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A Real Smoking Gun: Cigarettes, HIV and Cancer
By BA Laris, MPH | February 26, 2019
I learned so much when I attended last December’s HIV Endgame 3: Breakthrough Initiative Research Conference. I wrote previously about some of the outstanding work being done by the hosts, the Ontario HIV Treatment Network (OHTN).
One of the most informative plenary sessions for me was presented by Dr. Irv Salit, Director, of the Immunodeficiency Clinic at Toronto General Hospital. His research focuses on clinical and epidemiological studies on HIV/AIDS, both in Toronto and internationally. This includes effectiveness of antiretroviral therapy, outcomes, compliance and risk factors for disease progression.
Higher Cancer Rates for People Living with HIV
Dr. Salit’s presentation called attention to the recent research on cancer and HIV. Today, cancer is the leading cause of death of people living with HIV (PLWH). A study published in the Annals of Internal Medicine showed that between 1996 and 2009, there was a 50% increase in cancers of people living with HIV compared to the general population. Non-AIDS-related cancer deaths increased from 11% to 22%. PLWH had higher rates for 4 out of 5 forms of cancer.
Smoking and Cancer Risk in PLWH
The advances in antiretroviral treatments have enabled people living with HIV to live longer and healthier lives. However, PLWH who smoke have a higher risk of developing cancer than smokers who do not have HIV.
A 2017 study of lung cancer mortality and smoking among PLWH underscored the deadly combination of smoking and HIV. PLWH who use tobacco reduce their life expectancy by at least 16 years. Smoking is a known risk factor for the most common non-AIDS-related cancers:
- lung cancer
- anal cancer
- oral cancer
- cervical cancer
- vulvar cancer
- penile cancer
HIV independently increases the risk of lung cancer. Tobacco use and HIV together may accelerate the development of lung cancer due to chronic inflammation, immune system changes, and a range of infections common in PLWH. An estimated 40-75% of PLWH in the United States smoke cigarettes (compared with 14% of the general adult population).
PLWH who adhere to their antiretroviral medication but smoke are substantially more likely to die from lung cancer than from AIDS-related causes. In fact, lung cancer is the leading cause of death in this population.
Anal cancer is the second leading cause of death in PLWH. There are three primary risk factors associated with anal cancer: HPV, smoking and HIV. In his presentation, Dr. Salit explained that although anal cancer is prevalent and deadly, many providers do not conduct screening—despite the fact that they commonly conduct routine screening for other less common cancers.
Screening and Prevention
Given these statistics, what can we do? To prevent lung cancer, the best option is to stop smoking. The risk goes down when individuals stop smoking.
To prevent anal cancer, the best option is to increase screening and stop smoking.
Why Not Just Quit?
PLWH smoke at rates substantially higher than the general population. The majority of these smokers are interested in quitting and many have tried to quit. A review of cessation studies reveals that a variety of cessation modalities have been tried with PLWH, with limited success.
There are many different types of smoking cessation interventions (individual and group counseling, quit helplines, websites and apps, nicotine replacement therapy, and combinations of these approaches). Smokefree.gov provides an overview of many quit methods to help smokers understand and select the strategies that will work for them. The California Tobacco Control Branch and many other state and local health departments provide cessation resources and services.
However, there has been very little research exploring effective smoking cessation interventions for PLWH, particularly approaches which take into account co-morbidities and other implications of living with HIV.
Recently, the National Cancer Institute developed a position paper to validate the need for randomized clinical trials designed to work specifically with PLWH who smoke to examine the effectiveness of three types of cessation programs:
- Medications and behavioral interventions
- Motivational interviewing and educational approaches
- Social support networks
In response, funding was recently made available through the National Institutes of Health for Improving Smoking Cessation Interventions among PLWH.
Supporting PLWH: Quitting is Possible
As family, friends, co-workers and providers of PLWH, we can help people quit cigarettes, reduce their cancer risk, and prolong a healthy life. The Tobacco Education Clearinghouse of California, a project managed by ETR, has a wide array of products and materials to help understand tobacco and support cessation. (Most of these cite California resources, but many include national quit line numbers as well.)
Here are a few specific ideas:
- Family and friends. Learn about smoking cessation to support your loved ones. The California Smokers' Helpline has lots of easy-to-use resources.
- HIV workforce. HIV Test counselors, educators, peer navigators, linkage specialists and case managers work hard to create positive and caring relationships with clients. It is important for you to help your clients understand the link between smoking and HIV morbidity and mortality as you support them in their HIV prevention, care and treatment. Although there are limited interventions specifically for HIV and smoking, there are many other resources from the CDC that can help.
- Health care providers. PLWH on antiretroviral medications have regular medical visits with their care providers. This is an opportunity to help educate individuals about the severity of the impact of smoking and actively promote cessation options. Free training is available here.
- Pharmacists: PLWH on antiretroviral medications have a regular pharmacist for their HIV medication. Trained pharmacists are able to provide nicotine replacement therapy products. You can find specific information for pharmacists here.
Smoking and HIV are a deadly combination. We can all find ways to help educate and provide cessation support to people living with HIV.
BA Laris, MPH, is a Program Manager and Research Associate with ETR. Her work experience includes program planning, management and evaluation in the areas of HIV/AIDS, substance use prevention and treatment, and international health.
