The results suggest that HIV-positive smokers who are interested in quitting smoke about a pack of cigarettes a day and have a moderate level of nicotine dependence. This sample also reports high levels of desire to quit and high expectations for success. These findings are consistent with the findings from other HIV-positive cohorts (Mamary, Bahrs, & Martinez, 2002
; Vidrine et al., 2006
) and similar to recent findings in work with smokers from the general community (Humfleet, Hall, & Delucchi, 2008
Two findings stand out from the others. First, these HIV-positive smokers report that almost half of the individuals in their current social support networks are smokers. Social network research indicates that smoking appears to be maintained through social ties, that smokers tend to be marginalized socially, and that inter-connected people tend to quit as a group (Christakis & Fowler, 2008
). Treatment research suggests that provision of intratreatment and extratreatment social support predicts successful quitting (Fiore et al., 2000
). Although many smoking cessation programs provide intratreatment support through individual or group counseling, it may be particularly important to address the issue of extratreatment support with HIV-positive smokers. In addition to evaluating smoking cessation treatment on the individual level, future research with this population might benefit by focusing on interventions that modify the smokers' social network or target small interrelated groups. Second, less that half of the smokers in this sample chose a treatment goal of total abstinence with a significant proportion choosing a treatment goal that included some allowance for occasional or controlled tobacco use. The proportion choosing a total abstinence goal is significantly lower than we have found in general community cohorts (Humfleet et al., 2008
). This finding is significant because previous research has indicated that selecting a total abstinence goal is one of the strongest predictors of treatment success across a variety of drugs of dependence, including alcohol, opiates, and nicotine (Hall et al., 1990
). Although there are multiple possible explanations for this finding (low self-efficacy, lower motivation, etc.), a few may be particularly relevant to the study population. Treatment goals may be influenced by health status with those most physically impacted by HIV disease having less stringent goals. Recreational use of other drugs may also impact the smoker's abstinence goal. In addition, one might speculate that smoking cessation treatment goals of HIV-positive smokers could be influenced by the harm reduction model that is emphasized in many HIV risk reduction programs. In that case, smokers may be more likely to perceive reduced tobacco use as a healthier alternative to ongoing regular use. Exploration of specific treatment goals may be an important element of any smoking cessation intervention with this group. Further research is this area is warranted.
This group of smokers faces a variety of psychological, environmental, and economic challenges. Many of these characteristics are associated with high risks for smoking and lower levels of treatment success. A large proportion of this sample was unemployed, had extremely low incomes, and had unstable living situations. In addition, a significant proportion of the sample report current alcohol and illicit drug use which have been associated with smoking treatment failure (Humfleet, Munoz, Sees, Reus, & Hall, 1999
). Participants also had high rates of lifetime major depressive episodes, bipolar disorders, and alcohol dependence, all associated with tobacco use.
Somewhat surprisingly, we found few differences as a function of treatment site. Although there is no evidence to predict differences on demographics or tobacco use variables, one might expect higher rates of illicit substance use and mental health diagnoses from a cohort recruited from a mental health treatment clinic as compared to one recruited from a medical setting. However, we found no significant differences on current use of most drugs, including alcohol, opiates, barbiturates, cocaine, amphetamines, or cannabis, nor did we find a difference on rates of treatment for alcohol or drug dependence. Given these findings and the known association of substance use with increased risks for HIV infection, addressing illicit drug use as a part of smoking treatment may be important regardless of the treatment setting.
We were particularly struck by the high rate of bipolar disorders. Although it appears that overall rate of bipolar disorders may have been biased by recruiting from a mental health clinic, the rates of bipolar disorder from the medical clinic sample (15.2%) remain much higher than the rates of bipolar disorder in the general population (1.6%) (American Psychiatric Association, 2000
). Research on smoking cessation interventions with bipolar cigarette smokers may provide valuable strategies that may be applicable to the treatment of some HIV-positive smokers.
Given the multiple psychological, social, economic, and medical needs of this group of smokers, low-cost, generic smoking cessation interventions may be ill suited to this population. It is critical to develop and evaluate smoking cessation interventions that consider the potential psychosocial-environmental barriers faced by HIV-positive smokers and incorporate treatment strategies that address the influence of these variables. Findings from our current trial, which includes interventions that have been designed to address some of the psychosocial needs of this group of smokers, will help to improve our understanding of this high-risk group and can inform future research directions.
This study has several limitations. The sample size limits the generalizability of the findings and points to the need to examine these characteristics in additional treatment samples. Because the participants were recruited through public health care settings, the results may not generalize to all HIV-positive smokers, particularly those who are employed and have private health insurance. However, studies have shown that 70%-84% of HIV-positive individuals in the United States have public health insurance or no insurance (Bozzette et al., 1998
; Fleishman et al., 2005
). Therefore, the current findings may generalize to a significant proportion of HIV-positive smokers in the United States.