Smoking in HIV and Aging (6/12/17)

  • Providers should counsel patients at every visit to stop smoking.
  • Providers should make use of community smoking-cessation resources, online quit sites, and pharmacotherapy to assist patients in quitting tobacco use.

CIGARETTE SMOKING is known to be a significant cause of morbidity and mortality in the HIV-uninfected population, and is one of the leading causes of cardiovascular disease in Western cultures.

While about 15 % [1] of the general population in the U.S. smokes, between 39% and 59% of HIV-infected people smoke [2]. Older individuals, persons of color, those in lower education and socioeconomic levels, people who abuse substances, and those with depression are more likely to smoke [3]. Older HIV-infected MSM are more likely to have smoked, with only 28.6% having never smoked [4]. In the ART era, HIV-infected persons who smoke have a lower quality of life and a doubling of their mortality, even when factors such as age, CD4 cell count, and HIV RNA level are controlled. Smoking increases mortality compared with non-smokers. Current smokers are less likely to achieve virologic suppression on ART [5] although this does not appear to be related to poor adherence [6]. Older women infected with HIV who have smoked tobacco are more likely to exhibit frailty [7].

Smoking tobacco in persons with HIV infection produces enhanced oxidative stress which induces cellular damage via increased inflammation, altered immune response, early senescence and apoptosis.  This mechanism produces atherosclerosis and neoplastic growth.  In addition, smoking has effects on the central nervous system, bone metabolism and the reproductive system [8, 9].

The increased cardiovascular risk in patients infected with HIV is directly related to traditional risk factors, with smoking being the most important [10]. Up to 75% of all myocardial infarctions in HIV-infected patients occur in those who have smoked, whereas only 1 in 4 are associated with smoking in the general population [11].  Smoking has been found to be an important additional risk factor for neurocognitive decline in older patients infected with HIV [12].  Smoking is associated with the development of non-AIDS associated cancers[13] with lung cancer the most common non-AIDS associated malignancy in this group[14].

The number of life-years lost because of smoking is higher than those lost to HIV-infection [15-17]. The number of years lost to smoking-related cardiovascular disease was 7.9 years and for non–AIDS malignancies 5.9 years in 35-year-old HIV-infected men.  There is little difference in life expectancy between virally suppressed never-smokers and the general population [18]. COPD, atherosclerosis, osteopenia, periodontal disease, and human papillomavirus infections are higher in HIV-infected patients who smoke [19]. Smoking cessation may ameliorate some of these adverse effects and may increase life expectancy.

Marijuana use in the current era of ART and its more liberal access may be associated with less healthy aging.  Recent users of marijuana also tend to smoke tobacco [19].

Smoking Cessation

Nicotine addiction is particularly difficult to treat in the HIV-infected population. Traditional approaches, including behavior modification, motivational interviewing techniques, group therapy, nicotine replacement, nicotine receptor-blockade, and nontraditional methods such as acupuncture have met with varying degrees of success [20].  An intensive behavioral approach failed to improve success rates compared with a standard intervention, although patients who were highly motivated and used nicotine replacement therapy were the most successful [21, 22].  A recent Cochrane review showed moderate evidence that a combined approach to smoking cessation in HIV infected patients was successful over long periods of time [23]. There may be racial and ethnic differences in response to smoking cessation efforts [24]. There are no specific data on smoking cessation in the older HIV infected population.

Smoking cessation is critical to the management, health, and survival of patients infected with HIV. Healthcare providers need to continue to promote smoking cessation, and there is a need for more effective smoking cessation strategies designed specifically for patients with HIV/AIDS [25].

Updated by Jonathan S. Appelbaum, MD, FACP, AAHIVS

June 2017


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  21. Lloyd-Richardson EE, Stanton CA, Papandonatos GD, Shadel WG, Stein M, Tashima K, et al. Motivation and patch treatment for HIV+ smokers: a randomized controlled trial. Addiction 2009; 104(11):1891-1900.
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  25. Harris JK. Connecting discovery and delivery: the need for more evidence on effective smoking cessation strategies for people living with HIV/AIDS. Am J Public Health 2010; 100(7):1245-1249.

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