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. Author manuscript; available in PMC: 2022 Apr 1.
Published in final edited form as: AIDS Educ Prev. 2021 Apr;33(2):158–168. doi: 10.1521/aeap.2021.33.2.158

EXPERIENCES WITH SMOKING CESSATION ATTEMPTS AND PRIOR USE OF CESSATION AIDS IN SMOKERS WITH HIV: FINDINGS FROM A FOCUS GROUP STUDY CONDUCTED IN DURHAM, NORTH CAROLINA

Lauren R Pacek 1, Alicia D Holloway 1, Karen L Cropsey 1, Christina S Meade 1, Maggie M Sweitzer 1, James M Davis 1, F Joseph McClernon 1
PMCID: PMC8158019  NIHMSID: NIHMS1703675  PMID: 33821680

Abstract

Cigarette smoking remains disproportionately prevalent and is increasingly a cause of death and disability among people with HIV (PWH). Many PWH are interested in quitting, but interest in and uptake of first-line smoking cessation pharmacotherapies are varied in this population. To provide current data regarding experiences with and perceptions of smoking cessation and cessation aids among PWH living in Durham, North Carolina, the authors conducted five focus group interviews (total n = 24; 96% African American) using semistructured interviews. Interviews were recorded, transcribed, coded, and thematically analyzed. Major themes included ambivalence and/or lack of interest in cessation; presence of cessation barriers; perceived perceptions of ineffectiveness of cessation aids; perceived medication side effects; and conflation of the harms resulting from use of tobacco products and nicotine replacement therapy. Innovative and effective interventions must account for the aforementioned multiple barriers to cessation as well as prior experiences with and misperceptions regarding cessation aids.

Keywords: smoking, tobacco, cessation, HIV, qualitative research

Highly effective antiretroviral medications have resulted in people with HIV (PWH) now having life expectancies similar to their HIV-negative counterparts (Nakagawa et al., 2013). However, cigarette smoking is disproportionately prevalent among PWH (34%–43%) (Frazier et al., 2018; Mdodo et al., 2015; Pacek, Harrell, & Martin, 2014) as compared to the general population (14%) (Centers for Disease Control and Prevention, 2019). As a result, smoking-related illness is now a major cause of morbidity and mortality among PWH (Altekruse et al., 2018; Ehren et al., 2014; Shiels et al., 2011). In fact, it is estimated that 24% of all deaths among PWH receiving antiretroviral therapy are attributable to tobacco use (Lifson et al., 2010) and that smokers with HIV now lose more life-years to smoking than they do to HIV itself (13 versus 5 years) (Helleberg et al., 2013).

Many (49%–74%) smokers with HIV report an interest in quitting (Mamary et al., 2002; Pacek et al., 2017b; Pacek, Latkin, et al., 2014b). Despite this interest, smoking cessation remains challenging for this population. HIV-positive smokers have lower smoking abstinence rates than HIV-negative smokers, and evidence suggests that conventional smoking cessation interventions have moderate to limited effectiveness among PWH (Browning et al., 2013; Niaura et al., 2000; Pool et al., 2016). Some first-line smoking cessation treatments may also be underutilized in this population. Specifically, 43%–58% of smokers with HIV report using nicotine replacement therapy (NRT; e.g., nicotine patch) and only 4%–9% report using pill-based smoking cessation medications (e.g., varenicline, bupropion) during a smoking cessation attempt (Pacek et al., 2017b; Pacek, Latkin, et al., 2014a). Interest in using these modalities varies considerably as well: 59.1% report interest in using NRT, while 26.3% and 27.0% report interest in using bupropion or varenicline, respectively (Pacek et al., 2017b).

Despite data regarding interest in quitting, and interest in/use of smoking cessation aids among PWH, our understanding of HIV-positive smokers’ experiences when attempting cessation and using cessation aids remains incomplete. Of the existing qualitative research on this topic, a portion is somewhat outdated (i.e., published in 2004, 2011) (Matthews et al., 2011; Reynolds et al., 2004) and/or has been conducted in limited geographic areas (i.e., midwestern United States: Fletcher et al., 2019; Matthews et al., 2011; Reynolds et al., 2004; Shirley et al., 2018; central Canada: Schultz et al., 2014). Given the temporal and regional differences that may impact HIV-positive smokers’ experiences with, and perceptions related to, attempting to quit and use of various smoking cessation modalities, current research conducted among individuals in other geographic areas is warranted. Increased understanding of these experiences and perceptions can facilitate more precise thinking about targeted smoking cessation interventions for this vulnerable population.

To address these gaps in the literature, we used a series of focus group interviews to understand experiences with, and perceptions of, smoking cessation attempts and use of smoking cessation aids among PWH who smoke. Given the documented difficulties with smoking cessation, as well as relatively low use of smoking cessation aids among PWH, we hypothesized that our sample might express somewhat negative or unenthusiastic views of smoking cessation and smoking cessation aids.

METHODS

The methods have been described previously (Pacek et al., 2021), but briefly, we conducted five focus groups during January–March 2018 among PWH. Each group enrolled 2–8 English-speaking participants. Study inclusion criteria were as follows: (a) age 18–65; (b) HIV-positive; (c) current engagement in HIV care; (d) self-report smoking ≥ 5 cigarettes per day for the past year; (e) expired breath carbon monoxide reading > 8 ppm; and (f) expired breath alcohol level = 0.000. This research took place at an academic medical center in Durham, North Carolina, United States. Recruitment consisted of advertising in local infectious diseases clinics, word of mouth, and referral of participants from prior studies in our laboratory.

All study participants provided written informed consent prior to data collection. Focus groups were preceded by several self-report questionnaires to obtain sociodemographic information, tobacco use history, and HIV health history. Two facilitators led the focus group discussions, following a semistructured interview guide, which explored participants’ beliefs about and experiences with smoking in the context of HIV, prior use, and perceptions of smoking cessation medications. One facilitator (LRP) was the primary discussion leader, and the other (ADH) took notes on group dynamics.

DATA ANALYSIS

Focus group discussions were recorded and transcribed verbatim. Data were analyzed using the natural language processing software NVivo 12 (QSR International Pty Ltd, 2018). A priori topics were used to develop an initial qualitative codebook. Transcripts were analyzed using a two-stage deductive and inductive analysis approach; initial deductive coding was conducted independently by two analysts using the aforementioned a priori codebook. Intercoder agreement was assessed on three out of five of the interview transcripts; discrepancies were resolved through group discussion, and edits were made to the codebook to aid in application of the codes in future transcripts. Once initial deductive coding was complete, coding reports were generated and reviewed by two qualitative analysts to identify and code emergent data related to each a priori topic (i.e., inductive coding process). Emergent codes were grouped and categorized thematically based on how the data were directly described or implied in the interviews. Transcripts were analyzed by members of the BASE Lab at Duke University. The Institutional Review Board at Duke University School of Medicine approved all procedures prior to their implementation.

RESULTS

PARTICIPANTS

Participants were 24 HIV-positive current cigarette smokers (Table 1). On average, participants were 50.2 years of age (SD = 10.4); 38% were female, 96% were African American, and 100% were of non-Hispanic origin. Mean length time since HIV diagnosis was 17.3 years (SD = 11.2). Participants reported smoking 12.2 (SD = 4.6) cigarettes per day and had an average Fagerström Test for Nicotine Dependence (Heatherton et al., 1991) of 5.3 (SD = 1.8). Most participants (62.5%) reported being “slightly” or “somewhat” interested in quitting smoking, and 58.3% reported having made at least one serious quit attempt within the past year. Qualitative outcomes of structured interviews are provided below by category.

TABLE 1.

Characteristics of Current Smokers Living With HIV Who Participated in Focus Group Interviews (n = 24)

Characteristic % or mean (SD)
Female 37.5%
African American 96%
Non-Hispanic 100%
Age, years, Mean (SD) 50.2 (10.4)
Years since initial HIV diagnosis, Mean (SD) 17.3 (11.2)
Lifetime AIDS diagnosis 16.7%
CPD, Mean (SD) 12.2 (4.6)
FTND, Mean (SD) 5.3 (1.8)
Years smoking, Mean (SD) 35.0 (10.3)
Made a quit attempt in past year 58.3%
How interested in quitting smoking
 Not at all 12.5%
 Slightly 16.7%
 Somewhat 45.8%
 Very/extremely 4.2%
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Note. CPD = cigarettes per day; FTND = Fagerström Test for Nicotine Dependence.

INTEREST IN QUITTING

Ambivalence About Quitting.

When discussing current interest in quitting smoking, some participants indicated ambivalence about undertaking the process. One participant reported vacillating between beliefs that it is too late to quit while also expressing a desire to stop smoking.

In the back of my mind somewhere it’s, “Wait a minute. It’s too late to stop now.” You know? … You know, I never thought I would get to be this old. You know what I’m saying? And, um, now sometimes I get a little more reminded about the things that I do, but I would love to stop smoking cigarettes.

No Interest in Cessation.

Other participants were less ambiguous regarding their lack of desire to quit smoking at the present time. Two participants, when discussing smoking cessation assistance options with their health care provider, reported the following:

Participant A: They tell you at [the doctor’s office] … what kind of help do you want to help you stop smoking?

Participant B: None!

Participant A: Yeah. I just look at them and smile.

Participant B: I don’t want anything.

Participants also commonly reported a lack of interest in smoking cessation given that they had not yet experienced consequences of smoking and/or HIV that they considered to be severe enough to warrant quitting. One participant stated the following:

I mean—honestly, if I’m living with HIV and it ain’t killed me yet so I’mma keep doing what I’m doing nonstop. I ain’t got to [quit]. I mean, my old man smoked all his life and then when he got—when he retired, that’s when he died. So that’s letting me know I can keep pushing, you know, no matter what. HIV, smoking cigarettes, or whatever that’s what I do—that’s what I do. That’s just me.

BARRIERS TO QUITTING

Drug and Alcohol Use.

Participants commonly reported that drug use—and cannabis use, in particular—served as significant barriers to smoking cessation. This appeared to be largely due to the oftentimes concurrent use of cannabis and cigarettes. Illustrating this phenomenon, one participant stated: “I smoke marijuana also and when I smoke umm … When I smoke a blunt … and the cigarette intensifies my high.” Two additional participants had the following brief exchange during one focus group interview:

Participant A: If you get high, you got to have a cigarette, you know.

Participant B: A joint and a Newport.

Similarly, participants indicated that the consumption of alcohol served as a barrier to quitting, particularly given that the two substances are often administered concurrently. Specifically, one participant stated the following: “And drinking. When I drink, I gotta have me a cigarette.”

Social Environment.

It was frequently reported that encountering smoking cues within the social environment served as a significant barrier to participants’ smoking cessation attempts. One participant reported that a number of friends were current smokers, which complicated attempts to quit. Specifically, the individual stated: “I’d quit, but I don’t want to give up my friends and I know my friends smoke so I’mma keep my friends.” Another participant described experiences of being confronted with other smokers and tobacco advertisements during daily life:

And, you know, in this society, you can’t get around it. Every time you turn around it’s advertised. How a person gonna quit smoking, and he got a real bad smoking habit, how you gonna quit? Every time you turn around, this person lighting up a cigarette.

PRIOR EXPERIENCE WITH SMOKING CESSATION AIDS

Ineffective.

The perception of smoking cessation aids as being ineffective was commonly reported by participants. One participant, in particular, indicated that the nicotine patch was somewhat effective for a short time (i.e., on the order of hours), but ultimately was not effective at curbing cigarette cravings long term.

Well, the nicotine patch, for me—when I first tried it, it was—it did kind of wean me off for a little bit … I’ll give it between two to four hours, but I was like, “Man, I need me a cigarette.”

Another participant discussed past experiences of having utilized a variety of smoking cessation aids, with little success.

I mean, I have tried everything, you know, and none of it worked for me, I mean, maybe a little, you know, um, but, it, I’m still smoking. And so—and, but I think, you know, if I really wanna quit, I’m gonna have to really—I mean, I’m just gonna have to set my mind to it, and then, that’s gonna do it.

Unpleasant to Use.

Participants frequently mentioned that using smoking cessation aids—and nicotine replacement therapy, in particular—as directed could be relatively unpleasant. One participant articulated the difficulties experienced when using nicotine gum and nicotine lozenges:

I had gum that’s nasty. That sticks to my teeth. I had the lozenge that is the worst flavor that they ever dared to put in life something to give to somebody.

Side Effects.

Although relatively few participants had reported previously utilizing pill-based medications for smoking cessation (i.e., varenicline, bupropion), individuals who had previously used these cessation modalities discussed their experiences with side effects (e.g., sleep disturbances, mood swings). One participant indicated that prior experiences of side effects when taking bupropion would be a deterrent to using it again:

And like that [Zyban]. I would never touch it again. I done had too many side effects from that.

Another participant reported concerning side effects associated with the use of varenicline:

It [Chantix] had me flipping out. It did. Had me tripping. I had nightmares. I was … ‘bout to lose my mind. I wanted to hurt people.

CONCERNS ABOUT USING SMOKING CESSATION AIDS

Conflation of Harms Resulting From Use of Tobacco and Nicotine Replacement Therapy.

During discussions regarding participants’ prior use of various smoking cessation aids, a number of participants raised concerns regarding the use of nicotine-containing cessation aids. During one focus group interview, two participants questioned the purpose of nicotine in these cessation aids:

Participant A: Well, does the patch … puts nicotine into your body? You trying to get the nicotine out of your body. But you still getting nicotine in your body.

Participant B: [You want to get nicotine] out of your body. Why would they give it to put it in there?

Concerns about Drug–Drug Interactions.

Several participants also expressed concerns regarding potential drug–drug interactions that might occur between their antiretroviral medication regimens and smoking cessation medications. One participant stated the following:

And it’s like some people—some of us take so many pills that you might take this Chantix pill and take it with the other chemical reactions to our other stuff, be like you might get a setback from that pill, and it mess you up.

DISCUSSION

We conducted focus group interviews to explore the beliefs of PWH who smoke regarding experiences with and perceptions of smoking cessation attempts, and use of smoking cessation aids. In addition, findings emphasize the need to address multiple smoking cessation barriers among PWH and highlight common negative perceptions and prior experiences regarding first-line smoking cessation pharmacotherapies, as well as participants’ conflation of the harms resulting from tobacco product use and the role of nicotine in NRT.

Most participants reported being “slightly” or “somewhat” interested in smoking cessation—at least when completing a self-report questionnaire—which is consistent with what is seen in the larger literature (Mamary et al., 2002; Pacek et al., 2017a, 2017b; Pacek, Latkin, et al., 2014b; Tesoriero et al., 2010). However, during focus group discussions in the present study, participants voiced their ambivalence about quitting or outright lack of interest in cessation. This discrepancy may be at least partially explained in a number of ways. Affirmative answers to survey questions regarding interest in cessation may have been influenced by social desirability bias, whereas greater elaboration during focus group interviews may have allowed for clarification of participants’ actual intentions and interests. In addition, prior research has found that while interest in smoking cessation among PWH is reportedly high, individuals may have vastly differing interpretations of what “quitting” means. In one study among PWH who were in the “contemplation” and “preparation” Stages of Change (DiClemente et al., 1991), only 45% of participants indicated total abstinence from smoking as a cessation goal (Humfleet et al., 2009). Conversely, others reported goals of quitting smoking with the possibility of relapse (32.2%), abstaining for a time (5.6%), or smoking in a controlled manner (4.4%), while the remaining respondents indicated that they would like to smoke occasionally (2.2%), had no clear goal (4.4%), or had some other goal (6.1%) (Humfleet et al., 2009).

A number of barriers to cessation were also identified during focus group interviews that may dissuade smokers from making a cessation attempt. For instance, one participant articulated concerns regarding potentially losing friends if the individual were to quit smoking. Prior research has reported on the importance of social environmental factors in cessation attempt outcomes among the general population (Christakis & Fowler, 2008). Among PWH, having a significant other who is a current smoker increases the likelihood of smoking (Pacek, Latkin, et al., 2014a), and having a significant other who has used a smoking cessation aid in the past increases the likelihood of prior NRT/smoking cessation medication use (Pacek, Latkin, et al., 2014b). Moreover, prior qualitative research among PWH has found that social isolation and concerns about cessation having negative effects on social networks is a common barrier to cessation (Fletcher et al., 2019; Matthews et al., 2011; Reynolds et al., 2004; Shirley et al., 2018).

Participants commonly discussed alcohol and cannabis use as being barriers to successful smoking cessation. These reports are consistent with prior literature on PWH who smoke (Matthews et al., 2011; Schultz et al., 2014) as well as research on the general population indicating that comorbid substance and alcohol use may contribute to lapse events and temptation to smoke (Dermody & Shiffman, 2020). Collectively, these findings highlight the need to address both individual (e.g., substance use) and social factors in smoking cessation among PWH.

Participants expressed their dissatisfaction with various smoking cessation modalities. Consistent with prior research among PWH, participants reported perceiving that NRT was ineffective at curbing cravings to smoke and that nicotine gum is unpleasant to use (Shirley et al., 2018). Also consistent with prior research (Schultz et al., 2014; Shirley et al., 2018), participants in the present study reported experiencing side effects associated with non-nicotine prescription smoking cessation medications (i.e., varenicline, bupropion) that reduced their enthusiasm for using those medications in the future. Participants also expressed confusion regarding the presence of nicotine in NRT products. A perception that nicotine is a major causal factor in cancer, cardiovascular disease, and other tobacco-related disease outcomes is common among PWH (Pacek et al., 2017a), as well as among the general population of smokers and nonsmokers (King et al., 2018; O’Brien et al., 2017; Patel et al., 2013). Prior studies show that individuals are generally able to accurately identify nicotine as being the primary addictive component in tobacco products (King et al., 2018; O’Brien et al., 2017; Pacek et al., 2017a). However, a nuance is that they can conflate the lower health risks associated with use of NRT with the far more considerable health risks of smoking (King et al., 2018; O’Brien et al., 2017; Pacek et al., 2017a; Patel et al., 2013). These perceptions affect uptake of NRT as a cessation modality as well, with studies finding that smokers believe that NRT is as harmful as smoking (Shiffman et al., 2008) and that NRT is a cause of smoking-related diseases (Black et al., 2012; Mooney et al., 2006). These perceptions are unfortunate and have implications for reduced interest in, and uptake of, nicotine-containing smoking cessation aids. These implications are problematic for the general population of smokers, of course, but particularly so for vulnerable populations for smokers—such as PWH, who face a disproportionate burden in terms of the prevalence of smoking as well as smoking-related health sequelae. These findings suggest the need for educational interventions to clarify the role of nicotine in tobacco use and NRT products with the goal of increasing willingness to use NRT.

This study has several limitations that merit acknowledgment. These include the small sample size—although not uncommon for focus group studies—and that recruitment for this study was limited to Durham, North Carolina. As such, results may not generalize to PWH in other regions of the United States or to those living in other countries, as well as to those who are not currently engaged in HIV care. In addition, the focus of the present study was pharmacotherapies for smoking cessation. Future research should explore the experiences of PWH who are not engaged in HIV care, as well as former smokers, in order to understand additional barriers to cessation and experiences with smoking cessation and cessation aids. A significant strength of the article is that participants resided in the historical “tobacco belt” of the United States, a geographical region that is distinct from what has been included in the extant literature.

CONCLUSIONS

This study contributes to the evidence base for informing smoking cessation intervention development among PWH. Findings highlight the need to carefully consider multilevel factors (i.e., individual and social factors) that may serve as barriers to smoking cessation among PWH. In addition, HIV-positive smokers’ prior experiences with and perceptions of smoking cessation aids—including beliefs that use of NRT and tobacco products result in equivalent degrees of harm—should be considered when assisting cessation attempts in this population.

Acknowledgments

We would like to acknowledge and thank Mr. Brian Perry and Ms. Adora Nsonwu of the BASE Lab at Duke University for their work regarding transcript coding and data analysis.

This work was supported by National Institutes of Health grants (K01DA043413; P30AI064518; R01DA044112; DP2DA040226). NIDA and NIAID had no role in the study design, collection, analysis or interpretation of the data, writing the manuscript, or the decision to submit the paper for publication.

Footnotes

The authors have no competing financial interests to declare.

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