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. Author manuscript; available in PMC: 2015 Jan 22.
Published in final edited form as: AIDS Care. 2014 Mar 7;26(9):1201–1207. doi: 10.1080/09540121.2014.892565

Healthcare provider intervention on smoking and quit attempts among HIV-positive versus HIV-negative MSM smokers in Chengdu, China

Carla J Berg a,b, Eric J Nehl a, Xiaodong Wang c, Yingying Ding d, Na He a,d,*, Brent A Johnson e, Frank Y Wong a,b
PMCID: PMC4303341  NIHMSID: NIHMS654872  PMID: 24601710

Abstract

Given the implications for smoking among HIV-positive individuals and high smoking and HIV rates among men who have sex with men (MSM) in China, we examined sociodemographic, smoking-related, psychosocial, and substance use factors in relation to HIV status; receiving some sort of healthcare provider intervention regarding smoking; and having made a quit attempt in the past year in a sample of MSM smokers in Chengdu. We conducted a cross-sectional survey of 381 MSM smokers recruited by a nongovernmental organization in Chengdu in 2012–2013. Of these, 350 disclosed their HIV status and 344 (188 HIV-positive and 156 HIV-negative) provided completed data. Half (50.0%) reported at least one quit attempt in their lifetime; 30.5% reported a quit attempt in the past year. The majority (59.4%) reported that a healthcare provider had intervened in some way (assessed smoking, advised quitting, provided assistance), most commonly by assessing smoking status (50.0%). HIV-positive individuals were more likely to report a healthcare provider intervening on their smoking (p < .001). Those who received provider intervention were more likely to have attempted to quit ever (p = .009) and in the past year (p < .001). Those HIV-positive were more likely to have attempted to quit since diagnosis if a provider had intervened (p = .001). Multivariate regression documented that being HIV-positive (p < .001), greater cigarette consumption (p = .02), less frequent drinking (p = .03), and greater depressive symptoms (p = .003) were significant correlates of healthcare provider intervention. Multivariate regression also found that healthcare provider intervention (p = .003), older age (p = .01), and higher autonomous motivation (p = .007) were significant correlates of attempting to quit in the past year. Given the impact of healthcare provider intervention regarding smoking on quit attempts among MSM, greater training and support is needed to promote consistent intervention on smoking in the clinical setting among HIV-positive and HIV-negative MSM smokers.

Keywords: HIV, men who have sex with men, smoking, smoking cessation, healthcare provider

Introduction

Smoking rates in China are high (Yang, 2008); roughly 56% of men and 6% of women are current smokers (Lee et al., 2009). Men who have sex with men (MSM) are at high risk for smoking (Greenwood et al., 2005; Lampinen, Bonner, Rusch, & Hogg, 2006; McKirnan, Tolou-Shams, Turner, Dyslin, & Hope, 2006; Tang et al., 2004), but limited research has examined smoking among MSM in developing countries. One study of MSM in Shanghai, China documented a 66% smoking prevalence (Berg et al., 2011). Reasons for these elevated risks might include higher stress or depression, discrimination, and lack of social support (Choi et al., 2003; Liu & Choi, 2006; Pilcher, 2003). In addition, behaviors associated with smoking, such as alcohol use (Shiffman & Wills, 1985), may be higher among MSM (Greenwood et al., 2001; Stall, Greenwood, Acree, Paul, & Coates, 1999; Wong et al., 2008).

MSM are at increased risk for HIV/AIDS (Centers for Disease Control and Prevention [CDC], 2009). Smoking rates are high among HIV-positive individuals (Mamary, Bahrs, & Martinez, 2002; Niaura, Shadel, Morrow, Flanigan, & Abrams, 1999). Unfortunately, smoking is associated with reduced health-related quality of life in HIV-positive individuals and increased incidence of AIDS-defining illnesses, malignancies, and mortality (Crothers et al., 2005; Kirk et al., 2007; Kohli, Lo, & Homel, 2006; Miguez-Burbano, Ashkin, & Rodriguez, 2005), and disease progression (Abbud, Finegan, Guay, & Rich, 1995; Nieman, Fleming, Coker, Harris, & Mitchell, 1993). Unfortunately, HIV-positive smokers may be less likely to quit and less motivated to quit (Gritz, Vidrine, Lazev, Amick, & Arduino, 2004; Niaura et al., 1999). Thus, targeting smoking cessation among MSM, particularly those already infected with HIV, is critical. Physician-assisted smoking intervention is effective (Coleman, 2004; Schroeder, 2005; Stead, Bergson, & Lancaster, 2008a, 2008b; The Tobacco Use and Dependence Clinical Guideline Panel and Consortium Representatives, 2000); however, Chinese doctors infrequently offer cessation services and lack cessation resources (Jiang, Elton-Marshall, Fong, & Li, 2010; Li, Fish, & Zhou, 1999; Smith & Leggat, 2007).

The current study is the first to examine sociodemographic, smoking-related, psychosocial, and substance use factors in relation to HIV status; receipt of healthcare provider intervention regarding smoking; and having made a recent (past 12 months) quit attempt in a sample of MSM current (past 30 days) smokers in Chengdu, Sichuan Province, China.

Methods

Procedures

Using a cross-sectional design, we recruited a convenience sample of MSM through a nongovernmental organization in Chengdu that serves MSM to participate in a 15-minute self-administered paper-and-pencil survey between November 2012 and March 2013. Eligibility criteria included ≥ 18 years old, able to give consent (in Mandarin Chinese), ever had sex with men (oral, anal, or both), smoked ≥100 cigarettes in his lifetime, and smoked ≥1 cigarette in the past 30 days. The sample was comprised of 381 MSM, of whom 350 disclosed their HIV status, and 344 (188 HIV-positive, 156 HIV-negative) provided complete data. This study was approved by the Institutional Review Board at Fudan University.

Measures

All measures were translated and back-translated using previously published procedures yielding valid measures (He et al., 2007; Wong et al., 2008). Participants reported sociodemographics; smoking-related factors (number of days of smoking in the past 30 days, average cigarettes smoked per day [cpd; CDC, 2012]); social factors (living with a smoker, number of five closest friends that smoke [Maibach, Maxfield, Ladin, & Slater, 1996]); days of alcohol consumption in the past 30 (CDC, 2012); depressive symptomatology per the Center for Epidemiologic Studies Depression Scale-Short Form (CES-D) (Poulin, Hand, & Boudreau, 2005; Cronbach’s alpha = .94); and the Treatment Self-Regulation Questionnaire (TSRQ; Ryan & Connell, 1989; Williams et al., 2006) assessing autonomous motivation (e.g., “…I want to take responsibility for my own health”), controlled motivation (e.g., “I would feel guilty or ashamed of myself if I smoked”), and amotivation (i.e., “I really don’t think about it”) (Cronbach’s alphas = .84, .80, and .57, respectively).

Participants reported if they had ever been tested for HIV and, if they were, the result of the test. Participants were asked if any healthcare provider had ever assessed their smoking status; advised to quit; or provided assistance or resources for cessation. We created one factor indicating at least one versus none of these interventions. Finally, participants reported number of quit attempts in their lifetime, in the past 12 months (Fava, Velicer, & Prochaska, 1995), and among HIV-positive individuals, since HIV diagnosis.

Data analyses

Descriptive analyses were conducted; z-score transformations were done to address skewed continuous variables (in this case, days of alcohol consumption) for inclusion in regression models. Bivariate analyses examined correlates of HIV status; receipt of healthcare provider intervention; and recent quit attempt. We then conducted two binary logistic regression models. The first examined factors associated with having received provider intervention, with HIV status being the primary predictor of interest. The second examined factors associated with recent quit attempt; HIV status and provider intervention were the primary predictors of interest. In each model, important sociodemographics, cigarette consumption (days smoked multiplied by cpd), and the primary predictors of interest were forced into the model; we performed backward deletion on all other factors and retained those significant at the nominal level. Prevalence ratios were computed using a Poisson likelihood and log link function, but statistical inference was drawn using the robust, empirical covariance matrix (Zou, 2004). SPSS 21.0 and SAS 9.3 were used for all data analyses. Statistical significance was set at α = .05.

Results

Our sample smoked an average of 21.88 (SD = 10.35) days of the past 30 and an average of 11.97 (SD = 9.73) cpd (Table 1). The median number of days of alcohol consumption was 2.00 days (interquartile range: 0.00, 5.00). The majority (59.4%) reported that a healthcare provider had intervened; the most common intervention was assessment of smoking status (50.0%). Half (50.0%) reported at least one quit attempt in their lifetime; 30.5% reported a recent quit attempt.

Table 1.

Participant characteristics and bivariate analyses examining correlates of HIV status, receiving any healthcare provider cessation intervention, and making a quit attempt in the past among HIV-positive and HIV-negative MSM smokers in Chengdu, China.

Variable HIV status
Any healthcare provider interaction
Past year quit attempt
Total
N = 344		 Negative
N = 156
(45.3%)		 Positive
N = 188
(54.7%)		 p No
N = 129
(40.6%)		 Yes
N = 189
(59.4%)		 p No
N = 239
(69.5%)		 Yes
N = 105
(30.5%)		 p
Sociodemographics
Age (SD) 30.86 (8.41) 31.38 (9.85) 30.27 (6.95)   .22 29.82 (8.30) 30.34 (7.18)   .54 30.13 (8.08) 32.53 (8.93)   .01
Education (%) <.001   .009   .04
 <HS      22 (6.5)      18 (11.5)       4 (2.2)      13 (9.2)      11 (5.4)      19 (7.3)      10 (8.8)
 HS or equivalent    101 (29.6)      56 (35.9)     45 (24.3)      52 (36.9)      50 (242.5)      71 (27.2)      45 (39.5)
 >HS    218 (63.9)      82 (52.6)   136 (73.5)      76 (53.9)    143 (70.1)    171 (65.5)      59 (5.8)
Income (%)   .004   .002   .004
 <Y1000      18 (5.2)      10 (6.4)       8 (4.3)        7 (4.9)      10 (14.9)      13 (4.9)        6 (5.2)
 Y1000 to Y2999    120 (34.9)      67 (42.9)     53 (28.2)      61 (42.7)      61 (29.6)      92 (34.8)      44 (38.3)
 Y3000 to Y4999    136 (39.5)      58 (37.2)     78 (41.5)      58 (40.6)      76 (36.9)    111 (42.0)      35 (30.4)
 ≥Y5000      70 (20.3)      21 (13.5)     49 (26.1)      17 (11.9)      59 (28.6)      48 (18.2)      30 (26.1)
Marital status (%)   .32   .63   .02
 Never married    255 (76.3)    115 (74.2)   140 (78.2)    111 (79.3)    151 (75.9)    205 (79.5)      74 (67.3)
 Married/living with partner      44 (13.2)      25 (16.1)     19 (10.6)      16 (11.4)      30 (15.1)      29 (11.2)      24 (21.8)
 Divorced      35 (10.5)      15 (9.7)     20 (11.2)      13 (9.3)      11 (5.4)      24 (9.3)      12 (10.9)
Smoking characteristics
Days smoked, past 30 (SD) 21.88 (10.35) 21.58 (10.41) 21.31 (10.44)   .81 19.84 (11.16) 22.30 (9.83)   .03 21.95 (10.48) 20.71 (10.02)   .28
Average cpd (SD) 11.97 (9.73) 12.52 (10.36) 10.85 (8.82)   .11 10.11 (8.92) 12.33 (9.78)   .03 11.74 (9.91) 12.51 (9.80)   .48
Other related factors
Days alcohol use (SD)   4.00 (6.50)   4.64 (7.83)   3.20 (4.44)   .03   4.99 (8.52)   3.43 (4.82)   .03   4.19 (6.98)   3.56 (5.22)   .38
Live with another smoker (%)   .01   .005   .004
 No    148 (43.0)      56 (35.9)     92 (48.9)      49 (34.3)    100 (48.5)    100 (37.9)      61 (53.0)
 Yes    196 (57.0)    100 (64.1)     96 (51.1)      94 (65.7)    106 (51.5)    164 (62.1)      54 (47.0)
No. of five friends that smoke (SD)   3.08 (1.47)   3.41 (1.38)   2.72 (1.45) <.001   3.09 (1.48)   3.01 (1.49)   .62   3.05 (1.46)   3.15 (1.57)   .57
CESD-12 score (SD) 12.89 (8.53) 12.81 (9.39) 13.28 (7.69)   .62 12.12 (8.87) 14.25 (7.89)   .02 12.16 (8.39) 14.57 (8.65)   .01
TSRQ scores (SD)
 Controlled motivation 21.11 (7.78) 20.64 (8.47) 21.66 (7.27)   .24 20.37 (8.24) 21.75 (7.48)   .12 20.42 (7.68) 22.73 (7.81)   .01
 Autonomous motivation 26.81 (8.10) 27.80 (8.74) 26.46 (7.75)   .14 26.56 (8.32) 26.90 (8.06)   .71 25.82 (7.90) 29.13 (8.12) <.001
 Amotivation 11.09 (3.91) 10.95 (4.32) 11.09 (3.50)   .73 11.02 (3.99) 11.27 (3.81)   .56 11.16 (3.86) 12.51 (10.02)   .64
Outcomes
HIV status (%) – – – <.001   .17
 Negative      79 (61.2)      59 (31.2)    113 (47.3)      43 (41.0)
 Positive      50 (38.8)    130 (68.8)    126 (52.7)      62 (59.0)
Healthcare provider intervention (%) <.001 – – – <.001
 No    129 (40.6)      79 (57.2)     50 (27.8)    114 (48.1)      27 (25.5)
 Yes    189 (59.4)      59 (42.8)   130 (72.2)    123 (57.9)      79 (74.5)
Ever tried to quit smoking (%)   .01 <.001 – – –
 No    172 (50.0)      89 (57.1)     83 (44.1)      92 (64.3)      84 (40.8)
 Yes    172 (50.0)      67 (42.9)     43 (55.9)      51 (35.7)    122 (59.2)
Past year quit attempts (%)   .17 <.001 – – –
 No    239 (69.5)    113 (72.4)    126 (67.0)    115 (80.4)    127 (61.7)
 Yes    105 (30.5)      43 (27.6)      62 (33.0)      28 (19.6)      79 (38.3)
Quit attempt since HIV diagnosis (%) – – –   .001 – – –
 No      67 (28.4)      31 (43.7)      31 (21.8)
 Yes    169 (71.6)      40 (56.3)    111 (70.2)
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HIV-positive individuals were of greater educational attainment (p < .001), had higher incomes (p = .004), drank less frequently (p = .03), were less likely to live with another smoker (p = .01), had fewer friends that smoke (p < .001), were more likely to receive healthcare provider intervention (p < .001), and were more likely to have ever attempted to quit (p = .01).

Receiving healthcare provider intervention was associated with greater educational attainment (p = .009), higher incomes (p = .002), more frequent smoking and higher cpd (ps = .03), less frequent drinking (p = .03), less likelihood of living with another smoker (p = .005), greater depressive symptoms (p = .02), and greater likelihood of trying to quit ever (p = .009), in the past year (p < .001), and among HIV-positive individuals, since HIV diagnosis (p = .001). Regression documented that being HIV-positive (p < .001), greater cigarette consumption (p = .02), less frequent drinking (p = .03), and greater depressive symptoms (p = .003) were correlated with healthcare provider intervention (Table 2).

Table 2.

Multivariate model identifying correlates of any healthcare provider intervention with HIV status as the primary correlate of interest (controlling for sociodemographics, smoking level, and psychosocial factors).

Variable PR 95% CI p Value
HIV status
 Negative Ref – –
 Positive 3.18 1.87, 5.41 <.001   
Age 1.00 0.97, 1.04 .76
Education
 <HS Ref – –
 HS or equivalent 0.75 0.23, 2.39 .62
 >HS 1.91 0.62, 5.92 .26
Cigarette consumption 1.01 1.00, 1.02 .02
Days alcohol usea 0.73 0.55, 0.97 .03
CESD-12 score 1.05 1.02, 1.09 .003  
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Notes: PR, prevalence ratio.

Nagelkerke R2 = .214.

a

Z-score transformed values.

Having made a recent quit attempt was associated with being older (p = .01), educational attainment (p = .04), income level (p = .004), greater likelihood of being married or living with a partner (p = .02), greater likelihood of living with other smokers (p = .004), higher depressive symptoms (p = .01), and greater controlled (p = .01) and autonomous motivation (p < .001). Regression documented that receiving provider intervention (p = .003), older age (p = .01), and higher autonomous motivation (p = .007) was associated with recent quit attempts (Table 3).

Table 3.

Multivariate model identifying correlates of attempting to quit in the past year with healthcare provider intervention and HIV status as the primary correlates of interest (controlling for sociodemographics, smoking level, and psychosocial factors).

Variable PR 95% CI p Value
HIV status
 Negative Ref – –
 Positive 0.86 0.48, 1.55 .62
Any healthcare provider intervention
 No Ref – –
 Yes 2.62 1.39, 4.94 .003  
Age 1.05 1.01, 1.09 .01
Education
 <HS Ref – –
 HS or equivalent 1.30 0.40, 4.27 .66
 >HS 0.57 0.18, 1.81 .34
Cigarette consumption 1.00 1.00, 1.00 .94
TSRQ autonomous motivation 1.05 1.01, 1.08 .007  
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Note: Nagelkerke R2 = .174.

Discussion

We documented low rates of lifetime or recent quit attempts (50% and 30%, respectively) and low rates of providers ever intervening on smoking (60%) in this sample. HIV-positive individuals were more likely to have ever attempted to quit or to have had a provider intervene regarding smoking. Given the health benefits of cessation (Chaisson, 1994), particularly among HIV-positive MSM (Abbud et al., 1995; Nieman et al., 1993), these findings highlight the need for consistent provider cessation intervention among MSM in China.

Moreover, there were few differences in the smoking or psychosocial profiles of HIV-positive and HIV-negative MSM smokers in this sample. HIV-positive individuals were of greater socioeconomic status, drank less frequently, were less likely to live with another smoker, and had fewer friends who smoke, potentially indicating better odds of successful cessation, given that alcohol consumption and greater pro-smoking social factors decrease the odds of successful cessation (Baker et al., 2006; Chen, White, & Pandina, 2001; Gilman, Abrams, & Buka, 2003). Predictors of receiving healthcare provider intervention included being HIV-positive, less frequent drinking, and greater depressive symptoms. Predictors of having made a recent quit attempt included having received some healthcare provider intervention, further highlighting the critical need for healthcare providers to have the appropriate training and support to intervene. Other significant predictors included higher autonomous motivation, which coincides with existing literature (Cupertino et al., 2012; Williams et al., 2006, 2002).

Limitations of this study include a lack of generalizability, given that this was a convenience sample recruited through a nonprofit organization in Chengdu and were overrepresented by HIV-positive MSM. The cross-sectional nature of the data does not allow us to detect directionality of the relationships documented.

In summary, HIV-positive individuals were more likely to have a doctor intervene on smoking, which was related to having made a recent quit attempt. This highlights the important role of healthcare providers in promoting cessation in this population.

Acknowledgments

The study was approved by Fudan University’s Institutional Review Board. We would also like to thank our community partner, Chengdu Tongle Health Service and Counseling Center, for their efforts and support in conducting this research.

Funding: This study was supported by a grant from the Emory Center for AIDS Research [grant number P30 AI050409] to Drs Berg, Nehl and Wong and the Georgia Cancer Coalition (PI: Berg). All opinions expressed are those of the authors.

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