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. Author manuscript; available in PMC: 2015 May 1.
Published in final edited form as: Drug Alcohol Depend. 2014 Feb 15;138:220–224. doi: 10.1016/j.drugalcdep.2014.02.008

Interest in quitting and lifetime quit attempts among smokers living with HIV infection

Lauren R Pacek 1,2,*, Carl Latkin 3,4, Rosa M Crum 1,2,4, Elizabeth A Stuart 2,5, Amy R Knowlton 3
PMCID: PMC4015183  NIHMSID: NIHMS572854  PMID: 24602364

Abstract

Introduction

Cigarette smoking is highly prevalent among people living with HIV, and is associated with many negative health outcomes, including death. There is little research on smoking behaviors such as interest in quitting and lifetime quit attempts among smokers living with HIV. Existing research has focused on individual-level characteristics, to the neglect of social environmental characteristics. We explored individual- and social-level characteristics associated with interest in quitting and lifetime nicotine replacement (NRT) or medication use for smoking cessation.

Methods

Data are from a study of participants recruited from clinic and community venues originally designed to examine social environmental influences on current/former drug users’ HIV medication adherence and health outcomes. This analysis comprised 267 current smokers living with HIV. Chi-square tests were used to describe the sample; logistic regression was used to explore associations between covariates and outcomes.

Results

In adjusted analyses, older age (age 54–65: aOR=4.64, 95% CI=1.59–13.47) and lifetime use of NRT/medications (aOR=2.02, 95% CI=1.08–3.80) were associated with an interest in quitting smoking. Additionally, older age (age 45–49: aOR=3.38, 95% CI=1.57–7.26; age 54–65: aOR=2.70 95% CI=1.20–6.11), White race (aOR=3.56, 95% CI=1.20–10.62), and having a Supporter who had used NRT/medications for cessation (aOR=2.13, 95% CI=1.05–4.29) were associated with lifetime NRT/medications use.

Conclusions

Findings corroborate prior research concerning individual-level characteristics, and indicate the importance of social-level characteristics in association with prior use of NRT/medications for cessation. Findings have implications for the implementation of cessation interventions for smokers living with HIV.

Keywords: cigarette smoking, HIV/AIDS, social environment, social support, informal caregiving, multiple imputation

1. INTRODUCTION

The prevalence of smoking has declined among the US general population (Centers for Disease Control, 2012), but remains highly prevalent among people with HIV (40–70%; Gritz et al., 2004; Mamary et al., 2002; Burkhalter et al., 2005; Crothers et al., 2005; Lifson et al., 2010). Accordingly, smoking-related conditions have increasingly emerged among this group (Diaz et al., 2002; Crothers et al., 2006; Lifson et al., 2010; Miguez-Burbano et al., 2005; Kirk et al., 2007; Petoumenos et al., 2011; Friis-Møller et al., 2003). A Danish study found that HIV-infected smokers lose more life-years to smoking than to HIV (Helleberg et al., 2013) and among an international cohort 24% of deaths in the HAART era were attributable to tobacco use (Lifson et al., 2010).

Promoting smoking cessation is essential. In one study, 81% of smokers with HIV reported receiving medical advice to quit smoking (Burkhalter et al., 2005). Additionally, research indicates that most (63%–75%) smokers with HIV are interested in or thinking about quitting (Mamary et al., 2002; Tesoriero et al., 2010).

Research on cessation aid use and factors influencing interest in cessation among people with HIV is scarce. Among one sample, drug use, greater emotional distress, and fewer prior quit attempts were associated with less interest in quitting (Burkhalter et al., 2005). In other populations (e.g., homeless; injection drug users; methadone maintenance patients), self-efficacy for quitting, smoking-related health symptoms (Arnsten et al., 2004), older age, absence of alcohol abuse (Clarke et al., 2001), lower nicotine dependence, and lifetime cessation pharmacotherapy use (Nahvi et al., 2006) were associated with an interest in quitting.

Little research has explored factors associated with an interest in quitting and use of cessation aids among smokers with HIV. Previous research has focused on individual-level factors, like age and drug use, to the exclusion of social-level factors. Social factors are associated with drug use and medication adherence behaviors (Knowlton et al., 2006; Magura et al., 2011), and may influence interest in quitting or quit attempts.

The aim of this study was to examine individual- and social-level characteristics and their association with two outcomes: interest in quitting smoking and lifetime use of nicotine replacement therapy (NRT) or medications for cessation among smokers with HIV. A second aim was to explore the types of interventions that current smokers were interested in utilizing.

2. METHODS

2.1 Data Source

Data came from the BEACON Study, described previously (Pacek et al., 2013). Briefly, the study recruited: 1) Index participants on antiretroviral therapy who were current/former injection drug users; and 2) Supporter participants (i.e., individuals who provided social support to the Index participants), recruited with authorization from Index participants. This sample includes 267 Index participants who reported current smoking. The Institutional Review Board at Johns Hopkins University Bloomberg School of Public Health approved this study.

2.2 Measures

2.2.1 Individual-level variables

Sociodemographic variables included sex, age (28–44; 45–49; 50–53; 54–65), race (Black/White), past-month income (<$500/>$500), and marital status. Past-month use of drugs and alcohol and 12-step program use were assessed (yes/no) and a composite variable for “any past-month drug use,” excluding alcohol was created. Depressive symptoms were assessed with the Center for Epidemiologic Studies Depression Scale (CES-D; Radloff, 1977); a score of 16+ identified individuals with clinically meaningful depressive symptoms (Radloff, 1977). HIV primary care visits in the past 6 months was broken into approximate tertiles (0–2; 3–4; 5+).

2.2.2 Cigarette smoking variables

Smokers reported the number of cigarettes smoked per day (i.e., CPD: <1; 1–10; 11–20; 21+), time to first cigarette (TTFC) upon waking (i.e., <=30 minutes; 31–60 minutes; 60+ minutes), and lifetime NRT/medications use (yes/no). The Heaviness of Smoking Index (HSI) (Heatherton et al., 1989), a measure of nicotine dependence, was conceptualized as a 3-level variable: low, medium, high (Chaiton et al., 2007).

2.2.3 Dyadic-level variables

Dichotomous variables were created based on Supporters’ responses to questions regarding: 1) smoking status, 2) interest in quitting, and 3) lifetime NRT/medication use. 169 Index participants (63%) had a main Supporter who participated in the study.

2.2.4 Family-level variables

Index participants answered the following questions: “How many of your family [smoke cigarettes; encourage you to smoke; believe that smoking causes health problems; dislike smoking; have rules about smoking within their home]?” Responses included “none”, “some”, “most”, “all”. Dichotomous variables were created (none/any).

2.2.5 Statistical Analysis

Analyses were performed using STATA SE version 12.0 (StataCorp, 2011). Chi-square (χ2) tests were used to assess the statistical significance between individual-level, dyadic-level, and family-level variables with outcomes: 1) interest in quitting smoking; and 2) lifetime NRT/medication use. Since 37% of Index participants did not have a participating Supporter, missing data were correspondingly high for the following variables: Supporter smoking status, Supporter interest in quitting, and Supporter’s lifetime NRT/medication use. We used a multiple imputation by chained equations approach (“mi impute chained” STATA commands) with 100 imputations, and incorporated these covariates: sex, age, race, marital status, income, nicotine dependence, past-month drug use, past-month alcohol use, past 6 month 12-step program use, CESD score, family smoking, smoking status, interest in quitting, and lifetime NRT/medication use. Using “mi estimate, or: logistic” commands, unadjusted and adjusted logistic regression analyses were used to calculate unadjusted (ORs) and adjusted (aORs) odds ratios and 95% confidence intervals (CIs). Variable selection for adjusted models was based on prior literature, a priori theory, and χ2 p-values <0.05. Variables selected for the adjusted model concerning interest in quitting included: sex, age, race, income, marital status, nicotine dependence, past-month drug use, lifetime NRT/medication use, Supporter smoking, and Supporter interest in quitting. Variables selected for the adjusted model concerning lifetime NRT/medication use included: sex, age, race, income, marital status, nicotine dependence, and Supporter’s lifetime NRT/medication use.

3. RESULTS

3.1 Participant characteristics

Most participants were interested in quitting smoking (74%), reported lifetime NRT/medication use (59%), male (60.3%), and the average age was 48.6 years (SE=0.37). The majority was Black (90.6%), reported a monthly income of $500+ (81.6%), and not married (68.2%). There were 39% with a CESD score of 16+, and 42.3% had 0–2 HIV primary care visits in the past 6 months. Forty-one percent reported past-month alcohol use, 50.9% past-month drug use, and 55.8% reported 12-step program participation within the past 6 months.

Among Index participants with participating Supporters, 78.1% had a Supporter who currently smoked, 58.6% had a Supporter interested in quitting, and 38.5% had a Supporter with lifetime NRT/medication use. The majority reported that their family: included smokers (85.4%), encouraged them to quit (85.1%), believed that smoking causes health problems (97.4%), dislikes smoking (89.1%), and has rules about smoking within their home (86.9%). Few (8.2%) reported that their family encourages smoking.

Index participants interested in quitting were older (χ2 (1, N=267) = 15.10, p = 0.002), less likely to have past-month drug use (χ2 (1, N=267) = 7.38, p = 0.039), and more likely to have lifetime NRT/medication use (χ2 (1, N=267) = 4.28, p = 0.007) as compared to those not interested in quitting. In terms of differences between those who had ever used NRT/medications and those who had not, lifetime users were more likely to be White (χ2 (1, N=267) = 4.79, p = 0.029) and to have a Supporter with lifetime NRT/medication use (χ2 (1, N=169) = 4.15, p = 0.042).

3.2 Smoking characteristics

Most smokers (75.7%) smoked 1–10 CPD, and had a TTFC within 30 minutes of waking (64.0%) (Table 1). More than half (64.1%) exhibited a medium-level of nicotine dependence.

Table 1.

Smoking characteristics (n=267) and interest in various smoking cessation modalities (n=199) among current smokers living with HIV (BEACON study, Baltimore, MD, 2006–2012)

Smoking characteristics n %
Cigarettes per day
 <1 2 0.7
 1–10 202 75.7
 11–20 60 22.5
 21–30 1 0.4
 31+ 2 0.7
Time to first cigarette
 <−30 minutes 171 64.0
 31–60 minutes 25 9.4
 60+ minute 71 26.6
Nicotine dependencea
 Low 93 34.8
 Medium 171 64.1
 High 3 1.1
Cessation Modality n %
Nicotine replacementb,c
 No 19 26.0
 Maybe 25 34.3
 Yes 29 39.7
Pills/medicined,e
 No 64 35.2
 Maybe 59 32.4
 Yes 59 32.4
With a family member
 No 59 29.6
 Yes 140 70.4
With a friend
 No 53 26.6
 Yes 146 73.4
With main partnerf
 No 28 25.0
 Yes 84 75.0
In a group
 No 40 20.1
 Yes 159 79.9
Group + someone you know
 No 19 11.9
 Yes 140 88.1
Open in a new tab
a

According to the Heaviness of Smoking Index

b

Includes products like nicotine gum, nicotine patches, inhalers, or lozenges

c

Among those who were interested in quitting/cutting down on smoking and had not tried nicotine replacement methods in the past (n=73)

d

Includes products for reducing cigarette cravings, like Zyban, Wellbutrin, or Chantix (Bupropion or Varenicline)

e

Among those who were interested in quitting/cutting down on smoking and had not tried pills/medicine in the past (n=182)

f

Among those with a main partner (n=112)

3.3 Interest in smoking cessation

Of those interested in quitting, most were interested in participating in a smoking cessation intervention with a family member (70.4%), friend (73.4%), main partner (75.0%), in a group (79.9%), or in a group with someone they knew (88.1%) (Table 1). Of those who had not utilized NRT, 39.7% were interested in trying NRT. Of those who had not utilized pills/medications, 32.4% were interested in trying pills/medications.

3.4 Logistic regression analyses

When examining interest in quitting smoking, older individuals (54–65 versus 28–44; aOR=4.64, 95% CI=1.59–13.47), and those with lifetime NRT/medication use (aOR=2.02, 95% CI=1.08–3.80) were more likely to be interested in quitting (Table 2). In terms of lifetime NRT/medications use, older age (45–49 versus 28–44: aOR=3.38, 95% CI=1.57–7.42; 54–65: aOR=2.70, 95% CI=1.19–6.11), White race (aOR=3.56, 95% CI=1.20–10.62), and having a Supporter with lifetime NRT/medication use were associated with lifetime use (aOR=2.13, 95% CI=1.05–4.29).

Table 2.

Unadjusted and adjusted odds ratios to assess the association of characteristics with interest in quitting smoking and lifetime use of NRTa/medicationsb for cessation among a sample of smokers living with HIV (BEACON study, Baltimore, MD, 2006–2012; n=267)

Interest in quitting vs. no interest Lifetime use of NRT/meds vs. no use
aORc,d (95% CIe) aORc,f (95% CIe)
Sex
 Male 1.0 1.0
 Female 1.04 (0.55–1.98) 1.27 (0.71–2.28)
Age
 28–44 1.0 1.0
 45–49 1.69 (0.77–3.69) 3.38 (1.57–7.26)
 50–53 1.81 (0.79–4.14) 1.92 (0.89–4.16)
 54–65 4.64 (1.59–13.47) 2.70 (1.19–6.11)
Race
 Black 1.0 1.0
 White 1.30 (0.45–3.78) 3.56 (1.20–10.62)
Income
 <$500 1.0 1.0
 $500+ 0.77 (0.35–1.72) 1.22 (0.93–1.62)
Marital status
 Not married 1.0 1.0
 Married 0.74 (0.39–1.41) 0.65 (0.37–1.41)
Nicotine dependenceg
 Low 1.0 1.0
 Medium-high 0.58 (0.30–1.13) 1.44 (0.82–2.52)
Drug use
 No 1.0 --h
 Yes 0.59 (0.32–1.13) --h
Lifetime NRT/med use
 No 1.0 --h
 Yes 2.02 (1.08–3.80) --h
Supporter smokes
 No 1.0 --h
 Yes 0.58 (0.19–1.81) --h
Supporter interested in quitting
 No 1.0 --h
 Yes 1.30 (0.50–3.36) --h
Supporter lifetime NRT/med use
 No --h 1.0
 Yes --h 2.13 (1.05–4.29)
Open in a new tab
a

NRT = nicotine replacement therapy; includes products like nicotine gum, nicotine patches, inhalers, or lozenges

b

Includes products for reducing cigarette cravings, like Zyban, Wellbutrin, or Chantix (Bupropion or Varenicline)

c

aOR = adjusted odds ratio

d

Adjusted for sex, age, race, income, marital status, nicotine dependence, past 30 day drug use, lifetime use of NRT/medications for cessation, Supporter smoking, and Supporter interest in quitting

e

CI = confidence interval

f

Adjusted for sex, age, race, income, marital status, nicotine dependence, and Supporter lifetime use of NRT/medications for cessation

g

According to the Heaviness of Smoking Index

h

Covariate was not included in final adjusted model

4. DISCUSSION

This study identified individual- and social-level characteristics associated with an interest in quitting smoking and lifetime NRT/medication use among smokers with HIV. The individual-level characteristics of older age and use of NRT/medications were associated with an interest in quitting smoking. Older age and White race were associated with lifetime NRT/medication use.

Both associations (i.e., older age, NRT/medication use) with interest in quitting are consistent with literature in other populations (Clarke et al., 2001; Nahvi et al., 2006). The finding concerning lifetime NRT/medication use and interest in quitting, is congruent with prior research (Nahvi et al., 2006), and not surprising; actual quit attempts are associated with prior quit attempts (Zhou et al., 2009; Hagimoto et al., 2009; Vangeli et al., 2011). It logically follows that quit attempts correlate with an interest in quitting. Both individual-level findings associated with lifetime NRT/medications use (i.e., older age, White race) are consistent with prior research in other populations (Li et al., 2010, 2011; Fu et al., 2005; Zhu et al., 2000). Older smokers likely have a longer smoking history than younger smokers, allowing for more time to use cessation aids, and may also be more likely to have smoking-related health sequelae that prompt cessation attempts. Racial disparities were not explained by factors measured in this study. Research has found racial disparities in use of services and physician treatment among Medicare recipients (Gornick et al., 1996) and others with access to health care (Bach et al., 2004). Additional research is needed to explore racial/ethnic disparities in uptake of NRT/medications, particularly where socioeconomic status factors are concerned.

A novel outcome includes finding that Index participants with a main Supporter with lifetime NRT/medication use were more likely to have used NRT/medications themselves. This points to the potential importance of social characteristics in influencing smoking behaviors among people with HIV. Coupled with the high interest in cessation modalities involving a social component, this finding has implications for the development of novel social cessation interventions.

This study has several limitations: it utilizes cross-sectional, self-report data, and did not contain questions about quit attempts using other cessation aids, unassisted attempts, or success of past quit attempts. Additionally, the survey did not assess the degree of interest, or intentions to quit within a specified time frame. This study has a number of strengths to note as well. Most prior work has focused on characteristics associated with current smoking status; we focused on two additional smoking behaviors: interest in quitting and lifetime NRT/medication use. This study extends the literature by also investigating social environmental variables associated with smoking behaviors. Multiple imputation minimized measurement biases arising from missing data and allowed for greater statistical power that would have been lost with a complete case analysis.

Findings from this study corroborate research among other populations showing that individual-level characteristics are associated with smoking behaviors. Results extend existing research by demonstrating that social-level characteristics are also associated with smoking behaviors among a sample of smokers with HIV. Findings suggest that members of an individual’s social network may influence their smoking behaviors. Ultimately, characteristics traditionally associated with smoking cessation attempts are associated with attempts among smokers with HIV. Strategies successfully employed in other populations may be of utility among people with HIV and should be tailored to smokers with HIV (Encrenaz et al., 2010), accounting for factors such as substance use/disorders and mental health comorbidities that are highly prevalent among this group, as well as varying types and quality of social support that members of this group may possess. Additionally, although findings from cessation interventions that incorporate a social support component have been somewhat mixed (May and West, 2000; Westmaas et al., 2010), social interventions may be attractive to this population and should be explored in future investigations.

Acknowledgments

Role of Funding Source

This work was funded by the following National Institute on Drug Abuse (NIDA) grants: F31#DA033873 (Pacek), R01 DA032217-02S1 (Latkin), and R01 DA019413 (Knowlton).#

Footnotes

Contributors

Author Pacek conceptualized the research question and wrote the first draft of the manuscript. Authors Pacek and Stuart undertook the statistical analyses. Authors Pacek, Latkin, Crum, Stuart, and Knowlton contributed to subsequent drafts of the manuscript. All authors have contributed to and have approved the final manuscript.

Conflict of Interest

The authors have no conflicts of interest to declare.

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