Evidence-Based Smoking Cessation Counseling for

HIV-Infected Patients

Julia H. Arnsten, MD, MPHChief, Division of General Internal Medicine

Associate Professor of Medicine, Epidemiology, and PsychiatryAlbert Einstein College of Medicine

Montefiore Medical Center

Submitted by the NY/NJ AETC

Background

• More than 50% of HIV-infected patients smoke• Smoking poses unique health risks to HIV-

infected patients– pulmonary infections

– oropharyngeal lesions

– AIDS-defining and non-AIDS-defining malignancies.

• “Graying” of HIV-infected population necessitates screening for and prevention of chronic disease– Coronary heart disease

– Diabetes

– Obesity

Prevalence of Current Smoking in HIV-Infected Persons in 5 Cross-Sectional Studies

2001 – 2005

0

10

20

30

40

50

60

70

80

PCHIS(n=548)

SF General(n=228)

Houston(n=348)

HCSUS(n=2,864)

NYC(n=428)

PCHIS = SF, LA, IL, NJ, NY, MI; HCSUS = 8 metropolitan areas

Prevalence of smoking among HIV-infected patients in NYC

Burkhaler et al, Tobacco use and readiness to quit smoking in low-income HIV-infected persons, Nicotine Tob Res, 2005; 7(4):511-22.

• 428 HIV+ Medicaid recipients, NYC– Age: 22-75

– 59% males

– 53% African Americans, 30% Latinos

– HS education or less : 87%

• 67% current smokers (mean = 16 cig/day)• 19% former smokers, 16% never smokers• Current smokers

– Greater use of illicit substances (ever and current)

– Lower perceived health risk of continued smoking

Adult smoking rates

NYC

2003 21.5%

2004 18.9%

USA

2003 21.6%

2004 20.7%

HIV Patients are Living Longer

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10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

1994 1995 1996 1997 1998 1999 2000 2001 2002

% o

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Distribution of HIV/AIDS Discharges by Age-group, 1994-2002 (NYS)

Source: SPARCS (Statewide Planning and Research Cooperative System)

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20%

30%

40%

50%

60%

70%

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1993 1994 1995 1996 1997 1998 1999 2000 2001

%

0-19 20-29 30-49 50+

Source: NYS Medicaid Claims Database

Distribution of Medicaid recipients with HIV/AIDS by age group, 1993-2001 (NYS)

Living Longer = Changing Morbidity and Mortality

Cancer

Lung disease

Cardiovascular disease

Cancer rates before and after HAART

AIDS-Defining and Non AIDS-Defining Malignancies (non-ADM) Before and

After HAARTBedimo, R et al. Trends in AIDS-defining and non-AIDS-defining malignancies

among HIV-infected patients: 1989-2002. Clin Inf Dis 2004;39:1380-1384

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Cancers of the larynx and oropharynx

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Source: SPARCS

Cancers of the lung/tracheaCancers of the lung/trachea

Lung disease

Chronic Bronchitis and Emphysema

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400

600

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1000

1200

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per 1

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Source: SPARCS database, NYSDOH

Cardiovascular disease

Myocardial infarction

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Holmberg et al. Trends in rates of Myocardial infarction among patients with HIVN Engl J Med 2004; 350:730-731

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1994 1995 1996 1997 1998 1999 2000 2001 2002

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Acute Myocardial Infarction

Source: SPARCS database, NYSDOH

Risk Factors Are Additive The total severity of multiple low-level risk factors often exceeds that of a single severely elevated risk factor.

8%

Grundy SM et al. J Am Coll Cardiol 1999;34:1348-1359.

BP 165/95 mm Hg BP 165/95 mm HgAge 56 years

BP 165/95 mm HgAge 56 years

LDL-C 155 mg/dL

BP 165/95 mm HgAge 56 years

LDL-C 155 mg/dLSmoker

13%

19%

27%

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Are physicians intervening in tobacco use?

Ellerbeck, Ahluwalia, et al. Direct observation of smoking cessation activities in primary care practice. J Fam Pract. 2001; 50:688-693

In 38 primary care practices:

Tobacco was discussed in 21% of encounters.

Discussion was:– more common in those practices (58%) with standard forms for

recording smoking status

– more common during new patient visits

– less common with older patients

– less common with physicians in practice more than 10 years

Barriers to treating tobacco dependence

“Not enough time.”

“Patients don’t want to hear about it.”

“I can’t help patients stop.”

“Not enough time”

“Minimal interventions lasting less than 3

minutes increase overall tobacco abstinence

rates.”

The PHS Guideline

(Strength of Evidence = A)

“Patients don’t want to hear about it”

• In several studies, smoking cessation interventions during physician visits were associated with increased patient satisfaction with care among smokers

• 1,898 patients who reported that they had been asked about tobacco use or advised to quit during the latest visit had 10% greater satisfaction rating and 5% less dissatisfaction than those not reporting such discussions Mayo Clin Proc. 2001;76:138-143

Proportion of Patients Reporting Positive Changes in Health Promoting Behavior

Following Diagnosis with HIVCollins et al, Health Psychology 2001; 20(5):351-360

0102030405060708090

100

Exercise Diet Smoking Alcohol-druguse

Proportion of Patients Interested in Quitting Smoking

Mamary et al, Cigarette smoking and the desire to quit among individuals living with HIV, AIDS Patients Care and STDs 2002; 16(1):39-42

0102030405060708090

100

Thinking aboutquitting

Interested in agroup

Interested in NRT

“I can’t help patients stop”

Effective clinical interventions exist

The Public Health Service Clinical Practice Guideline Treating Tobacco Use and Dependence was published in June, 2000 and offers effective treatments for tobacco dependence.

Summary Algorithm for Treating Tobacco Dependence

The 5 A’sFor Patients Willing To Quit

• ASK about tobacco use at every visit.• ADVISE to quit with a clear, strong, personalized

message.• ASSESS willingness to make a quit attempt within

the next 30 days.• ASSIST in quit attempt with a brief (3-5 min)

counseling intervention.• ARRANGE for follow-up (ANTICIPATE relapse).

ASK

VITAL SIGNS Blood Pressure: _______________________________ Pulse: ________________ Weight: _______________ Temperature: ________________________________ Respiratory Rate: _____________________________ Tobacco Use: Current Former Never (circle one)

EVERY patient at EVERY visit

ADVISE

• Once tobacco use status has been identified and documented, advise all tobacco users to quit

• Even brief advice to quit results in greater quit rates

• Advice should be:- clear - strong- personalized

“As your health care provider, I must tell you that the most important thing you

can do to improve your health is to stop smoking.”

ASSESS

After providing a clear, strong, and personalized message to quit, you must determine whether the patient is willing to quit at this time

“Are you willing to try to quit at this time? I can

help you.”

ASSIST• Help develop a quit plan• Provide practical counseling

– Identify events, internal states, or activities that increase the risk of smoking or relapse (e.g. drinking, other smokers).

– Identify and practice coping or problem-solving skills.– Provide basic information about smoking and successful quitting.

• Provide intra-treatment social support– Encourage the patient in the quit attempt.– Communicate caring and concern.– Encourage the patient to talk about the quitting process

• Help patient obtain extra-treatment social support• Recommend pharmacotherapy (ex. special circumstances)• Provide supplementary materials

Developing a quit plan• Set a quit date

• Review past quit attempts

• Anticipate challenges

• Remove tobacco products

• Avoid

– Alcohol use

– Exposure to tobacco

Counsel your patients to quit

“Minimal interventions lasting less than 3 minutes increase overall tobacco abstinence rates”

The PHS Guideline

(Strength of Evidence = A)

“There is a strong dose-response relation between the session length of person-to-person contact and successful treatment outcomes. Intensive interventions are more effective than less intensive interventions and should be used whenever possible”

The PHS Guideline

(Strength of Evidence = A)

Brief Intervention

• 5-15 minute counseling session• Four components

– State your concern about your patient’s behaviors (smoking, use of alcohol/drugs, diet)

– Make explicit recommendation for change in behavior

– Discuss patient’s reaction– Review treatment options; negotiate plan

ARRANGE and ANTICIPATE

• Schedule a follow-up contact within one week after the quit date– Telephone contact– Quit lines

• The majority of relapse occurs in the first two weeks after quitting

• Preventing Relapse– Congratulate success– Encourage continued abstinence– Discuss with your patient:

• benefits of quitting• barriers

• If your patient has used tobacco, remind him or her that the relapse should be viewed as a learning experience

• Relapse is consistent with the chronic nature of tobacco dependence; not a sign of failure

Relapse

“How has stopping tobacco use helped

you?.”

Cell Phone Intervention Pilot Study: Houston, Texas

Lazev et al, Increasing access to smoking cessation treatment in a low-income, HIV-positive population: The feasibility of cellular telephones. Nicotine &

Tobacco Research, 2004; 6(2):281-286.

• Pilot study of a proactive cell phone smoking cessation intervention (n=20)

• Thomas St. Clinic – 4000 medically indigent patients (mostly Black and Hispanic)

• Six scheduled cell-phone delivered counseling sessions delivered over two weeks (1 d prior to quit date, on quit date, and 2, 4, 7, and 14 d post) – average 5 min

• 24 hr/7 d/week quit line, patient info also provided• Highly successful: 95% made a quit attempt and 75% were

abstinent at 1 and 2 weeks post quit date

A Nurse-Managed, Peer-Led Cessation Intervention for HIV-Positive Smokers

Wewers et al, Jour Assn of Nurses in AIDS Care 2000; 11(6):37-44

• Randomized trial of 15 participants

• Intervention = weekly counseling sessions plus NRT

• Control group = written materials

• Follow-up: 8 weeks, 8 months

• Outcomes = point abstinence and continuous abstinence

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100

8 week 8 month

Intervent

Control

Treating patients who are not ready to make a quit attempt with Motivational Interviewing (a Form

of Brief Intervention)

• RELEVANCE: Tailor advice and discussion to each patient, avoid argument!

• RISKS: Outline specific risks of smoking.

• REWARDS: Outline the benefits of quitting.

• ROADBLOCKS: Identify barriers to quitting.

• REPETITION: Reinforce the motivational message at every visit, avoid argument!

Motivational Interviewing

Motivational interviewing is a directive, client-centered counseling style for eliciting

behavior change by helping clients to explore and resolve ambivalence.

Stephen Rollnick, William R. Miller, 1995

Rollnick, S., & Miller, W. R. What is motivational interviewing? Behavioural and Cognitive Psychotherapy. 1995;23:325-334.

Readiness to Change Model Precontemplation Relapse

Contemplation Maintenance

Preparation Action

Stages of Change in Two Populations of HIV-Infected Smokers, Compared to

General Population

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Precont Contemp Prep

New York

Houston

Gen Pop

NY: Burkhaler et al, Tobacco use and readiness to quit smoking in low-income HIV-infected persons, Nicotine Tob Res, 2005; 7(4):511-22.Houston: Gritz et al, Smoking behavior in a low-income multiethnic HIV/AIDS population, Nicotine Tob Res, 2004; 6(1):71-77.

Precontemplation

Goal is to raise doubt, increase perception/ consciousness of problemexpress concernstate the problem non-judgmentallyagree to disagreeadvise a trial of abstinence or cutting down importance of follow-up (even if still smoking/using drug

& alcohol ) less intensity is better

Samet, JH, Rollnick S, Barnes H. Arch Intern Med. 1996;156:2287-93.

ContemplationGoal is to tip the balance

elicit positive and negative aspects of smoking or drug & alcohol use

elicit positive and negative aspects of not smoking or using drugs & alcohols

summarize (patient could write these down)demonstrate discrepancies between values and actionsadvise a trial of abstinence or cutting down

PreparationGoal is to help determine the best course of action

working on motivation is not helpfulsupporting self-efficacy is (remind of strengths--i.e.

previous quits, periods of sobriety, coming to doctor)help decide on achievable goalscaution re: difficult road ahead relapse won’t disrupt relationship

ActionGoal is to help patient take steps to change

support and encouragementacknowledge discomfort (losses, withdrawal) reinforce importance of recovery

MaintenanceGoal is to help prevent relapse

anticipate difficult situations (triggers) recognize the ongoing strugglesupport the patient’s resolve reiterate that relapse won’t disrupt your relationship

RelapseGoal is to renew the process of contemplation

explore what can be learned from the relapseexpress concernemphasize the positive aspects of prior abstinence and of

current efforts to quit smoking or drug & alcohol usesupport self-efficacy

Ingredients of Effective Brief Interventions (FRAMES)

FEEDBACK of personal risk or impairment i.e. CHD, lung disease, state consequences or risks

emphasis on personal RESPONSIBILITY for change“…it’s up to you to decide…”

clear ADVICE to change identify the problem, explain why change is important,

advocate specific change

Ingredients of Effective Brief Interventions (FRAMES)

a MENU of alternativesa range of options

EMPATHIC counseling styleunderstanding and reflective

enhancement of SELF-EFFICACYreinforce it, state your belief they can do it

Physician’s Treatment Goals

• Maintain awareness of smoking (and other drug & alcohol issues)

• Ask, assess and advise about smoking• Consider smoking (and drug & alcohol problems) as

a mainstream medical issues• Counsel patients about behavior change at every

visit

SMOKING CESSATION FOR THE SECONDARY PREVENTION OF CORONARY HEART DISEASE

Critchley, J. Capewell, S. Cochrane Heart Group Cochrane Database of Systematic Reviews. 1, 2006

BACKGROUND

• Smoking is an established risk factor for coronary heart disease

• The impact of smoking cessation on risk for coronary heart disease is less well established

METHODS

• Meta-analysis to estimate the magnitude of risk reduction when a patient with CHD stops smoking

• Search: – Cochrane Register of Controlled Trials (CENTRAL),

MEDLINE, EMBASE, Science Citation Index, CINAHL, PsychLit, Dissertation Abstracts, BIDSISI Index to Scientific and Technical Proceedings, UK National Research Register

METHODS

• Selection: – Prospective cohort studies of patients with a diagnosis

of CHD, which include all-cause mortality as an outcome measure

– Smoking status measured at least twice to ascertain which smokers have quit

– Subjects followed-up for at least two years

RESULTS

• Twenty studies• Reduction in crude relative risk (RR) of mortality

for those who quit smoking compared with those who continued to smoke – RR 0.64, 95% confidence interval 0.58 to 0.71

• Reduction in non-fatal myocardial infarctions – RR 0.68, 95% confidence interval 0.57 to 0.82

RESULTSSIX HIGHEST QUALITY STUDIES

CONCLUSION

• Smoking cessation is associated with a substantial reduction in the risk of all-cause mortality among patients with CHD

• Risk reduction comparable with other secondary preventive therapies such as cholesterol lowering

• The risk reduction associated with smoking cessation consistent regardless of differences between the studies in terms of index cardiac events, age, sex, country, and time period