Racial disparities and factors associated with prescription for smoking cessation medications among smokers receiving routine clinical care for HIV.

Factors associated with prescription of smoking cessation medication (SCM), including the impact of race, have not been well described among a large population of people living with HIV (PLWH) engaged in routine clinical care. Our study investigated whether there are racial differences between African-American and White PLWH regarding SCM prescription and sought to identify other factors associated with these prescriptions at a large HIV clinic in the Southeastern United States. Among 1899 smokers, 38.8% of those prescribed SCMs were African-American and 61.2% were White. Factors associated with lower odds of SCM prescription included African-American race (AOR, 0.63 [95% CI: 0.47, 0.84]) or transferring care from another HIV provider during the study period (AOR, 0.63 [95% CI: 0.43, 0.91]). Whereas major depression (AOR, 1.54 [95% CI: 1.10, 2.15]), anxiety symptoms (AOR, 1.43 [95% CI: 1.05, 1.94]), and heavy smoking (>20 cigarettes/day) (OR, 3.50 [95% CI: 2.11, 5.98]) were associated with increased likelihood of SCM prescription. There were racial disparities in the prescription of SCM in African Americans with HIV. These findings underscore the need to increase pharmacotherapy use among African Americans to improve smoking cessation outcomes across racial groups among PLWH.

Mental health disorders and alcohol use are associated with increased likelihood of smoking relapse among people living with HIV attending routine clinical care.

BACKGROUND: People living with HIV (PLWH) have a high level of interest in quitting smoking, but only a small proportion have sustainable abstinence 6 months after cessation. Few investigations have focused on relapse to smoking among PLWH. In this investigation, we evaluated the prevalence of relapse after smoking cessation and the characteristics associated with smoking relapse using a retrospective, longitudinal cohort of PLWH during an eight-year observation. METHODS: All patients aged ≥19 years that reported current smoking during the study period and then reported not smoking on a subsequent tobacco use questionnaire (quitters) were eligible for the study. In addition, patients required at least one subsequent follow-up visit after quitting where smoking status was again reported to allow for assessment of relapse. A Cox proportional hazard model was fit to evaluate factors associated with smoking relapse in PLWH attending routine clinical care. RESULTS: Of the 473 patients who quit smoking in the study, 51% relapsed. In multivariable analysis, factors significantly associated with a higher likelihood of relapse were anxiety symptoms (HR = 1.55, 95% CI [1.11, 2.17]) and at-risk alcohol use (HR = 1.74, 95% CI [1.06, 2.85]), whereas antiretroviral therapy (ART) adherence (HR = 0.65, 95% CI [0.49, 0.99]) and longer time in care (HR = 0.94, 95% CI [0.91, 0.98]) were associated with a reduced likelihood of relapse after cessation. CONCLUSION: Our study underscores the high prevalence of smoking relapse that exists among PLWH after they quit smoking. Successful engagement in mental health care may enhance efforts to reduce relapse in the underserved populations of PLWH.

Predictors of smoking cessation among people living with HIV receiving routine clinical care.

People living with HIV (PLWH) have a higher prevalence of smoking and are less likely to quit smoking than the general population. Few studies involving a large sample of PLWH receiving routine care have evaluated factors associated with smoking cessation. This retrospective longitudinal cohort study evaluated factors associated with smoking cessation among PLWH from 2007 to 2018. Of 1,714 PLWH smokers included in the study, 27.6% reported quitting smoking. Suppressed plasma HIV-1 RNA (<200 copies/ml) was significantly associated with an increased likelihood of smoking cessation (HRadjusted = 1.27, 95% CI [1.03, 1.58]); whereas age/10 year increments (HRadjusted = 0.12, 95% CI [0.04, 0.38]), greater length of care at the HIV clinic (HRadjusted = 0.97, 95% CI [0.94, 0.99]), lack of insurance (HRadjusted = 0.77, 95% CI [0.61, 0.99]) or having public insurance (HRadjusted = 0.74, 95% CI [0.55, 0.97)]), current substance use (HRadjusted = 0.66, 95% CI [0.43, 0.97]) and risk of developing alcohol use disorder (HRadjusted = 0.60, 95% CI [0.43, 0.84]) were associated with a reduced likelihood of quitting smoking. These findings underscore the importance of early smoking cessation intervention among PLWH. In addition, targeted smoking cessation intervention strategies are needed for groups at risk for being less likely to quit, including older patients, and those with alcohol and substance use disorders.

The impact of non-concordant self-report of substance use in clinical trials research.

BACKGROUND: Studies comparing self-report substance use data to biochemical verification generally demonstrate high rates of concordance. We argue that these rates are due to the relatively high true negative rate in the general population, and high degree of honestly in treatment seeking individuals. We hypothesized that high risk individuals not seeking treatment would demonstrate low concordance and a high false negative rate of self-reported substance use. METHODS: A sample of 500 individuals from a smoking cessation clinical trial was assessed over 1 year. Assessments included semi-structured interviews, questionnaires (e.g. Addiction Severity Index, etc.), and urine drug screen assays (UDS). Generalized estimating equations (GEEs) were used to predict false negative reports for various substances across the study and determine the influence of substance use on the primary study outcome of smoking cessation. RESULTS: Participants demonstrated high false negative rates in reporting substances use, and the false negative rates increased as the study progressed. Established predictors of false negatives generalized to the current sample. High concordance and low false negative rates were found in self-report of nicotine use. A small but significant relationship was found in for effect of biochemically verified substance use on smoking cessation. CONCLUSIONS: Biochemical verification of substance use is needed in high risk populations involved in studies not directly related to the treatment of substance use, especially in populations with high threat of stigmatization. Testing should continue through the time period of the study for maximal identification of substance use.

Factors Associated With Smoking Status among HIV-Positive Patients in Routine Clinical Care.

BACKGROUND: Treatment-related reductions in morbidity and mortality among human immunodeficiency virus (HIV)-positive patients have been attenuated by cigarette smoking, which increases risk of cardiovascular, respiratory, and neoplastic diseases. This study investigated factors associated with smoking status among HIV-positive patients. METHODS: This cross-sectional study included 2,464 HIV-positive patients attending the HIV Clinic at the University of Alabama at Birmingham between April 2008 and December 2013. Smoking status (current, former, never), psychosocial factors, and clinical characteristics were assessed. Multinomial logistic regression was used to obtain unadjusted and adjusted odds ratios (OR) and 95% confidence intervals (CI) for the association of the various factors with smoking status. RESULTS: Among HIV-positive patients (mean age 45 years, 75% male, 55% African-American), the majority reported a history of smoking (39% current and 22% former smokers). In adjusted models, patient characteristics associated with increased odds of current smoking were male gender (OR for heterosexual men, 1.8 [95% CI: 1.3-2.6]; for men who have sex with men, 1.5 [1.1-1.9]), history of respiratory diseases (1.5 [1.2-1.9]), unsuppressed HIV viral load (>50 copies/mL) (1.5 [1.1-1.9]), depression (1.6 [1.3-2.0]), anxiety (1.6 [1.2-2.1]), and prior and current substance abuse (4.7 [3.6-6.1] and 8.3 [5.3-13.3] respectively). Male gender, anxiety, and substance abuse were also associated with being a former smoker. CONCLUSIONS: Smoking was common among HIV-positive patients, with several psychosocial factors associated with current and former smoking. This suggests smoking cessation programs in HIV clinic settings may achieve greater impact by integrating interventions that also address illicit substance abuse and mental health.