A Qualitative Systematic Review of Cigarette Smoking Cessation Interventions for Persons Living with HIV

Abstract

Persons living with HIV (PLWH) have disproportionately high rates of both cigarette smoking and tobacco-induced negative health outcomes. The goal of this qualitative systematic review was to identify gaps in the existing literature and future directions for smoking cessation support for PLWH. Three online databases were searched from their inception through December 31, 2017, using designated search terms. Peer-reviewed English-language articles that documented an intervention designed to increase smoking cessation among PLWH were reviewed. Data were abstracted using a standardized form to document study and intervention characteristics and results. Thirty-two articles, describing 28 unique intervention studies, met inclusion criteria. Interventions consisted primarily of combinations of counseling, pharmacotherapy, and the use of information and communications technology; few interventions were implemented at the clinic level. Thirteen interventions resulted in significant improvements in cessation-related outcomes. Information and communications technology and clinic-level interventions had the greatest potential for increasing smoking cessation among PLWH. Efficacious interventions designed for PLWH in the U.S. South, and for groups of PLWH facing additional health disparities (e.g., communities of color and sexual and gender minorities), are needed. There is also a need for more rigorous research designs to test the efficacy of interventions designed to increase cessation-related outcomes among PLWH.

INTRODUCTION

Despite decreasing cigarette smoking rates in the general U.S. population, the rate of smoking among persons living with HIV (PLWH) remains disproportionately high. As of 2016, an estimated 15.5% of U.S. adults 18 years or older smoked cigarettes [1], but recent estimated rates among PLWH range from 42.4% to 70% [2–5]. There are a variety of health risks related to smoking that may be enhanced by the presence of HIV infection, including increased susceptibility to pneumonia and chronic obstructive pulmonary disease and an increased risk of non-AIDS defining cancers [4, 6–9]. The negative effects of smoking for PLWH can also limit the HIV treatment benefits of antiretroviral therapy (ART) [10, 11]. PLWH have an increased risk of cancer on average compared to the general population overall, and lung cancer is currently a leading cause of mortality among PLWH [11–13]. PLWH who are on antiretroviral therapy (ART) with viral suppression but smoke cigarettes are predicted to lose more life years to smoking than to HIV infection [11, 13]. PLWH who smoke are also less likely to quit smoking than persons who do not have HIV (32.4% vs. 51.7%) [4].

Thus, smoking cigarettes is an important modifiable risk factor that should be a high priority among PLWH, even amid other important health care priorities. However, the need for smoking cessation and the potential health risks of smoking are often not thoroughly emphasized to PLWH by health care providers, in part due to multiple competing health care needs of this population. Therefore, interventions for PLWH and providers that care for PLWH are necessary to increase cessation among this population.

There are many evidence-based smoking cessation interventions with varying degrees of efficacy, efficiency, and cost. These include pharmacotherapy, counseling, information and communications technology (i.e., utilizing the internet, email, cell phones, or text messaging), and clinic-level interventions. Pharmacotherapy used in smoking cessation interventions, such as nicotine replacement therapy (NRT), bupropion, and varenicline, can be applied among PLWH who smoke as there are limited to no drug interactions when combined with ART [14]. In addition to pharmacotherapy-based interventions, counseling-based interventions can include brief information sessions, individual or group therapy, and motivational interviewing. Many interventions combine pharmacotherapy with counseling to increase cessation-related outcomes [15]. Information and communications technology interventions, including the use of cell phones for delivery of counseling and Internet-based cessation interventions, have also recently been developed and used, including with PLWH [16].

Clinic-level interventions can also be implemented to address the challenges of engaging PLWH in smoking cessation by encouraging provider and clinic staff involvement in promoting cessation. Based on extensive evidence supporting the use of screening and brief interventions, the U.S. Public Health Services Clinical Practice Guideline for Treating Tobacco Use and Dependence (PHS Guidelines) recommends clinic-level interventions, such as tobacco-user identification systems coupled with provider-led interventions that focus on robust patient care to help patients quit (e.g., the 5 As [Ask, Advise, Assess, Assist, Arrange] and pharmacotherapy) [17]. The importance of providers’ role in supporting smoking cessation through the 5As for PLWH has been well documented. Recommendations for smoking cessation by providers during regular care, even brief advice (e.g., 3 minutes), and further involvement in cessation interventions in clinical settings have been found to increase cessation attempts and abstinence rates in the general population [17, 18]. However, providers working with PLWH are less likely to emphasize smoking cessation recommendations than providers working with persons who do not have HIV [19]. For populations with multiple competing health care needs such as PLWH, the effective engagement of providers and clinic staff in smoking cessation efforts is an important goal.

There is also a need for particular attention to PLWH who may be especially susceptible to tobacco-induced disease. For example, persons living in the U.S. South have among the highest rates of HIV infection in the country [20], live in a region with strong ties to tobacco growing and manufacturing, and have high rates of smoking [21]. Persons of color, particularly African American/Black and Latinx¹ communities, bear a disproportionate burden of HIV infection and also face smoking-related health disparities [22–24]. African Americans/Blacks, for example, have similar smoking rates to Whites but are more likely to die from tobacco-induced diseases and have fewer successful quit attempts, and some Latinx subgroups (e.g., Puerto Ricans) have higher smoking rates than the general population [22, 23]. Gay, bisexual, and other men who have sex with men (MSM) and transgender women are also disproportionately affected by HIV and have higher rates of smoking than their heterosexual and cisgender peers, respectively [25–28]. In addition, communities of color and lesbian, gay, bisexual, and transgender (LGBT) communities are more heavily targeted by tobacco industry marketing [22, 23, 27]

Purpose

In order to reduce smoking rates among PLWH and promote cessation to improve their health, interventions are needed to address their unique needs. The purpose of this qualitative systematic review was to assess the literature on smoking cessation interventions for PLWH and to identify gaps and opportunities for future intervention-oriented research.

METHODS

A qualitative systematic review [29] of the published literature was conducted using three online databases: PubMed, PsychInfo, and EBSCO Academic Search Premier. The Boolean terms and search terms used were: (HIV OR HIV/AIDS OR AIDS) AND (tobacco OR smoking) AND (cessation OR quit OR abstinence) AND (intervention OR program OR treatment). Databases were searched from their inception through December 31, 2017. Citations from previous systematic reviews of smoking cessation interventions with PLWH were also searched for relevant papers.

After initial search results were retrieved from the databases, articles written in English were further screened. Articles from peer-reviewed journals describing interventions for smoking cessation in adults (≥ 18 years old) living with HIV were included. Duplicates were removed, and search results were screened by title and abstract to determine whether the articles met criteria for inclusion in the review. Finally, relevant articles were selected and interventions described by those articles were identified.

Data Collection

An abstraction form was created to abstract data from the identified articles. This form collected information on intervention study location, participant description (i.e., sample size and demographic characteristics), theories/models, intervention description, study design, primary cessation-related behavioral outcome measures, and study results. Articles that did not describe an intervention or did not report sufficient information to be abstractable were excluded. Data from multiple articles that described the same intervention study were abstracted under the same intervention.

RESULTS

The initial search retrieved 1,031 English articles. From these articles, 65 potentially relevant articles were identified by screening their titles and abstracts. Screening the full text of the potentially relevant articles initially identified led to the exclusion of 15 articles, and an additional 18 were excluded during data abstraction based on the criteria described above. From the remaining 32 articles, 28 unique intervention studies were identified, and data were abstracted from these articles (See Figure 1).

Fig. 1.

PRISMA diagram of steps of the qualitative systematic review of the literature Intervention Locations and Participant Characteristics

Of the 28 intervention studies outlined in Table 1, seven were conducted in the U.S. Northeast [30–38], five in the South [39–45], five in the Midwest [46–50], and four in the West [51–54]; six were conducted in international settings [55–60] and the location of one study was not specified [61].

Table 1.

Review of smoking cessation interventions for persons living with HIV

Study	Location	Description of Participants	Theories/Models	Description of Intervention	Study Design	Primary Cessation-Related Outcome Measures	Results
Balfour et al. (2017) [60]	Canada	N=50; 4% African American/Black; 57% LGB; 2% transgender	CBT, Ottawa Model for Smoking Cessation	5 face-to-face individual counseling sessions over 24 weeks and Rx for 10-week supply of NRT.	Quasi-experimental design (results compared to Lloyd-Richardson et al. study [31]). Data collection at baseline, quit date, 4, 12, and 24 weeks post-quit date.	Self-reported continuous abstinence, biochemically verified via expired CO levels <10ppm.	Abstinence rate at follow-up significantly higher than in comparison study (p<0.001).
Browning et al. (2016) [49]	Ohio	N=247; 56% White	CBT, PHS Guidelines	Weekly nurse-delivered phone-based counseling sessions and provision of varenicline or NRT over 12 weeks.	Single-group longitudinal design. Data collection at baseline, 3-, and 12-month follow-up.	Self-reported 7-day PPA, biochemically verified via saliva cotinine screen or expired CO levels <8ppm, and number of 24-hour quit attempts in past year.	10% abstinence rate at 12 months; no p-value reported.
Chew et al. (2014) [30]	New Jersey	N=774; among intervention group (n=123): 85% African American/Black	N.D.	1 1-hour face-to-face individual counseling session and Rx for NRT, varenicline, bupropion, or combination.	Prospective cohort study with case-control analysis. Data collection at baseline and 6-month follow-up.	Self-reported 7-day PPA.	16% abstinence rate at 6 months; no p-value reported.
Cropsey et al. (2013) [40]	Alabama	N=40; 58% African American/Black	SBIRT Model	Clinic-level strategies (electronic screening and documentation of patient smoking status) and provision of 1 20-minute face-to-face individual counseling session, 3 weeks of NRT, and workbook with daily smoking diary.	Randomized pilot study. Data collection at baseline and 2-, 4-, and 8-week follow-up.	Self-reported cigarettes smoked per day.	Trend toward reduction in cigarettes per day among intervention group (N.S.).
Cropsey et al. (2015) [41]; Valera et al. (2017) [42]	Alabama	N=100; 75% African American/Black	SBIRT Model	Clinic-level strategies (patients who smoke identified via EMR and offered varenicline, bupropion, or NRT based on algorithm) and provision of 1 20-minute face-to-face individual counseling session.	Randomized pilot clinical trial. Data collection at baseline; every 2 weeks during 12- week intervention period; and at 1-month follow-up.	Self-reported cigarettes smoked per day and 24-hour quit attempts.	Significantly greater reduction in cigarettes per day and more quit attempts among intervention participants; no p-value reported.
Cui et al. (2012) [55]	Canada	N=36; 92% White	PHS Guidelines	Varenicline twice daily over 12 weeks, with brief counseling delivered by physician or trained counselor and provision of written materials.	Multi-center pilot study. Data collection at baseline, 4-, 12-, and 24-week follow-up.	4-week continuous abstinence, biochemically verified via serum cotinine screen; self-reported 7-day PPA; and cigarettes smoked per day.	28% continuous abstinence rate and 42% 7-day PPA at 24 weeks; significant decrease in cigarettes per day (p<0.05).
Cummins et al. (2005) [56]	Australia	N=45 (n=27 participated in intervention); 84% LGB	SRT	1 face-to-face individual counseling session delivered by social worker and 8–12 weeks of NRT, daily smoking diary, written materials, and hotline number.	Single-group longitudinal study. Data collection at baseline and at 4 follow-ups every 6 weeks for 5 months.	Self-reported smoking cessation and reduction in nicotine intake.	6 out of 27 participants (22%) reported cessation and 11 (40%) reported reduced nicotine intake at 5 months; no p-value reported.
Elzi et al. (2006) [57]	Switzerland	N=34	TTM; CBT	Weekly 30-minute nurse-delivered face-to-face individual counseling sessions for first month and monthly sessions for following 11 months; NRT provided to interested participants.	Pilot study with non-randomized control group (n=383). Data collection at baseline and 3-month follow-up.	Self-reported 12-month smoking abstinence.	Abstinence rate at follow-up significantly higher among intervention group than control group (OR 6.2, 95% CI 2.8–14.3).
Ferketich et al. (2013) [48]	Ohio	N=228; among varenicline group (n=118): 61% White	PHS Guidelines	Varenicline or NRT, 1 face-to-face individual counseling session, and 11 weekly phone-based counseling sessions delivered by advanced practice nurse over 3 months.	Quasi-experimental study design with non-random group assignment; participants who used varenicline were compared to those who used NRT. Data collection at baseline and 3-month follow-up.	Self-reported 7-day PPA, biochemically verified via expired CO levels <10ppm or saliva cotinine concentrations <15ng/ml.	2.54 times greater odds of reporting abstinence among varenicline group than among NRT group (95% CI 1.43–4.49).
Huber et al. (2012) [58]	Switzerland	N=1689 clinic patients seen during intervention period; 45% MSM	TTM	Clinic-level strategies including half-day training in smoking cessation counseling and pharmacotherapy for all providers and checklist for providers to document patients’ smoking status and receipt of counseling.	Part of multi-site prospective observational cohort study; smoking cessation outcomes were compared between participating clinic and other clinics that did not receive the intervention.	Smoking prevalence among patients, smoking cessation (defined as 6 months or more of nicotine abstinence), and smoking relapses.	Participating clinic had increased smoking cessation (p=0.004) and fewer smoking relapses (p=0.007) compared with other sites.
Humfleet et al. (2013) [51]	California	N=209; 27% African American/Black; 14% Latinx, 2% American Indian/Native American; 69% LGB; 3% transgender	CBT	6 20–40 minute face-to-face individual counseling sessions delivered by social work or psychology clinicians over 12 weeks and NRT or 12-month access to web-based intervention with 5 interactive educational units and NRT.	RCT with individual counseling intervention + NRT, web-based intervention + NRT, and self-help comparison intervention + NRT groups. Data collection at baseline, 2-, 24-, 36-, and 52-week follow-up.	Self-reported 7-day PPA, biochemically verified via expired CO levels <10 ppm, and sustained abstinence (not exceeding 7 consecutive days of smoking).	N.S.
Ingersoll et al. (2009) [61]	N.D.	N=40; 95% African American/Black; 3% transgender	CBT; Elicit-Provide-Elicit Model for MI; Self-Guided Change Model	1 MI session delivered by psychologist or counselor and at least 1 month of NRT or self-guided change reading packet with written information and self-assessment exercises and at least 1 month of NRT.	RCT comparing MI intervention + NRT and self-guided change intervention + NRT. Data collection at baseline, 1-, and 3-month follow-up.	Self-reported smoking abstinence, biochemically verified via expired CO levels <3ppm; self-reported cigarettes smoked per day; and smoking days.	N.S.
Krebs et al. (2015) [38]; Tseng et al. (2017) [36]	New York	N=158; 51% African American/Black, 32% Latinx; 3% transgender	Information-Motivation-Behavioral Skills Model (includes components from SCT and TPB)	2 daily text messages, 7 standardized phone-based counseling sessions with MI component, and 12 weeks of varenicline.	3-arm RCT with text messaging + standard care, text messaging + counseling/MI + standard care, and standard care (varenicline) alone groups. Data collection at baseline, 1-, 4-, 8- and, 12-week follow-up.	Self-reported 7-day PPA, biochemically verified via expired CO levels <8ppm.	Significantly higher probability of abstinence in text messaging + counseling/MI + standard care group compared to standard care alone group (p=0.05).
Lazev et al. (2004) [39]	Texas	N=20; 80% African American/Black	CBT; PHS Guidelines	6 counseling sessions over 2 weeks on provided prepaid cell phone and provision of written materials and hotline number.	Single group study with pre-test and immediate post-test.	Self-reported quit attempts and 2-week end of treatment PPA rate.	19 participants (95%) had made quit attempt and 15 (75%) were abstinent 2 weeks post-quit date; no p-value reported.
Lloyd-Richardson et al. (2009) [31]; de Dios et al. (2016) [32]	New England	N=444; 19% African American/Black, 16% Latinx, 5% Cape Verdean, 5% American Indian/Native American	TTM; FRAMES Model for MI	4 30-minute MI sessions and quit-day counseling phone call delivered by health educator, with materials tailored to PLWH; 8 weeks of NRT provided to participants who were willing to set a quit date.	RCT with MI intervention + NRT and standard care intervention + NRT groups. Data collection at baseline, 2-, 4-, and 6-month follow-up.	Self-reported 7-day PPA, biochemically verified via expired CO levels <10 ppm.	N.S.
Manuel et al. (2013) [52]	California	N=30; 47% African American/Black, 13% Latinx; 33% LGB; 100% female	PHS Guidelines	1 MI session delivered by therapist and referral to NRT programs.	Randomized pilot study with intervention and prescribed advice control groups. Data collection at baseline and 1-month follow-up	Self-reported 7-day PPA, biochemically verified via urine screen for nicotine and cotinine, and cigarettes smoked per day.	No significant differences in abstinence rates between groups at follow-up, but significant decrease in cigarettes per day in intervention compared to control group.
Matthews et al. (2013) [46]	Illinois	N=31; 100% African American/Black; 90% gay or bisexual	CBT, PHS Guidelines, intervention model from King et al. [68]	6 weekly 90-minute small-group counseling sessions delivered by clinician and 4-week supply of NRT.	Single-group feasibility and acceptability study. Data collection at baseline, 1-, and 3-month follow-up.	Self-reported 7-day PPA, biochemically verified via expired CO levels <8ppm, and cigarettes smoked per day.	6% abstinence rates at 3 months; significant reduction in cigarettes per day among participants who did not quit smoking (p<0.05).
Moadel et al. (2012) [33]	New York	N=145; mean age=49; 86% African American/Black, 23% Latinx, 3% American Indian/Native American; 1% transgender	SCT	8 intensive small-group counseling sessions delivered by professional and peer co-facilitators over 7 weeks using curriculum tailored to PLWH; participants were offered 3 months of NRT.	RCT with intervention and standard care groups. Data collection at baseline, 42-, and 132-day (3-month) follow-up.	Self-reported 7-day PPA, biochemically verified via expired CO levels <10ppm.	Trend toward higher abstinence rates in intervention group compared to standard care group (N.S.); when participants who were lost to follow-up and/or did not attend sessions were excluded intervention was significantly associated with higher abstinence rates.
Mussulman et al. (2018) [50]	Kansas	n=25; 48% African-American	N.D.	Clinic-level intervention designed for delivery to hospitalized PLWH who smoke; at bedside, hospital staff called quitline for on-the-spot smoking cessation enrollment and counseling.	RCT pilot study with warm handoff intervention group and fax referral at discharge group. Data collection at baseline, 1-, and 6-month follow-up.	Self-reported 6-month abstinence, biochemically verified via salivary cotinine <15 ng/ml.	Trend toward higher abstinence rates in intervention group compared to standard care group (N.S.).
Nerín, et al. (2007) [59]	Spain	N=1120	TTM; CBT	9 group counseling sessions delivered over 3 months and pharmacotherapy (NRT or bupropion) administered over 8 weeks	Single group longitudinal study. Data collection at baseline, 1-week, 1-, 3-, and 6-month follow-up.	Self-reported continued smoking abstinence, biochemically verified via expired CO levels <10ppm.	Probability of abstinence at 6-months was 62.2%; no p-value reported.
Shadel et al. (2016) [53]	California	N=49; 100% Latinx	N.D.	1 20-minute face-to-face individual counseling session delivered by bilingual staff and provision of written materials and 8 weeks of NRT.	Formative qualitative study; semi-structured telephone interviews with intervention participants 1–2 times per week for 8 weeks.	Adherence to NRT	88% adherence to NRT at follow-up; no p-value reported.
Shuter et al. (2014) [34]	New York	N=138; among intervention group (n=69): 78% African American/Black, 49% Latinx, 6% American Indian/Native American; 1% transgender	SCT; intervention model from Moadel et al. [33]	8 interactive web-based sessions over 7 weeks; participants were offered Rx for 3-month supply of NRT.	RCT with intervention and standard care groups. Data collection at baseline, 6-week, and 3-month follow-up.	Self-reported 7-day PPA, biochemically verified via expired CO levels <10ppm.	Trend toward higher abstinence rates in intervention group compared to standard care group (N.S.).
Stanton et al. (2015) [37]	U.S. Northeast	N=302; 100% Latinx; 79% heterosexual	TRA	2 face-to-face individual counseling sessions + 2 additional sessions on relapse prevention with option to bring social support buddy to all sessions, phone call on quit date + 2 additional 10-minute booster phone calls, culturally tailored written materials and videos, and 8 weeks of NRT.	RCT with tailored intervention and non-tailored enhanced standard care groups. Data collection at baseline, 6-, and 12-month follow-up.	Self-reported 7-day PPA, biochemically verified via expired CO levels <10ppm, cigarettes smoked per day, and smoking frequency.	No significant differences in abstinence rates between groups at follow-up, but significant reduction in heavy smoking (>10 cigarettes per day).
Tucker et al. (2017) [54]	California	N=40; 100% Latinx	N.D.	1 face-to-face individual counseling session that included module on adherence delivered by bilingual staff and provision of written materials and 8 weeks of NRT.	Randomized pilot study with adherence-focused intervention and standard brief smoking cessation treatment groups. Data collection at baseline and 3-month follow-up.	7-day point prevalence, biochemically verified via expired CO levels <5ppm, and 90-day continuous abstinence	Abstinence rates 2–3 times higher in intervention group compared to standard group (clinically meaningful though N.S.).
Vidrine et al. (2006) [43]	Texas	N=95; 72% African American/Black, 8% Latinx; 38% MSM	CBT; PHS Guidelines	8 scheduled counseling sessions over 2 months on provided prepaid cell phone and provision of hotline number, written materials, and 10 weeks of NRT.	RCT with intervention and recommended standard of care groups. Data collection at baseline and 3-month follow-up.	Self-reported 24-hr PPA and 7-day sustained abstinence, biochemically verified via expired CO levels <7ppm.	Intervention group more likely to report 24-hour abstinence (statistically significant; p=0.016) and 7-day abstinence (trending) at follow-up.
Vidrine et al. (2012) [44]; Aigner et al. (2017) [45]	Texas	N=474; 77% African American/Black, 9% Latinx; 25% MSM	CBT; PHS Guidelines	11 scheduled counseling sessions over 3 months on prepaid cell phone and provision of hotline number, written materials, and information about how to obtain NRT.	RCT with intervention and usual care groups. Data collection at baseline, 3- (immediate post-intervention), 6-, and 12-month follow-up.	Self-reported 7-day PPA, biochemically verified 24-hr abstinence (expired CO level <7ppm), self-reported 30-day abstinence, and self-reported continuous abstinence.	Intervention group 4.33 times more likely to report 7-day abstinence at 3 months (p<.0001); other abstinence measures also statistically significant.
Wewers et al. (2000) [47]	Ohio	N=15; mean age=40; 100% male	IDT; PHS Guidelines	3 face-to-face individual counseling sessions and weekly phone calls delivered by peer educator (PLWH who formerly smoked) and nurse manager over 8 weeks; participants also received 6 weeks of NRT.	Feasibility study; participants were randomized to intervention or control group. Data collection at baseline, 8-week (immediate post-intervention), and 8-month follow-up.	Self-reported 7-day PPA and continuous abstinence (0 cigarettes smoked since quit date), biochemically verified via expired CO levels <8 ppm.	Significantly higher rates of 7-day (p=0.002) and continuous (p=0.006) abstinence in intervention group compared to control group at 8 months.
Zwiebel & Hughes (2010) [35]	New York	N>1,564 patient charts	Ask-Advise-Assess-Assist Framework	Clinic-level strategies included training of clinic staff about smoking cessation; tracking sheet to record patients’ tobacco use; nurse-delivered counseling sessions and 2 90-minute workshops delivered by nurse, social worker, and dietician for patients who smoke; and referrals for telephone counseling programs, hotlines, and NRT starter kits.	Longitudinal study using quarterly review of randomly selected patient charts over 18 month	Number of active smokers among patient population.	The number of patients who were active smokers decreased from 45% to 33% within the first 4 months of the intervention; no p-value reported.

CBT Cognitive Behavioral Therapy; CI confidence interval; CO carbon monoxide; EMR electronic medical records; FRAMES Feedback, Responsibility, Advice, Menu, Empathy, Self-efficacy; IDT Innovation Diffusion Theory; LGB lesbian, gay, or bisexual; MI motivational interviewing; N.D. not described; N.S. not significant; OR odds ratio; ppm parts per million; Rx prescription; SBIRT Screening, Brief Intervention, and Referral for Treatment; SCT Social Cognitive Theory; SRT Self-Regulation Theory; TPB Theory of Planned Behavior; TRA Theory of Reasoned Action; TTM Transtheoretical Model of Change; PHS U.S. Public Health Service

Intervention study sample sizes ranged from 15 [47] to 1,689 [58], with half of the studies having sample sizes under 100 [39, 40, 43, 46, 47, 50, 52–57, 60, 61]. Ten of the 28 intervention studies had samples that were majority African American/Black [30, 33, 34, 36, 38, 39, 41–46, 61], but only one intervention was tailored specifically for African American/Black communities [46]. Eleven had Latinx representation that ranged from eight to 100% [31–34, 36–38, 43–45, 51–54], of which five presented any Latinx-specific findings [31–33, 37, 53, 54]. Four intervention studies explicitly noted American Indian/Native American representation [31–34, 51], but these groups only constituted two to six percent of the sample population, and thus no significant results were identified specifically for this group. Only one intervention study included an Asian or Asian American participant [43]. Seven intervention studies included men who identified as gay, bisexual or other MSM, who constituted between 25 to 84% of study samples [43–46, 51, 56, 58, 60], and six documented participation of transgender persons but only in small numbers constituting one to three percent of study samples [33, 34, 38, 51, 60, 61]. Only one study described an intervention that was specifically designed to address the needs of MSM in a culturally congruent manner [46], and none were focused specifically on transgender persons.

Theoretical Underpinnings

Twenty-four of the 28 interventions described a theoretical model or framework. The most commonly used theories included cognitive behavioral therapy (CBT), which was used in 10 of the interventions [39, 43–46, 49, 51, 57, 59–61]; the transtheoretical model of change (TTM), which was used in four interventions [31, 32, 57–59]; social cognitive theory (SCT), which was used in two interventions [33, 36, 38]; and the Screening, Brief Intervention, and Referral for Treatment (SBIRT) model, which was also used in two interventions [40–42]. Two intervention studies did not report theoretical underpinning or framework beyond the PHS Guidelines [48, 55], which were used in eight of the intervention studies overall [39, 43–46, 48, 49, 52, 55]. Four intervention studies did not report any theoretical underpinning [30, 50, 53, 54].

Study Designs

There were 15 randomized controlled trials (RCTs) among the 28 intervention studies, all of which involved randomization at the participant level [31–34, 36–38, 40–45, 47, 50–52, 54, 61]. Of these RCTs, cessation rates at follow-up ranged from four to 63%, and seven produced statistically significant improvements in cessation-related outcomes [36–38, 41–45, 47, 52].

The 13 intervention studies that were not RCTs were primarily single-group longitudinal studies with pre- and post-test and pilot studies with non-randomized control groups [30, 35, 39, 46, 48, 49, 53, 55–60]. Among these non-randomized studies, cessation rates at follow-up ranged from six to 75%, and six demonstrated significant improvements in cessation-related outcomes [46, 48, 55, 57, 58, 60].

Among the 21 intervention studies that included a comparison group, comparison group participants received usual care [31–34, 36, 38, 40–45, 47, 50, 52, 54, 57] or a comparison intervention such as self-guided reading or brief advice sessions [37, 48, 51, 61].

Outcome Measures

Across the intervention studies, the measures used to determine cessation-related outcomes varied. Reported outcome measures included self-reported 24-hour [43–45], seven-day [30–34, 36–38, 43–49, 51, 52, 54, 55], and two-week [39] point prevalence abstinence (PPA); self-reported four-week [55], 30-day [44, 45], 90-day [54], six-month [50, 58], 12-month [57], or continuous abstinence [44, 45, 47, 59–61] or cessation [56]; self-reported number of cigarettes smoked per day [37, 40–42, 46, 52, 55, 61] or daily nicotine intake [56]; self-reported quit attempts [39, 41, 42, 49]; and adherence to NRT [53]. The most frequently used measures were 7-day PPA, usually at three or six months after baseline, and self-reported number of cigarettes smoked per day. Self-reported measures were often biochemically verified using expired carbon monoxide measures (e.g., three [61], five [54], seven [43], eight [36, 38, 46, 47, 49], or 10 [31–34, 37, 48, 51, 59, 60] parts per million) or cotinine or nicotine levels in blood [55], saliva [48–50], or urine [52].

Follow-up periods for collecting data on outcome measures varied from immediate post-test [39] to one month [41, 42, 52] to one year [37, 44, 45, 49, 51].

Intervention Results by Strategy

Most interventions used multiple strategies, including combinations of counseling, pharmacotherapy, and information and communications technology.

Counseling was a widely used intervention strategy, and several different kinds of counseling approaches were applied. Twenty-four of the 28 interventions used one or more forms of counseling [30– 33, 36–49, 51–57, 59–61]. Thirteen interventions used face-to-face individual counseling delivery methods [30, 37, 40–42, 47, 48, 51, 53–57, 60], nine used phone-based counseling [31, 32, 36–39, 43–45, 47–49], and three used group counseling [33, 46, 59]. Four of the counseling interventions used motivational interviewing techniques [31, 32, 36, 38, 52, 61]. Eight interventions included a single counseling session [30, 40–42, 52–54, 56, 61] and 16 were multi-session, ranging from two to 15 sessions [31–33, 36–39, 43–49, 51, 55, 57, 59, 60]. Fourteen of the intervention studies using counseling were RCTs [31–34, 36–38, 40–45, 47, 51, 52, 54, 61].

All of the 13 intervention studies that used face-to-face individual counseling also included pharmacotherapy, and seven showed statistically significant improvements in cessation-related outcomes [37, 41, 42, 47, 48, 55, 57, 60]. Three of these successful interventions also included a cell phone-based counseling component [37, 47, 48].

Of the three group counseling interventions, all used combined strategies that also included pharmacotherapy, but only one demonstrated a significant improvement in cessation-related outcomes (significant reduction in cigarettes smoked per day) [46]. Another resulted in a trend toward higher cessation rates in the intervention group, and produced significant results when participants who were lost to follow-up or did not attend intervention sessions were excluded [33].

All four interventions using motivational interviewing also used pharmacotherapy, and two showed significant improvements in cessation-related outcomes [36, 38, 52], one of which also incorporated cell phone voice and text communications [36, 38].

Eleven interventions incorporated the use of information and communications technology [31, 32, 34, 36–39, 43–45, 47–49, 51]. These included all nine phone-based counseling interventions, of which all but one [39] incorporated pharmacotherapy and six had statistically significant improvements in cessation-related outcomes [36–38, 43–45, 47, 48]. In addition to the three phone-based counseling interventions with significant results that also included face-to-face individual counseling [37, 47, 48], another also included text messaging and a motivational interviewing component [36, 38]. Two interventions were web-based [34, 51], both in combination with NRT and one with a face-to-face individual counseling component [51]; however, neither produced significant improvements in cessation-related outcomes.

Nearly all (n=24) of the reviewed interventions used some form of pharmacotherapy [30–34, 36–38, 40–49, 51–57, 59–61], which included NRT, bupropion, and varenicline; three out of the four interventions that did not use pharmacotherapy were clinic-level interventions [35, 50, 58]. Of the interventions that used pharmacotherapy, 17 offered NRT alone [31–34, 37, 40, 43–47, 51–54, 56, 57, 60, 61], two offered varenicline alone [36, 38, 55], two offered both NRT and varenicline [48, 49], one offered both NRT and bupropion [59], and two offered all three forms of pharmacotherapy [30, 41, 42]. Fourteen of the intervention studies that used pharmacotherapy were RCTs [31–34, 36–38, 40–45, 47, 51, 52, 54, 61], seven of which showed statistically significant improvements in cessation-related outcomes [36–38, 41–45, 47, 52]; five of the 10 intervention studies that involved pharmacotherapy and did not randomize participants also produced statistically significant results [46, 48, 55, 57, 60]. All of the studies using pharmacotherapy paired this with another intervention strategy.

There were only five clinic-level smoking cessation interventions [35, 40–42, 50, 58]. Clinic-level interventions involved changes to the clinic environment in order to promote smoking cessation for PLWH. Intervention components included trainings for staff [35, 58], checklists or electronic processes for screening and documenting patients’ smoking status [35, 40, 58], electronic algorithms to create personalized treatment plans [41, 42], and processes for making referrals for smoking cessation services [35, 50]. These strategies were often implemented in combination with individual-level strategies such as counseling and pharmacotherapy [40–42]. All of the clinic-level smoking cessation intervention studies reported increases in smoking cessation, though not all were statistically significant. Of the five intervention studies that involved clinic-level strategies, three were RCTs (with randomization at the patient level) [40–42, 50] and one had significant results [41, 42]; this intervention also involved the use of NRT and face-to-face individual counseling. One of the clinic-level intervention studies that did not involve randomization or any other intervention strategies also produced significant improvements in cessation-related outcomes [58].

DISCUSSION

The importance of developing interventions tailored to specific at-risk populations has been noted by other reviews of smoking cessation interventions among PLWH [62], yet there are still many gaps within the literature in terms of interventions for PLWH with identities that are part of marginalized groups. Although a few studies evaluated interventions that were tailored specifically to the racial/ethnic, sexual, and/or gender identities of their participants, more studies aimed at developing, implementing, and evaluating culturally congruent interventions are needed. In particular, there is a need for more studies that focus on PLWH who are from underrepresented racial/ethnic groups such as Asian Americans or American Indian/Native Americans and PLWH who are sexual and gender minorities, particularly MSM and transgender women of color. It is important that these interventions consider the specific cultural, social, and structural factors that influence smoking within these groups, as behaviors, barriers to cessation, and resources may differ across different groups of PLWH. Such culturally congruent interventions may be more likely to achieve successful results among these particularly vulnerable groups than interventions not tailored to these specific contexts.

Although the number of interventions developed to promote smoking cessation among PLWH in the South is similar to the number of interventions developed in other regions, it is important to note that there have only been two research teams in two states within the South working on these types of intervention studies, which explore the efficacy of cell phone and electronic algorithm interventions. There remains little diversity in these studies, both in terms of intervention strategies and population groups for which the interventions are designed. Furthermore, contextual factors in the South may mean that some intervention strategies may be more appropriate and feasible than others; for example, a high proportion of persons in the South live in rural settings [63] and may face challenges traveling long distances to clinics to participate in multi-session face-to-face interventions. Given the disproportionate burden of HIV and smoking and the unique context of the South, more varied research is needed in this region.

There have been a number of pilot studies and quasi-experimental studies that show promising results; however, more robust studies with more statistical power are needed to obtain more generalizable results. Due to the wide variety of measures used to assess smoking cessation, it is difficult to compare across studies and to gauge the relative success of interventions. It is important that future studies utilize reliable and standardized measures for cessation to ensure internal and external validity; it is also recommended that a standard be established in order to more effectively compare the results of different types of interventions among different populations of PLWH.

Most of the studies used a theoretical framework to design their interventions. The TTM is based on the understanding that there are discrete stages in the process of behavioral change that relate to the likelihood of successful behavior modification and assumes that individuals must be ready to change their behavior before being encouraged to act. The SBIRT model, on the other hand, does not require expressed interest or readiness for change in order for an individual to be offered an opportunity to participate in a behavior change intervention. Interventions informed by both frameworks have been found to be feasible and promising, but there are fewer interventions that explore the idea of offering cessation opportunities to all PLWH who smoke, regardless of stated openness to or readiness for behavioral change. Studies that further explore the theoretical differences in these two frameworks would be helpful in determining the best theoretical foundation for smoking cessation among PLWH. In particular, more studies using SBIRT and other models that do not rely on patient interest and readiness to quit smoking are warranted.

Despite having been found to be effective for promoting smoking cessation in the general population [64–66], intervention studies using motivational interviewing have had mixed results. However, no findings indicated that the unique characteristics of PLWH would make this strategy inappropriate or not well-suited for this population.

The use of information and communications technology in interventions produced promising results. Cell phone-based counseling tended to yield positive results, and intervention studies that provided prepaid cell phones to study participants may have been particularly effective in part because some PLWH do not have regular access to cell phone service. Web-based interventions had less success in producing statistically significant outcomes. Web-based intervention studies may be able to increase their efficacy and cessation rates by ensuring that participants have regular and easy access to computers and a reliable Internet connection, and further studies with improved experimental designs are necessary to better gauge the efficacy and feasibility of these types of interventions.

Clinic-level interventions are especially promising for PLWH who smoke because this population tends to come into contact with providers on a regular basis due to HIV-related medical care. Studies have found that care provider recommendations for smoking cessation increase attempts; however, cessation has not been found to be a priority among HIV care providers. Providers may need additional training to understand smoking cessation for PLWH and the unique barriers to cessation that this population faces. For example, studies have documented that PLWH indicate that they would welcome education or smoking cessation information from their provider, but that the topic is rarely addressed by providers [67]. Clinic-level interventions have the potential to help address these issues; some of those reviewed showed high feasibility and efficacy in their results, but there were few examples of these types of interventions. Thus, more studies are needed to identify effective models for clinic-level interventions to increase smoking cessation in an HIV care setting.

CONCLUSIONS

Cigarette smoking is a modifiable factor that poses great health risk to PLWH. This review identified a need for more robust studies focused on specific vulnerable groups to explore various strategies and theoretical frameworks for smoking cessation among PLWH. In particular, more smoking cessation interventions for PLWH are necessary in the South and for historically marginalized and underrepresented groups such as PLWH of color and PLWH who are sexual and gender minorities. Pilot or quasi-experimental studies have been conducted for PLWH, but more rigorous studies are necessary to better assess intervention effectiveness and increase generalizability of findings. Additionally, standardized measures for cessation must be identified to better compare and gauge the relative efficacy of various interventions across different populations. Intervention types that merit further development and research are those that utilize the SBIRT model, operate at the clinic level, and utilize web-based strategies.