HIV and Smoking Is a Deadly Intersection

Study shows smoking is more harmful than HIV itself

Man smoking cigarette.
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Cigarette smoking remains among the most daunting and detrimental health concerns facing people with HIV today. Compared to the general U.S. population, where the smoking prevalence has dropped in recent years to around 21 percent, as many as 42 percent of people living with HIV are classified as current smokers. That's an alarming statistic and one that is directly linked to an increase in both HIV-related co-morbidities and premature death.

HIV-Positive People Are Twice as Likely to Smoke

There is little research available to fully explain the disproportionately high rates of smoking within the HIV population. Some studies have suggested that high levels of anxiety and depression play an important part and that many turn to nicotine as a means to cope with the daily stresses of HIV.

But it's unclear whether these emotional issues are an instigating factor for tobacco use, or if they simply make cessation efforts less effective for those living with HIV.

Data is conflicting. According to a statistical analysis from the U.S. Centers for Disease Control and Infection (CDC), current HIV-positive smokers in U.S. tend to be older rather than younger, with 58 percent aged 45 and older, 40 percent aged 25 to 44, and only two percent aged 18 to 24.

These numbers suggest that HIV-related stress is not necessarily a causal factor for tobacco use, insofar as younger HIV-positive smokers—who comprise 26 percent of new infections—are far less likely to smoke than even their HIV-negative counterparts (two percent versus 19 percent). Rather, the figures echo a general trend in the U.S., whereby older smokers are simply less likely to explore smoking cessation than younger smokers (84 percent versus 66 percent).

By contrast, sexual orientation plays little part in smoking rates. In fact, the numbers are somewhat counterintuitive, with just as many heterosexuals smoking (51 percent) as gay, lesbians, or bisexuals (49 percent)—despite the fact that new infections among men who have sex with men (MSM) are three times higher than among heterosexuals.

This means that a greater percentage of HIV-positive smokers are, in fact, heterosexual. Why this remains unclear—particularly since smoking rates among gays, lesbians, and bisexuals in the general population are nearly twice that of heterosexuals, according to a 2010 report from the American Lung Association.

How Smoking Directly Impacts People With HIV

Smoking has a far greater impact on the prognosis of HIV-infected people in the developed world than any HIV-related illness. This is according to a 2013 study from Copenhagen University Hospital, which showed that smoking, in and of itself, reduces life expectancy in people with HIV by 12.3 years.

Furthermore, the risk of mortality (whether HIV-related and non-HIV related) was seen to be as much as five times greater in HIV-positive smokers than HIV-positive people who have never smoked.

Among the HIV-specific smoking risks:

  • Smoking is the single greatest risk factor associated with acute heart disease (ACS) in people with HIV. According to research from the University of Barcelona, the contribution of smoking to ACS in HIV-positive adults was greater than the contributions of either diabetes or hypertension and was almost twice as high as that in HIV-negative adults (54 percent versus 31 percent). The use of antiretrovirals or a person's CD4 count/viral load appeared to have little-to-no impact on whether HIV-positive smokers developed ACS or not.
  • Smoking is considered the foremost risk factor in the development of lung cancer. In fact, there is a 14-fold increase in lung cancer risk among HIV-positive smokers, independent of the person's CD4 count or history of HIV-related lung disease. Research from the Swiss HIV Cohort Study suggests that survival rates are poor for HIV-positive smokers who develop lung malignancies, with only 14 percent still alive two years after diagnosis. That said, former smokers were shown to have significantly lower risk than current smokers, highlighting the importance of smoking cessation in those with HIV.
  • Smoking further raises the risk of chronic obstructive pulmonary disease (COPD) and community-acquired bacterial pneumonia. Current smokers with HIV not only have more respiratory symptoms than non-smoking counterparts, they have a two-fold increase in the risk of death. Other studies have shown the relationship between smoking and esophageal candidiasis.
  • There is a strong association between smoking and human papillomavirus (HPV) infection in both women and men with HIV. HIV-positive women who smoke have between two and three times the risk for HPV infection than HIV-positive women who don't smoke. Similarly, smoking in HIV-positive men was associated with an increased risk for the development of precancerous HPV lesions. Recurrent HPV infections are directly linked to an increased risk of cervical cancer in women and anal cancer in men. Numerous studies suggest that smoking has adverse effects on a person's immunity, both systemic and mucosal (the latter of which include the protective Langerhans cells that line the cervix and anus). CD4 counts under 350 cells/mL are also considered an associative contributor.
  • Cigarette smoking can increase woman's risk of transmitting HIV to her baby during delivery, with premature membrane ruptures occurring more frequently in mothers who had smoked during the first trimester of their pregnancy. All told, the risk of vertical transmission was shown to be as high as three times that of non-smoking women with HIV.
  • Smoking is also associated with an increased risk of bone density loss (e.g. osteopenia, osteoporosis), and is considered an independent risk factor for fractures among those with HIV. Older age and white race are also predictors of incident fractures.

Benefits of Quitting

The long- and short-term benefits of quitting are both undeniable and clear. Smoking cessation progressively reduces the risk of cardiovascular disease in people with HIV, with one study demonstrating a reduction in risk of nearly 65 percent after three years. (Research from the Aquitaine Cohort Study in France suggests that cessation may, in fact, be the only factor associated with improvement of cardiovascular risk in people with HIV—greater even than lipid-lowering drugs or antiretroviral therapy.)

Similarly, the risk of lung cancer can be reduced by as much as 50 percent in HIV-positive smokers who have quit for a year or more. Comparable results are seen in patients with COPD, bacterial pneumonia, and other infectious and non-infectious respiratory conditions.

It's equally important to stress that sooner is better than later when it comes to quitting, particularly for those with compromised immune systems. Research from the Anderson Cancer Center at the University of Texas showed that smoking cessation can reduce the burden of HIV-related symptoms within as little as three months and that the symptoms can continue to decrease as the period of time without smoking increases.

Moreover, smoking abstinence is independently associated with improved adherence for those on antiretroviral therapy.

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