Nicotine Replacement Aids Smoking Cessation in Program for HIV Positive Participants

By Liz Highleyman

It is well known that tobacco smoking is a risk factor for lung cancer, cardiovascular disease, and other illnesses, and several surveys have indicated that people with HIV are more likely to smoke (50%-70% in some studies) relative to the general population (20%) -- a major concern since HIV positive people taking antiretroviral therapy (ART) are already at incraesed risk for these conditions.

At the 16th Conference on Retroviruses and Opportunistic Infections (CROI 2009) last month in Montreal, Karen Tashima presented results of a study of a smoking cessation trial using a program designed for people with HIV.

The study included 444 HIV positive individuals from 8 New England clinics (referred by their physicians) who were currently smoking at least 5 cigarettes per day (mean 18). A majority (63%) were men, the average age was 42 years, about half were white, 18% were black, and 16% were Hispanic. About two-thirds had tried nicotine patches in the past and 20% had previously quit for more than a year before relapsing.

The patients were randomly assigned to participate in either 2 brief (less than 5 minute) standard intervention sessions modeled on U.S. Public Health Service guidelines (n = 232), or 4 more intensive (30 minute) motivational counseling intervention sessions, plus phone support, in the "Positive Paths" program (n = 212).

Participants were not required to set a quit date -- a recommended first step in the quitting process -- but those who did were given an 8-week supply of nicotine replacement patches. Smoking abstinence was based on self-report confirmed by biochemical testing.

Results

In total, 72% of participants completed the 6 month follow-up visit, with equal retention in each arm.

73% of participants set a quit date and 68% used nicotine replacement patches.

In an intent-to-treat (ITT) analysis at 6 months, overall quit rates were similar: 10% in the standard intervention arm and 9% in the motivationally enhanced intervention arm (P = 0.76).

Rates were also similar in an as-treated analysis of those who remained in the program at 6 months, 14% and 12%, respectively.

Quit rates differed by race/ethnicity, and the effect of the intervention also varied across these groups.

Hispanics had the highest quit rates: 19% overall (ITT), 24% in the standard intervention arm, and 14% in the motivationally enhanced arm -- a difference that reached statistical significance.

White patients had an intermediate quit rate of 8% (ITT).

Black participants had the lowest rates: 5% overall (ITT), 0% in the standard intervention arm, and 9% in the motivationally enhanced arm.

Participants who did not use nicotine patches were significantly more likely to be smoking at 6 months -- in fact, none who declined to use the patch were still abstinent (P <0.05).

In a multivariate analysis, predictors of smoking abstinence at 6 months included Hispanic ethnicity, high motivation to quit, reported "self-efficacy" (ability to resist temptation to smoke), lower Fagerstrom score (a measure of nicotine dependence), change in "decisional balance," and a supportive social network.

Based on these findings, the investigators concluded that, "6-month quit rates were low with no difference between the motivationally enhanced group and the standard care intervention group."

However, they added, "Brief and frequent contacts focused on nicotine patch use were effective in smoking cessation among HIV+ patients."

Given these results, Tashima said that more frequent contacts and an intervention longer than 6 months might have greater success. As for future directions, she suggested exploring culturally sensitive interventions, strategies to improve access and adherence to patch use, and use of smoking cessation medications such as varenicline (Chantix) or bupropion (Zyban or Wellbutrin).

3/06/09

References
K Tashima, R Niaura, E Richardson, and others. Positive Paths: A Motivational Intervention for Smoking Cessation among HIV+ Smokers. 16th Conference on Retroviruses and Opportunistic Infections (CROI 2009). Montreal, Canada. February 8-11, 2009. Abstract 148.