People Living with HIV

Smoking can lead to severe health consequences, especially for people living with human immunodeficiency virus (HIV). Approximately 13.7% of adults in the general population are current cigarette smokers.1 It has been estimated that 37.9% of adults living with HIV, are current cigarette smokers.2 It is important to also note that quit rates for smokers are significantly less among adults living with HIV, even though they are interested in quitting.

Smoking among people living with HIV can have deleterious effects on disease prognosis. Specifically, one study highlighted that smokers living with HIV were 25% less likely to have an undetectable viral load compared to their nonsmoking counterparts, meaning they are at a higher risk of becoming ill because of HIV.

Increased risk of common HIV-opportunistic infections: 

    Studies comparing individuals living with HIV who were current smokers with their nonsmoking counterparts have found: 

  • An increased risk of developing community-acquired pneumonia (bacterial or viral pneumonia acquired outside the hospital), with findings ranging from a 2-5 fold increase.5 This vulnerability exists even amongst those who take highly active antiretroviral therapy (HAART), with incidence increasing as CD4 cell counts decrease.5 

  • A 3.2x increased risk of developing tuberculosis.

  • A 2.5x increased risk of developing oral candidiasis (a yeast or fungal infection of the mouth).

Negative effect on adherence to and effectiveness of antiretroviral treatment: 

  • Smokers with HIV have been found to be less adherent to ART treatment, take medication less frequently, and attend fewer outpatient medical visits than nonsmokers. This was found to be independent of other factors such as other substance use and depression.8 This is problematic because not taking antiretroviral drugs as directed may impact one’s ability to successfully manage HIV.   

Individuals living with HIV have a compounded risk for smoking-related problems: 

  • Chronic Obstructive Pulmonary Disease (COPD) is a common lung disease associated with smoking. HIV status appears to be an independent risk factor for the development of COPD. A recent meta-analysis found that HIV positive individuals have significantly higher odds of having COPD, independent of tobacco use and other factors.

  • Evidence suggests that incidence of lung cancer is greater among people living with HIV, with one study estimating a 2.6x increased rate independent of smoking status.10 Thus, smoking and AIDS may have a synergistic effect on the development of lung cancer. Another study found that among ART-adherent individuals living with HIV, smokers were 6-13 times more likely to die from lung cancer than from traditional AIDS-related diseases. Being a heavy smoker and male were found to incur a higher lung cancer mortality rate than being a moderate or light smoker and being female.11 

  • HIV status has been found to be associated with the development of emphysema independent of smoking status. One study found a 2.24x increased rate of emphysema among people living with HIV.12 

  • Smoking among people living with HIV can also increase risk of cardiovascular issues. One study found that individuals living with HIV who smoke have an 72% increased risk of a Myocardial Infarction (MI) compared with a 24% risk in nonsmoking peers.13  

Smoking cessation efforts and adherence amongst people living with HIV 

  • Participation in smoking cessation has historically been low amongst people living with HIV; with one study estimating that only 8% of smokers participate in cessation efforts.14 

  • Though cessation participation has been low among this group, there is a substantial amount of interest in quitting and an effort to quit amongst the population. One study found that among smokers living with HIV approximately 59% had participated in lifetime Nicotine-Replacement Therapy (NRT) and that 74% were interested in quitting.15 

  • Interest in quitting may be influenced by provider-patient interaction. Specifically, when smokers living with HIV have frequent interactions with their provider, the likelihood of them showing interest in cessation doubles compared to those who have no or little interaction. Interest may also be affected by smoking frequency, with the same study showing over half (51%) of those with no interest in quitting were heavy smokers.16 

  • Efforts to complete cessation interventions may be hindered by individual factors such as motivation and interest. In a study assessing adherence to a smoking cessation intervention (consisting of pharmacotherapy and telephone calls) among smokers living with HIV, it was found that less than half (46%) of participants completed 80% or more of both parts of the intervention. Those who were most successful in cessation efforts were those showed high interest in the initial intervention and to treatment.17 

Current and future smoking cessation options for people living with HIV 

  • Evidence suggests that approaches that address behavioral health in conjunction to smoking cessation are the most effective. In a study examining the differences in a standard smoking intervention and one that also addressed depressive and anxiety symptoms with weekly cognitive-behavioral therapy (CBT) sessions, the CBT group performed better at maintaining abstinence at 7 day (59%) and 6 month (46%) follow ups compared to the group that performed a standard smoking intervention (9% at 7 days, 5% at 6 months).18 

  • While intensive interventions can have a greater effect on increasing cessation, research also suggests that simply giving cessation advice can increase quit rates.19 

Why change is needed in the future of care for HIV-positive smokers: 

To achieve effective tobacco cessation among this population, there is an identified need to implement multi-modal approaches to cessation that are tailored to individual conditions. Research suggests the more tobacco cessation is encouraged by health providers, the more interest patients will show for it.16,19 Thus, providers should be continually engaging their patients in conversations around cessation. Additionally, other factors such as other substance abuse, anxiety, or depression, should be screened for and addressed, as they are known detriments to tobacco cessation and ART medication adherence.17-19 This sort of multi-modal approach that addresses individual characteristics and utilizes efficacious tobacco cessation techniques, i.e. counseling, coaching (quit lines, etc), pharmacotherapy, and NRT, seems to be the most effective way to increase tobacco cessation among this group. 

Additional Resources: 

  1. Creamer, M. R., Wang, T. W., Babb, S., Cullen, K. A., Day, H., Willis, G., Jamal, A., & Neff, L. (2018). Tobacco product use and cessation indicators among adults. Morbidity and Mortality Weekly Report 2019, 68(45), 1013–1019. 

  2. Centers for Disease Control and Prevention. People Living with HIV. (2020). Retrieved September 08, 2020, from 

  3. Mdodo, R., Frazier, E. L., Dube, S. R., Mattson, C. L., Sutton, M. Y., Brooks, J. T., & Skarbinski, J. (2015). Cigarette smoking prevalence among adults with HIV compared with the general adult population in the United States: Cross-sectional surveys. Annals of Internal Medicine, 162(5), 335–344. 

  4. Cropsey, K. L., Willig, J. H., Mugavero, M. J., Crane, H. M., McCullumsmith, C., Lawrence, S., Raper, J. L., Mathews, W. C., Boswell, S., Kitahata, M. M., Schumacher, J. E., Saag, M. S., & CFAR Network of Integrated Clinical Systems (2016). Cigarette smokers are less likely to have undetectable viral loads: Results from four HIV clinics. Journal of Addiction Medicine, 10(1), 13–19. 

  5. Rossouw, T. M., Anderson, R., & Feldman, C. (2015). Impact of HIV infection and smoking on lung immunity and related disorders. European Respiratory Journal, 46(6), 1781-1795; 

  6. Murrison, L., Martinson, N., Moloney, R., Msandiwa, R., Mashabela, M., Samet, J., & Golub, J. (2016). Tobacco smoking and tuberculosis among men living with HIV in Johannesburg, South Africa: A case-control study. PLoS ONE, 11, 1-11. 

  7. Chattopadhyay, A., & Patton, L. L. (2013). Smoking as a risk factor for oral candidiasis in HIV-infected adults. Journal of Oral Pathology & Medicine, 42(4), 302–308. 

  8. O'Cleirigh, C., Valentine, S. E., Pinkston, M., Herman, D., Bedoya, C. A., Gordon, J. R., & Safren, S. A. (2015). The unique challenges facing HIV-positive patients who smoke cigarettes: HIV viremia, art adherence, engagement in HIV care, and concurrent substance use. AIDS and Behavior, 19(1), 178-185. 

  9. Bigna, J. J., Kenne, A. M., Asangbeh, S. L., & Sibetcheu, A. T. (2018). Prevalence of chronic obstructive pulmonary disease in the global population with HIV: A systematic review and meta-analysis. The Lancet: Global Health, 6(2), 193–202. 

  10. Hessol, N. A., Martínez-Maza, O., Levine, A. M., Morris, A., Margolick, J. B., Cohen, M. H., Jacobson, L. P., & Seaberg, E. C. (2015). Lung cancer incidence and survival among HIV-infected and uninfected women and men. AIDS, 29(10), 1183–1193. 

  11. Reddy, K. P., Kong, C. Y., Hyle, E. P. Baggett, T. P., Huang, M., Parker, R. A., David, A. P., Losina, E., Weinstein, M. C., Freedberg, K. A., & Walensky, R. P. (2017). Lung cancer mortality associated with smoking and smoking cessation among people living with HIV in the United States. JAMA Internal Medicine, 177(11), 1613–1621. 

  12. Attia, E. F., Akgün, K. M., Wong, C., Goetz, M. B., Rodriguez-Barradas, M. C., Rimland, D., Brown, S. T., Soo Hoo, G. W, Kim, J., Lee, P. J., Schnapp, L. M., Sharafkhaneh, A., Justice, A. C., & Crothers, K. (2015). Increased risk of radiographic emphysema in HIV is associated with elevated soluble CD14 and nadir CD4. Chest, 146(6), 1543–1553. 

  13. Rasmussen, L. D., Helleberg, M., May, M. T., Afzal, S., Kronborg, G., Larsen, C. S., Pedersen, C., Gerstoft, J., Nordestgaard, B. G., & Obel, N. (2015). Myocardial infarction among Danish HIV-infected individuals: Population-attributable fractions associated with smoking. Clinical Infectious Diseases, 60(9), 1415–1423. 

  14. Cioe, P. A., Crawford, S. L., & Stein, M. D. (2014). Cardiovascular risk-factor knowledge and risk perception among HIV-infected adults. The Journal of the Association of Nurses in AIDS Care, 25(1), 60–69. 

  15. Pacek, L. R., Latkin, C., Crum, R. M., Stuart, E. A., & Knowlton, A. R. (2014). Interest in quitting and lifetime quit attempts among smokers living with HIV infection. Drug and Alcohol Dependence, 138, 220–224. 

  16. Pacek, L.R., Rass, O. & Johnson, M.W. (2017). Positive smoking cessation-related interactions with HIV care providers increase the likelihood of interest in cessation among HIV-positive cigarette smokers. AIDS Care, 29(10), 1309-1314. 

  17. Browning, K. K., Wewers, M. E., Ferketich, A. K., Diaz, P., Koletar, S. L., & Reynolds, N. R. (2016). Adherence to tobacco dependence treatment among HIV-infected smokers. AIDS and Behavior, 20(3), 608–621. 

  18. O'Cleirigh, C., Zvolensky, M. J., Smits, J. A. J., Labbe, A. K., Coleman, J. N., Wilner, J.G., Stanton, A. M., Gonzalez, A., Garey, L., Regenauer, K., & Rosenfield, D. (2018). Integrated treatment for smoking cessation, anxiety, and depressed mood in people living with HIV: A randomized controlled trial. Journal of Acquired Immune Deficiency Syndromes, 79(2), 261-268. 

  19. Stead, L., Buitrago, D., Preciado, N., Sanchez, G., Hartmann-Boyce, J., & Lancaster, T. (2013). Physician advice for smoking cessation. The Cochrane Database of Systematic Reviews, 8, 1-70.