33 cases identified (85 current smokers
  
  12
  former smokers)
• SIR Detroit gen. pop. 4.7
• US pop. 6.9

Engels, EA et al. Elevated incidence of lung
cancer among HIV-infected individuals. J Clin
Oncol 2006 24 138388
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Lung Cancer in PLWHA

• Elevated incidence of lung cancer
• As people with HIV live longer and age,
  clinicians should be alert to the possible
  diagnosis of lung cancer in HIV-inf. patients
• Need to develop effective interventions to assist
  individuals in their attempts to quit smoking
• Smoking might not entirely explain the excess of
  lung ca. among HIV-inf. persons, hence the need
  for research regarding pathogenesis

Engels, EA et al. Elevated incidence of lung
cancer among HIV-infected individuals. J Clin
Oncol 2006 24 138388
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Other Conditions
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Chronic Bronchitis and Emphysemaamong PLWHA
Discharged from Hospitals in NY
Source SPARCS database, NYSDOH
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Oral Health

• HIV smokers are more likely to develop
• Oral candidiasis
• Periodontitis
• Oral hairy leukoplakia
• Cancers

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Oral Health

• HIV Cost and Services Utilization Study. National
  probability sample of HIV inf. Adults in the US
• Self-reported, 3 sets of interviews
• Smokers were 62 more likely to report oral
  white patches than non-smokers

Marcus, M. et al. Oral white patches in a
national sample of medical HIV patients in the
era of HAART. Community Dent Oral Epidemiol 2005
33 99106
43
Minkoff H et al. Relationship between smoking and
Human Papillomavirus infections in HIV-infected
and -uninfected women. J Infect Dis
20041891821-8
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Impact of Smoking on Outcome in the HIV Infected
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Women Cigarrette Smoking and HIV Prognosis in
the HAART Era
Feldman JG, Minkoff H et al. The association of
cigarette smoking with HIV prognosis among women
in the HAART eraA report from the Womens
Interagency HIV Study. Am J Public Health
200696(6)1-6
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Women Cigarrette Smoking and HIV Prognosis in
the HAART Era
Cumulative percentage remaining free from an
AIDS-defining condition, by smoking status before
HAART initiation
Feldman JG, Minkoff H et al. The association of
cigarette smoking with HIV prognosis among women
in the HAART eraA report from the Womens
Interagency HIV Study. Am J Public Health
200696(6)1-6
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Impact of Cigarette Smoking on Mortality and QOL
Among PLWHA

• 867 HIV from Veterans Aging Cohort 3 Site Study
• 63 current smokers, 22 former smokers
• Current smokers had highest VL (compared to form.
  or never smokers. p.001)
• Smoking was strongly associated with increased
  respiratory symptoms (cough, dyspnea),
  noninfectious pulmonary disease (COPD /or
  asthma), and bacterial pneumonia

Crothers, K et al. The impact of cigarette
smoking on mortality, quality of life, and
comorbid illness among HIV-positive veterans. J
Gen Intern Med 2005201142-45
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Impact of Cigarette Smoking on Mortality
After adjusting for age, race/ethnicity, baseline
CD4 cell count, VL, hemoglobin, illegal
drug/alcohol use, mortality was significantly
increased in current smokers compared with never
smokers (hazard ratio HR 1.99, 95 CI 1.03 to
3.86).
Unadjusted mortality rate per 100 person-years
Smokers
Never smokers
Crothers, K et al. The impact of cigarette
smoking on mortality, quality of life, and
comorbid illness among HIV-positive veterans. J
Gen Intern Med 2005201142-45
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Cigarette Smoking and QOL
N129
QOL
N189
N549
Crothers, K et al. The impact of cigarette
smoking on mortality, quality of life, and
comorbid illness among HIV-positive veterans. J
Gen Intern Med 2005201142-45
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How Serious is the Problem?

• Prevalence of smoking among people with HIV ---
  estimated to be higher than among the general
  population
• New England clinics More than 70 of HIV smoke
• Swiss HIV Cohort Study
• 72 are current/former smokers
• 96 among IDUs

Niaura R et al. Smoking among HIV-positive
persons. Ann Behav Med 1999 21(Suppl)S116
Clifford, GM et al. Cancer risk in the Swiss HIV
Cohort Study Associations with immunodeficiency,
smoking and Highly Active Antiretroviral Therapy.
J Natl Cancer Inst 200597425-432
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New York

• 482 HIV Medicaid recipients, NYC
• Age 22-75 59 males 53 African
  Americans 30 Latinos
• HS education or less 87
• 66 current smokers (mean16 cig./day)
• 18 former smokers
• Current smokers
• Greater use of illicit substances
• Lower state of health
• Lower perceived health risk of continued smoking

Burkhalter, JE et al. Tobacco use and readiness
to quit smoking in low-income HIV-infected
persons. Nicotine Tob Res 2005 7(4)511-522
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Smoking Prevalence among PLWHA Receiving Care in
NYS 2005

• 3-page self-administered survey
• Input from NYSDOH Tobacco Control Program
• Instruments used to measure tobacco use
• Survey collected
• Demographics
• Current and past tobacco use. Frequency.
• Perceptions regarding tobacco use
• Cessation history. Intentions/readiness to quit

NYS DOH AIDS Institute
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Smoking Prevalence among PLWHA Receiving Care in
NYS 2005

• NYC Region
• Bronx Lebanon
• Harlem United
• Housing Works 13th Street
• Housing Works 98th Street
• NY Hospital of Queens
• PROMESA
• Saint Vincent Medical Center
• SUNY Brooklyn
• Village Center

• Upstate NY Region
• Erie County Medical Center
• Nassau University
• Strong Memorial Hospital
• SUNY Syracuse
• United Health Services
• Westchester County Medical Center
• Designated AIDS Care Center
• Adult Day Health Center

NYS DOH AIDS Institute
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Smoking Prevalence among PLWHA Receiving Care in
NYS 2005

• Target Sample 1228
• Surveys completed 1094
• Return rate 89

NYS DOH AIDS Institute
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Smoking Prevalence among PLWHA Receiving Care in
NYS 2005
NYS DOH AIDS Institute, OMD/OPER
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Percentage Correct on Smoking Knowledge Statements
NYS DOH AIDS Institute, OMD/OPER
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Willingness to Quit

• Stopped smoking for one day or longer during the
  past 12 months
• Currently interested in quitting

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NYS DOH AIDS Institute, OMD/OPER
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How Big is the Problem?

• HUGE!
• In NY, smoking is 3 times higher among PLWHA than
  among the general pop.
• HIV populations include the following
  overlapping conditions
• Substance use
• Mental health
• Poverty, low educational attainment

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2004 Surgeon General Report on Smoking

• Updates the health effects of smoking
• Identifies substantial number of diseases that
  were not previously associated with smoking
• Cancer of the stomach, uterine cervix, pancreas,
  kidney
• Acute myeloid leukemia
• Pneumonia
• Abdominal aortic aneurysm
• Cataracts
• Periodontitis
• Single most preventable cause of death and illness

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Conclusions

• Significant changes in mortality and morbidity
  among people with HIV
• PLWHA are living longer and increasingly becoming
  ill or dying of non HIV- related conditions
• Smoking is highly prevalent among PLWHA
• Smoking cessation should be a priority in the
  medical management of PLWHA

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Conclusions

• Significant, and immediate, benefits for HIV
  individuals can be achieved by quitting
• Significant public health benefits can be derived
  from reducing smoking among PLWHA
• To further improve survival and quality of life
  for PLWHA, we MUST promote smoking cessation

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Acknowledgements

• Kumara Singaravelu, MD, MPH
• James Tesoriero, Ph.D.
• Susan Gyeric
• The AIDS Institutes HIV and Smoking Workgroup