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Original Research |

Cigarette Smoking Prevalence Among Adults With HIV Compared With the General Adult Population in the United States: Cross-sectional SurveysCigarette Smoking Prevalence Among Adults With HIV

Rennatus Mdodo, DrPH, MS; Emma L. Frazier, PhD, MS; Shanta R. Dube, PhD, MPH; Christine L. Mattson, PhD; Madeline Y. Sutton, MD, MPH; John T. Brooks, MD; and Jacek Skarbinski, MD
[+] Article, Author, and Disclosure Information

From National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention; Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention; and School of Public Health, Georgia State University, Atlanta, Georgia.

Disclaimer: The findings and conclusions in this article are those of the authors and do not necessarily represent the views of the Centers for Disease Control and Prevention.

Acknowledgment: The authors thank all MMP and NHIS participants and staff members for their time and efforts. They also thank Dr. Yunfeng (Tracy) Tie for MMP data analytic support and Ms. Kat Asman, MSPH, for NHIS data analytic support.

Grant Support: By the CDC (cooperative agreement PS09-937 with MMP participating areas).

Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M14-0954.

Reproducible Research Statement:Study protocol: The MMP protocol is available at www.cdc.gov/hiv/statistics/systems/mmp/resources.html. The NHIS survey description and methodology are available at ftp://ftp.cdc.gov/pub/Health_Statis tics/NCHS/Dataset_Documentation/NHIS/2009/srvydesc.pdf. Statistical code: Available from Dr. Sutton (e-mail, msutton@cdc.gov). Data set: The MMP data sets are not available. The NHIS data sets are available at www.cdc.gov/nchs/nhis/quest_data_related_1997_forward.htm.

Requests for Single Reprints: Madeline Y. Sutton, MD, MPH, Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Office of Infectious Diseases, Centers for Disease Control and Prevention, 1600 Clifton Road Northeast, Mail Stop E-45, Atlanta, GA 30329; e-mail, msutton@cdc.gov.

Current Author Addresses: Drs. Mdodo, Sutton, and Brooks: Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Office of Infectious Diseases, Centers for Disease Control and Prevention, 1600 Clifton Road Northeast, Mail Stop E-45, Atlanta, GA 30329.

Drs. Frazier, Mattson, and Skarbinski: Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Office of Infectious Diseases, Centers for Disease Control and Prevention, 1600 Clifton Road Northeast, Mail Stop E-46, Atlanta, GA 30329.

Dr. Dube: Associate Professor, Division of Epidemiology and Biostatistics, School of Public Health, Georgia State University, 1 Park Place, Suite 711, Atlanta, GA 30303.

Author Contributions: Conception and design: R. Mdodo, C.L. Mattson, M.Y. Sutton, J.T. Brooks, J. Skarbinski.

Analysis and interpretation of the data: R. Mdodo, E.L. Frazier, S.R. Dube, C.L. Mattson, M.Y. Sutton, J.T. Brooks, J. Skarbinski.

Drafting of the article: R. Mdodo, E.L. Frazier, S.R. Dube, C.L. Mattson, M.Y. Sutton, J.T. Brooks, J. Skarbinski.

Critical revision of the article for important intellectual content: R. Mdodo, S.R. Dube, C.L. Mattson, M.Y. Sutton, J.T. Brooks, J. Skarbinski.

Final approval of the article: E.L. Frazier, S.R. Dube, C.L. Mattson, M.Y. Sutton, J.T. Brooks, J. Skarbinski.

Statistical expertise: R. Mdodo, E.L. Frazier, C.L. Mattson.

Obtaining of funding: J. Skarbinski.

Collection and assembly of data: S.R. Dube, E.L. Frazier, C.L. Mattson, J. Skarbinski.


Ann Intern Med. 2015;162(5):335-344. doi:10.7326/M14-0954
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Background: The negative health effects of cigarette smoking and HIV infection are synergistic.

Objective: To compare the prevalence of current cigarette smoking and smoking cessation between adults with HIV receiving medical care and adults in the general population.

Design: Nationally representative cross-sectional surveys.

Setting: United States.

Patients: 4217 adults with HIV who participated in the Medical Monitoring Project and 27 731 U.S. adults who participated in the National Health Interview Survey in 2009.

Measurements: The main exposure was cigarette smoking. The outcome measures were weighted prevalence of cigarette smoking and quit ratio (ratio of former smokers to the sum of former and current smokers).

Results: Of the estimated 419 945 adults with HIV receiving medical care, 42.4% (95% CI, 39.7% to 45.1%) were current cigarette smokers, 20.3% (CI, 18.6% to 22.1%) were former smokers, and 37.3% (CI, 34.9% to 39.6%) had never smoked. Compared with the U.S. adult population, in which an estimated 20.6% of adults smoked cigarettes in 2009, adults with HIV were nearly twice as likely to smoke (adjusted prevalence difference, 17.0 percentage points [CI, 14.0 to 20.1 percentage points]) but were less likely to quit smoking (quit ratio, 32.4% vs. 51.7%). Among adults with HIV, factors independently associated with greater smoking prevalence were older age, non-Hispanic white or non-Hispanic black race, lower educational level, poverty, homelessness, incarceration, substance use, binge alcohol use, depression, and not achieving a suppressed HIV viral load.

Limitation: Cross-sectional design with some generalizability limitations.

Conclusion: Adults with HIV were more likely to smoke and less likely to quit smoking than the general adult population. Tobacco screening and cessation strategies are important considerations as part of routine HIV care.

Primary Funding Source: Centers for Disease Control and Prevention.

Topics

smoking ; hiv

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HIV clinicians must address underlying reasons for smoking
Posted on March 31, 2015
Reed A.C. Siemieniuk MD (1), M. John Gill, MB ChB (2)
1. Department of Medicine, University of Toronto, Toronto, Ontario, Canada; 2. Department of Medicine, University of Calgary, Calgary, Alberta, Canada
Conflict of Interest: None Declared
In their cross-sectional population-representative study of people living with HIV (PLWH) Mdodo and colleagues (1) report that 42% are current smokers, in stark contrast to 21% of their general population. Moreover, only 32% of PLWH had stopped smoking compared to 52% of ever-smokers in the general population. While the authors found associations with some clinical parameters, most of the increased risk remained unexplained.

Interventions to reduce the burden of smoking among PLWH need to address the underlying reasons people start and continue to smoke tobacco. While people smoke for many reasons, research has consistently shown that stress is an important contributor. HIV researchers will likely have to address such modifiable risk factors associated with smoking initiation and persistence.

As many as 1 in 2 PLWH have experienced intimate partner violence (IPV) (2,3), which is accepted to be highly stressful and indeed might contribute to the high rates of smoking. In Southern Alberta, Canada, similar to Mdodo (1) we found high rates of smoking: 29% of females (4) and 42% of gay or bisexual males (5) were current smokers. After adjusting for confounders, IPV was associated with 2.5 and 5 times increased odds for current smoking vs. never smoking for these populations, respectively. The combined cessation rate among ever-smokers was similar to the study by Mdodo et al. at 27%. However, among patients with a history of IPV, it was only 17% compared to 31% without a history of IPV (P=0.002).

We support the authors’ conclusion that interventions to reduce smoking among PLWH are essential for optimizing clinical outcomes. However, we caution that success may well depend on addressing the underlying stressors and social determinants, like IPV, that lead to smoking in the first place and to difficulty quitting thereafter. Multidisciplinary teams may increase success of smoking cessation interventions in HIV care.


1. Mdodo R, Frazier EL, Dube SR, Mattson CL, Sutton MY, Brooks JT, et al. Cigarette Smoking Prevalence Among Adults With HIV Compared With the General Adult Population in the United States: Cross-sectional Surveys. Ann Intern Med. 2015; 162:335-44.

2. Siemieniuk RA, Krentz HB, Gill MJ. Intimate partner violence and HIV: a review. Curr HIV/AIDS Rep. 2013; 10:380-9.

3. Dhairyawan R, Tariq S, Scourse R, Coyne KM. Intimate partner violence in women living with HIV attending an inner city clinic in the UK: prevalence and associated factors. HIV Med. 2013; 14:303-10.

4. Siemieniuk RA, Krentz HB, Miller P, Woodman K, Ko K, Gill MJ. The clinical implications of high rates of intimate partner violence against HIV-positive women. J Acquir Immune Defic Syndr. 2013; 64:32-8.

5. Siemieniuk RA, Miller P, Woodman K, Ko K, Krentz HB, Gill MJ. Prevalence, clinical associations, and impact of intimate partner violence among HIV-infected gay and bisexual men: a population-based study. HIV Med. 2013; 14:293-302.
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