How health systems can integrate tobacco-cessation interventions for HIV, tuberculosis patients

HIV, tuberculosis and tobacco use are among the leading causes of death worldwide because of the social, systemic and biologic factors. The interplay makes treatment difficult, but there are ways that health systems can get through to patients, starting specifically with tobacco-cessation techniques, according to a recent perspective published in The New England Journal of Medicine.

“Many people throughout the world living with tuberculosis or HIV who use tobacco are receiving the medications they need to treat those life-threatening infections," the authors write, including Jonathan Shuter, M.D., from the Division of Infectious Diseases, Department of Medicine, Albert Einstein College of Medicine, New York. "The benefits associated with such treatment could be even greater if their care was delivered by medical systems that were ready, willing, and able to offer comprehensive care, including effective tobacco-cessation treatment."

The integration of tobacco-cessation services into HIV and tuberculosis care begins when there is a sense of urgency within health systems. This can look like screening patients for tobacco use at intake.

“All clinicians should be trained to — at a minimum — use the ‘three As’ (ask about tobacco use, advise users to quit, and assist users in accessing cessation resources) or the ‘ABCs’ (ask about tobacco use and offer brief counseling and cessation support to users) at every clinical encounter,” the authors continue.

Anti-tobacco messaging should also be present throughout the office, whether that appears as brochures, posters or a strict anti-smoking policy around the building parameters.

Health systems should also partner with public health officials and policymakers to implement taxes on tobacco sales, support staff for cessation help lines and fund tobacco use research. For example, in low- and middle-income countries (LMICs) such as Nepal and Bangladesh, the World Health Organization’s Framework Convention of Tobacco Control (WHO FCTC) has successfully implemented anti-tobacco care in tuberculosis treatment settings. This is significant because 84% of the world's 1.2 billion smokers currently reside in LMICs. Adopted in 2005, the WHO FCTC was the first international treaty to bring attention specifically to tobacco cessation.

The authors write that it’s important to understand most patients will not be successful at their first attempt to quit smoking, and because of this, clinicians and health systems should be persistent and meet patients where they are.

“Most people living with tuberculosis or HIV know that tobacco use is harmful, but far fewer are aware that tobacco use amplifies the health risks associated with these infections,” the authors write.

Tobacco use causes approximately 7 million deaths a year, killing approximately half of all users who don’t quit.

There are more than 1.2 million people living with HIV in the United States, and approximately 34 to 47% smoke cigarettes, which can impair immune function and render antiretrovirals less effective. People living with HIV smoke at approximately twice the rate of the general population, and one study found that HIV patients on antiretrovirals who smoke are more likely to die from lung cancer than from HIV itself.

Tobacco addiction can be treated. Long, frequent counseling sessions are more effective than shorter ones. Additionally, behavioral therapy is more effective when paired with pharmacotherapy. The most effective treatments are nicotine replacement therapy, in which the doses of nicotine are progressively decreased, and bupropion, an antidepressant that lessens the side effects of nicotine withdrawal.