NYSDOH AI HIV Tobacco Cessation Improvement Campaign

January 2017

Introduction

This concept paper describes the implementation of the New York State Department of Health AIDS Institute (NYSDOHAI) HIV Tobacco Cessation Improvement Campaign, which isdesigned to improve the healthand decrease morbidity and mortality of people living with HIV in New York State. The purpose of this campaign is to promote tobacco screening and tobacco cessation in this population.

The campaign will be managed by AIDS Institute staff with the guidance and support of the Tobacco Cessation steering committee, which consists of members of the Quality of Care Clinical Advisory Committee (QAC), members of the Consumer Advisory Committee (CAC), members of the Young Adult Consumer Advisory Committee (YACAC), as well as representatives from New York City Department of Health and Mental Hygiene (DOHMH), NYSDOH, and other key stakeholders.

Background

Tobacco use is the single most preventable cause of death among the general adult population in the United States, resulting in approximately 480,000 smoking-related deaths every year throughout the country and accounting for over $133 billion a year in medical costs.[1]

To combat tobacco use, the NYSDOH Bureau of Tobacco Control offers a variety of resources for providers and consumers aimed at improving treatment and outcomes of tobacco cessation throughout New York State. To assist individuals with quit attempts, the NYSDOH Bureau of Tobacco Control offers a service called ‘New York State Smokers’ Quitline,’ which provides free and confidential telephone counseling, discounted smoking cessation medications, nicotine replacement therapy starter kits, and a variety of other resources including a savings calculator.[2] NYC DOHMH also provides a website called ‘NYC Quits’ which includes tools and information on quitting, coping with withdrawal, and locations of smoking cessation programs through New York City. NYC Quits directs individuals to the NYS Smokers’ Quitline for assistance with counseling and medications.[3]

Cigarette smoking is disproportionately common among people living with HIV/AIDS (PLWHA), with estimates of national prevalence ranging from approximately twice to triple that of the general adult population[4],[5],[6]According to the CDC, 16.6% of the New York State general adult population identified as smokers in 2013.[7]However, in the 2013 eHIVQUAL data set, approximately 44% (n=4556) of HIV infected individuals in NYS reported using tobacco.[8]

Mortality risk is significantly elevated among PLWHA who smoke tobacco, compared with those who do not smoke.6,[9]This risk is driven by the combined effects of HIV/AIDS-related and smoking-related illnesses.Helleberg et al. (2013) found that PLWHA who smoke tobacco are at a greater risk of AIDS-related deaths than HIV-infected nonsmokers, and that approximately 61% of deaths among PLWHA can be attributed to tobacco smoking. This study concluded that with advances in HIV treatment and management, PLWHA who smoke tobacco now lose more years of life to smoking than to the virus.7

Cigarette smoking exacerbates immune system impairment in PLWHA, and results in a diminished response to antiretroviral therapies.[10]PLWHA who smoke tobacco are also at greater risk of smoking-related cancers[11] as well as cardiovascular and pulmonary diseases6,9,[12] compared to smokers who are not HV-infected.

Tobacco use among PLWHA is associated with lower viral load suppression rates and poor health outcomes. According to eHIVQUAL data, only 70% (n=3205) of HIV-infected smokers were virally suppressed at last test in 2013, compared to 81% (n=4658) of non-smoking PLWHA.As a result, these individuals are at increased risk for co-morbid illnesses and death.

Tobacco Road to Cessation

Screened / Counseled / Prescribed Pharmacotherapy / Reduced Tobacco Use / Quit > 7 days / Quit > 30 days

There is much evidence to support the use of screening, counseling and medication to increase the likelihood of successful tobacco cessation.While the most effective methods of tobacco cessation for PLWHA remain unestablished, treatment typically consists of medication (including Bupropion SR, Varenicline (Chantix), and nicotine replacement therapies such as nicotine patches and gum) along with counseling.

Shuter et al. recently demonstrated success in a web-based tobacco cessation intervention by adapting a group therapy counseling program, “Positively Smoking Free”, into a web-based curriculum called “Positively Smoking Free on the Web” (PSFW).[13] Completion of this online program combined with the offer of nicotine replacement patches showed significant impact on tobacco cessation, with increased rates of smoking abstinence compared to the group receiving standard care, defined as distribution of a brochure and offer of nicotine replacement patches. While previous studies have suggested the effectiveness of web-based interventions for smoking cessation among the general population[14] as well as the success of online and mobile device tools with PLWHA,[15],[16] this study is unique in examining the delivery of tobacco cessation counseling specifically for PLWHA and is the first to demonstrate the efficacy of web-based counseling for smokers living with HIV/AIDS.11Gritz et al. (2013) also saw success in a phone-delivered smoking cessation intervention for PLWHA, with counseling via prepaid cell phones resulting in increased abstinence rates when combined with the standard treatment of written materials and instructions on obtaining nicotine patches.[17]

Due to the extensive impact of tobacco use on PLWHA, smoking cessation has garnered national attention as a healthcare priority for HIV-infected individuals. In July 2014, the CDC highlighted an HIV-infected smoker in its anti-smoking “Tips from Former Smokers” campaign. Organizations such as the AIDS Education and Training Center National Coordinating Resource Center (AETC NCRC) and POZ magazine have further publicized the issue through recent blog posts and articles.[18],[19]

Healthcare providers play an important role in facilitating and supporting tobacco cessation. In 2012 throughout New York State, 90.9% of adult smokers were asked by a health care provider if they smoked, 74% were advised by the provider to quit smoking, but only 47.8% were assisted by a provider in the quit attempt, based on data from NYSDOH Bureau of Tobacco Control New York State Adult Tobacco Survey.[20]According to eHIVQUAL data, 83% of HIV positive tobacco users throughout New York State received cessation counseling in 2013.6Rates of treatment and referrals to treatment were not captured in the 2013 eHIVQUAL review.

To ensure that providers are adequately addressing and treating tobacco dependence, the NYSDOH Bureau of Tobacco Control encourages standardized clinic-level system changes. These changes include the implementation of a tobacco-user identification system in EMRs at every clinic, the provision of trainings, materials, and feedback to providers, and the establishment of clearly defined responsibilities for staff members regarding dependence treatment. Widespread implementation of these systems canimprove screening, treatment and outcomes of smoking cessation for all populations, including HIV-infected individuals, throughout New York State.[21]

Thefirst 2014 joint meeting of the advisory committees (QAC, CAC, and YACAC) included an extensive breakout discussion on improving the rates of tobacco cessation among PLWHA in NYS.Participants of the breakout group provided the followingrecommendations to reduce tobacco use throughout the state[22]:

  1. Identify appropriate clinical indicators and reporting mechanisms for measuring tobacco cessation
  2. Develop multipronged campaign components including quality improvement activities and marketing/media campaigns
  3. Identify consumer leaders in the campaign
  4. Provide capacity building to improve provider-patient interactions related to tobacco cessation
  5. Monitor self-reported data on the use of clinical treatment for tobacco cessation
  6. Engage HIV community stakeholders to support tobacco cessation efforts

Campaign Infrastructure

Steering Committee
The campaign will be advised by a committee comprised of members of the Quality of Care Clinical Advisory Committee, Consumer Advisory Committee, Young Adult Consumer Advisory Committee, NYSDOH Tobacco Control program, NYCDOHMH, other clinical experts and key stakeholders. The steering committee will meet monthly between January and June 2016 to advise the Working Group on clinical issues for the campaign.

Working Group
The campaign will be implemented by a working group comprised of key NYSDOH AIDS Institute Office of the Medical Director staff. The working group will work closely with the steering committee as well as the QAC and CAC.

1

New York State Department Of Health AIDS Institute HIV Tobacco Cessation Improvement Campaign

[1] CDC, “Smoking & Tobacco Use: Fast Facts”

[2] NYSDOH, “New York State Smokers’ Quitline”

[3] NYC DOHMH, “NYC Quits”

[4] CDC, “Tips from Former Smokers: Cigarette Smoking in the United States”

[5]Tesoriero, James M., et al. "Smoking among HIV positive New Yorkers: prevalence, frequency, and opportunities for cessation." AIDS and Behavior 14.4 (2010): 824-835.

[6]Lifson, Alan R., et al., “Smoking-related health risks among persons living with HIV in the strategies for management of antiretroviral therapy clinical trial.” American Journal of Public Health. 100.10 (2010).

[7] CDC, 2011 – 2013, “Behavior Risk Factor Data: Tobacco Use (2011 to present)”

[8] NYSDOH AIDS Institute eHIVQUAL, 2013

[9]Helleberg, Marie, et al. "Mortality attributable to smoking among HIV-1–infected individuals: a nationwide, population-based cohort study." Clinical Infectious Diseases 56.5 (2013): 727-734.

[10]MIGUEZ‐BURBANO, MARIA JOSE, et al. "Impact of tobacco use on the development of opportunistic respiratory infections in HIV seropositive patients on antiretroviral therapy." Addiction biology 8.1 (2003): 39-43.

[11]Helleberg, Marie, et al. "Risk of cancer among HIV-infected individuals compared to the background population: impact of smoking and HIV." AIDS 28.10 (2014): 1499-1508.

[12]Moscou-Jackson, Gyasi, et al. "Smoking-cessation interventions in people living with HIV infection: a systematic review." Journal of the Association of Nurses in AIDS Care 25.1 (2014): 32-45.

[13]Shuter, Jonathan, et al. "Feasibility and preliminary efficacy of a web-based smoking cessation intervention for HIV-infected smokers: A randomized controlled trial." JAIDS Journal of Acquired Immune Deficiency Syndromes 67.1 (2014): 59-66.

[14]Rooke, Sally, et al. "Computer‐delivered interventions for alcohol and tobacco use: a meta‐analysis." Addiction 105.8 (2010): 1381-1390.

[15]Côté, José, et al. "Acceptability and feasibility of a virtual intervention to help people living with HIV manage their daily therapies." Journal of telemedicine and telecare 18.7 (2012): 409-412.

[16] Horvath, K., Oakes, J., Rosser, B., Danilenko, G., Vezina, H., Amico, K., Williams, M., Simoni, J. 2013.

Feasibility, acceptability and preliminary efficacy of an online peer-to-peer social support ART adherence intervention. AIDS and Behavior 17(6): 2031-2044.

[17]Gritz, Ellen R., et al. "Long-term Outcomes of a Cell Phone–Delivered Intervention for Smokers Living With HIV/AIDS." Clinical infectious diseases 57.4 (2013): 608-615.

[18]Brooks, 2014

[19] POZ, “CDC Campaign Wants HIV-Positive Smokers to Quit”

[20] Wendland, 2014

[21] Wendland, 2014

[22]NYSDOHAI Advisory Meeting Report, September 2014