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Drug and Alcohol Dependence 138 (2014) 220–224

Contents lists available at ScienceDirect

Drug and Alcohol Dependence

journa l homepage: www.e lsev ier .com/ locate /drugalcdep

hort communication

nterest in quitting and lifetime quit attempts among smokers livingith HIV infection

auren R. Paceka,b,∗, Carl Latkinc,d, Rosa M. Cruma,b,d, Elizabeth A. Stuartb,e,my R. Knowltonc

Johns Hopkins University School of Medicine, Department of Psychiatry and Behavioral Sciences, Baltimore, MD 21205, United StatesJohns Hopkins University Bloomberg School of Public Health, Department of Mental Health, Baltimore, MD 21205, United StatesJohns Hopkins University Bloomberg School of Public Health, Department of Health, Behavior & Society, Baltimore, MD 21205, United StatesJohns Hopkins University Bloomberg School of Public Health, Department of Epidemiology, Baltimore, MD 21205, United StatesJohns Hopkins University Bloomberg School of Public Health, Department of Biostatistics, Baltimore, MD 21205, United States

r t i c l e i n f o

rticle history:eceived 29 October 2013eceived in revised form 31 January 2014ccepted 2 February 2014vailable online 15 February 2014

eywords:igarette smokingIV/AIDSocial environmentocial supportnformal caregiving

ultiple imputation

a b s t r a c t

Introduction: Cigarette smoking is highly prevalent among people living with HIV, and is associated withmany negative health outcomes, including death. There is little research on smoking behaviors such asinterest in quitting and lifetime quit attempts among smokers living with HIV. Existing research hasfocused on individual-level characteristics, to the neglect of social environmental characteristics. Weexplored individual- and social-level characteristics associated with interest in quitting and lifetimenicotine replacement (NRT) or medication use for smoking cessation.Methods: Data are from a study of participants recruited from clinic and community venues originallydesigned to examine social environmental influences on current/former drug users’ HIV medicationadherence and health outcomes. This analysis comprised 267 current smokers living with HIV. Chi-squaretests were used to describe the sample; logistic regression was used to explore associations betweencovariates and outcomes.Results: In adjusted analyses, older age (age 54–65: aOR = 4.64, 95% CI = 1.59–13.47) and lifetimeuse of NRT/medications (aOR = 2.02, 95% CI = 1.08–3.80) were associated with an interest in quittingsmoking. Additionally, older age (age 45–49: aOR = 3.38, 95% CI = 1.57–7.26; age 54–65: aOR = 2.7095% CI = 1.20–6.11), White race (aOR = 3.56, 95% CI = 1.20–10.62), and having a Supporter who hadused NRT/medications for cessation (aOR = 2.13, 95% CI = 1.05–4.29) were associated with lifetime

NRT/medications use.Conclusions: Findings corroborate prior research concerning individual-level characteristics, and indicatethe importance of social-level characteristics in association with prior use of NRT/medications for ces-sation. Findings have implications for the implementation of cessation interventions for smokers livingwith HIV.

© 2014 Elsevier Ireland Ltd. All rights reserved.

. Introduction

The prevalence of smoking has declined among the US gen-ral population (Centers for Disease Control, 2012), but remainsighly prevalent among people with HIV (40–70%; Gritz et al., 2004;

amary et al., 2002; Burkhalter et al., 2005; Crothers et al., 2005;

ifson et al., 2010). Accordingly, smoking-related conditions havencreasingly emerged among this group (Diaz et al., 2002; Crothers

∗ Corresponding author at: 5510 Nathan Shock Drive, Suite 1708, Baltimore, MD1224, United States. Tel.: +1 410 550 1975; fax: +1 410 550 0030.

E-mail address: lpacek@jhmi.edu (L.R. Pacek).

ttp://dx.doi.org/10.1016/j.drugalcdep.2014.02.008376-8716/© 2014 Elsevier Ireland Ltd. All rights reserved.

et al., 2006; Lifson et al., 2010; Miguez-Burbano et al., 2005; Kirket al., 2007; Petoumenos et al., 2011; Friis-Møller et al., 2003). ADanish study found that HIV-infected smokers lose more life-yearsto smoking than to HIV (Helleberg et al., 2013) and among an inter-national cohort 24% of deaths in the HAART era were attributableto tobacco use (Lifson et al., 2010).

Promoting smoking cessation is essential. In one study, 81% ofsmokers with HIV reported receiving medical advice to quit smok-ing (Burkhalter et al., 2005). Additionally, research indicates that

most (63–75%) smokers with HIV are interested in or thinking aboutquitting (Mamary et al., 2002; Tesoriero et al., 2010).

Research on cessation aid use and factors influencing inter-est in cessation among people with HIV is scarce. Among one

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ample, drug use, greater emotional distress, and fewer prior quitttempts were associated with less interest in quitting (Burkhaltert al., 2005). In other populations (e.g., homeless; injection drugsers; methadone maintenance patients), self-efficacy for quit-ing, smoking-related health symptoms (Arnsten et al., 2004), olderge, absence of alcohol abuse (Clarke et al., 2001), lower nicotineependence, and lifetime cessation pharmacotherapy use (Nahvit al., 2006) were associated with an interest in quitting.

Little research has explored factors associated with an inter-st in quitting and use of cessation aids among smokers with HIV.revious research has focused on individual-level factors, like agend drug use, to the exclusion of social-level factors. Social factorsre associated with drug use and medication adherence behaviorsKnowlton et al., 2006; Magura et al., 2011), and may influencenterest in quitting or quit attempts.

The aim of this study was to examine individual- and social-levelharacteristics and their association with two outcomes: interestn quitting smoking and lifetime use of nicotine replacement ther-py (NRT) or medications for cessation among smokers with HIV. Aecond aim was to explore the types of interventions that currentmokers were interested in utilizing.

. Methods

.1. Data source

Data came from the BEACON Study, described previously (Pacek et al., 2013).riefly, the study recruited: (1) Index participants on antiretroviral therapy whoere current/former injection drug users; and (2) Supporter participants (i.e., indi-

iduals who provided social support to the Index participants), recruited withuthorization from Index participants. This sample includes 267 Index participantsho reported current smoking. The Institutional Review Board at Johns Hopkinsniversity Bloomberg School of Public Health approved this study.

.2. Measures

.2.1. Individual-level variables. Sociodemographic variables included sex,ge (28–44; 45–49; 50–53; 54–65), race (Black/White), past-month income<$500/>$500), and marital status. Past-month use of drugs and alcohol and 12-steprogram use were assessed (yes/no) and a composite variable for “any past-monthrug use,” excluding alcohol was created. Depressive symptoms were assessed withhe Center for Epidemiologic Studies Depression Scale (CES-D; Radloff, 1977); acore of 16+ identified individuals with clinically meaningful depressive symptomsRadloff, 1977). HIV primary care visits in the past 6 months was broken intopproximate tertiles (0–2; 3–4; 5+).

.2.2. Cigarette smoking variables. Smokers reported the number of cigarettesmoked per day (i.e., CPD: <1; 1–10; 11–20; 21+), time to first cigarette (TTFC)pon waking (i.e., ≤30 min; 31–60 min; 60+ min), and lifetime NRT/medications useyes/no). The Heaviness of Smoking Index (HSI) (Heatherton et al., 1989), a measuref nicotine dependence, was conceptualized as a 3-level variable: low, medium, highChaiton et al., 2007).

.2.3. Dyadic-level variables. Dichotomous variables were created based on Sup-orters’ responses to questions regarding: (1) smoking status, (2) interest in quitting,nd (3) lifetime NRT/medication use. 169 Index participants (63%) had a main Sup-orter who participated in the study.

.2.4. Family level variables. Index participants answered the following questions:How many of your family [smoke cigarettes; encourage you to smoke; believe thatmoking causes health problems; dislike smoking; have rules about smoking withinheir home]?” Responses included “none”, “some”, “most”, “all”. Dichotomous vari-bles were created (none/any).

.2.5. Statistical analysis. Analyses were performed using STATA SE version 12.0StataCorp, 2011). Chi-square (�2) tests were used to assess the statistical sig-ificance between individual-level, dyadic-level, and family level variables withutcomes: (1) interest in quitting smoking; and (2) lifetime NRT/medication use.ince 37% of Index participants did not have a participating Supporter, missing dataere correspondingly high for the following variables: Supporter smoking status,

upporter interest in quitting, and Supporter’s lifetime NRT/medication use. Wesed a multiple imputation by chained equations approach (“mi impute chained”TATA commands) with 100 imputations, and incorporated these covariates: sex,ge, race, marital status, income, nicotine dependence, past-month drug use, past-onth alcohol use, past 6 month 12-step program use, CESD score, family smoking,

pendence 138 (2014) 220–224 221

smoking status, interest in quitting, and lifetime NRT/medication use. Using “mi esti-mate, or: logistic” commands, unadjusted and adjusted logistic regression analyseswere used to calculate unadjusted (ORs) and adjusted (aORs) odds ratios and 95%confidence intervals (CIs). Variable selection for adjusted models was based on priorliterature, a priori theory, and �2 p-values <0.05. Variables selected for the adjustedmodel concerning interest in quitting included: sex, age, race, income, marital status,nicotine dependence, past-month drug use, lifetime NRT/medication use, Supportersmoking, and Supporter interest in quitting. Variables selected for the adjustedmodel concerning lifetime NRT/medication use included: sex, age, race, income,marital status, nicotine dependence, and Supporter’s lifetime NRT/medication use.

3. Results

3.1. Participant characteristics

Most participants were interested in quitting smoking (74%),reported lifetime NRT/medication use (59%), male (60.3%), and theaverage age was 48.6 years (SE = 0.37). The majority was Black(90.6%), reported a monthly income of $500+ (81.6%), and not mar-ried (68.2%). There were 39% with a CESD score of 16+, and 42.3%had 0–2 HIV primary care visits in the past 6 months. Forty-onepercent reported past-month alcohol use, 50.9% past-month druguse, and 55.8% reported 12-step program participation within thepast 6 months.

Among Index participants with participating Supporters, 78.1%had a Supporter who currently smoked, 58.6% had a Supporterinterested in quitting, and 38.5% had a Supporter with lifetimeNRT/medication use. The majority reported that their family:included smokers (85.4%), encouraged them to quit (85.1%),believed that smoking causes health problems (97.4%), dislikessmoking (89.1%), and has rules about smoking within their home(86.9%). Few (8.2%) reported that their family encourages smoking.

Index participants interested in quitting were older (�2 (1,N = 267) = 15.10, p = 0.002), less likely to have past-month drug use(�2 (1, N = 267) = 7.38, p = 0.039), and more likely to have lifetimeNRT/medication use (�2 (1, N = 267) = 4.28, p = 0.007) as comparedto those not interested in quitting. In terms of differences betweenthose who had ever used NRT/medications and those who had not,lifetime users were more likely to be White (�2 (1, N = 267) = 4.79,p = 0.029) and to have a Supporter with lifetime NRT/medicationuse (�2 (1, N = 169) = 4.15, p = 0.042).

3.2. Smoking characteristics

Most smokers (75.7%) smoked 1–10 CPD, and had a TTFC within30 minutes of waking (64.0%) (Table 1). More than half (64.1%)exhibited a medium-level of nicotine dependence.

3.3. Interest in smoking cessation

Of those interested in quitting, most were interested in partici-pating in a smoking cessation intervention with a family member(70.4%), friend (73.4%), main partner (75.0%), in a group (79.9%), orin a group with someone they knew (88.1%) (Table 1). Of those whohad not utilized NRT, 39.7% were interested in trying NRT. Of thosewho had not utilized pills/medications, 32.4% were interested intrying pills/medications.

3.4. Logistic regression analyses

When examining interest in quitting smoking, older individuals(54–65 vs. 28–44; aOR = 4.64, 95% CI = 1.59–13.47), and those withlifetime NRT/medication use (aOR = 2.02, 95% CI = 1.08–3.80) were

more likely to be interested in quitting (Table 2). In terms of life-time NRT/medications use, older age (45–49 vs. 28–44: aOR = 3.38,95% CI = 1.57–7.42; 54–65: aOR = 2.70, 95% CI = 1.19–6.11), Whiterace (aOR = 3.56, 95% CI = 1.20–10.62), and having a Supporter with

222 L.R. Pacek et al. / Drug and Alcohol Dependence 138 (2014) 220–224

Table 1Smoking characteristics (n = 267) and interest in various smoking cessation modal-ities (n = 199) among current smokers living with HIV (BEACON study, Baltimore,MD, 2006–2012).

Smoking characteristics n %

Cigarettes per day<1 2 0.71–10 202 75.711–20 60 22.521–30 1 0.431+ 2 0.7

Time to first cigarette<−30 min 171 64.031–60 min 25 9.460+ min 71 26.6

Nicotine dependencea

Low 93 34.8Medium 171 64.1High 3 1.1

Cessation modalityNicotine replacementb,c

No 19 26.0Maybe 25 34.3Yes 29 39.7

Pills/medicined,e

No 64 35.2Maybe 59 32.4Yes 59 32.4

With a family memberNo 59 29.6Yes 140 70.4

With a friendNo 53 26.6Yes 146 73.4

With main partnerf

No 28 25.0Yes 84 75.0

In a groupNo 40 20.1Yes 159 79.9

Group + someone you knowNo 19 11.9Yes 140 88.1

a According to the Heaviness of Smoking Index.b Includes products like nicotine gum, nicotine patches, inhalers, or lozenges.c Among those who were interested in quitting/cutting down on smoking and

had not tried nicotine replacement methods in the past (n = 73).d Includes products for reducing cigarette cravings, like Zyban, Wellbutrin, or

Chantix (Bupropion or Varenicline).

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Table 2Unadjusted and adjusted odds ratios to assess the association of characteristicswith interest in quitting smoking and lifetime use of NRTa/medicationsb for ces-sation among a sample of smokers living with HIV (BEACON study, Baltimore, MD,2006–2012; n = 267).

Interest in quittingvs. no interest

Lifetime use ofNRT/meds vs. no use

aORc,d (95% CIe) aORc,f (95% CIe)

SexMale 1.0 1.0Female 1.04 (0.55–1.98) 1.27 (0.71–2.28)

Age28–44 1.0 1.045–49 1.69 (0.77–3.69) 3.38 (1.57–7.26)50–53 1.81 (0.79–4.14) 1.92 (0.89–4.16)54–65 4.64 (1.59–13.47) 2.70 (1.19–6.11)

RaceBlack 1.0 1.0White 1.30 (0.45–3.78) 3.56 (1.20–10.62)

Income<$500 1.0 1.0$500+ 0.77 (0.35–1.72) 1.22 (0.93–1.62)

Marital statusNot married 1.0 1.0Married 0.74 (0.39–1.41) 0.65 (0.37–1.41)

Nicotine dependenceg

Low 1.0 1.0Medium-high 0.58 (0.30–1.13) 1.44 (0.82–2.52)

Drug useNo 1.0 –h

Yes 0.59 (0.32–1.13) –h

Lifetime NRT/med useNo 1.0 –h

Yes 2.02 (1.08–3.80) –h

Supporter smokesNo 1.0 –h

Yes 0.58 (0.19–1.81) –h

Supporter interested in quittingNo 1.0 –h

Yes 1.30 (0.50–3.36) –h

Supporter lifetime NRT/med useNo –h 1.0Yes –h 2.13 (1.05–4.29)

Bold values indicate statistically significant findings.a NRT = nicotine replacement therapy; includes products like nicotine gum, nico-

tine patches, inhalers, or lozenges.b Includes products for reducing cigarette cravings, like Zyban, Wellbutrin, or

Chantix (Bupropion or Varenicline).c aOR = adjusted odds ratio.d Adjusted for sex, age, race, income, marital status, nicotine dependence, past 30

day drug use, lifetime use of NRT/medications for cessation, Supporter smoking, andSupporter interest in quitting.

e CI = confidence interval.f Adjusted for sex, age, race, income, marital status, nicotine dependence, and

Supporter lifetime use of NRT/medications for cessation.g According to the Heaviness of Smoking Index.h

e Among those who were interested in quitting/cutting down on smoking andad not tried pills/medicine in the past (n = 182).

f Among those with a main partner (n = 112).

ifetime NRT/medication use were associated with lifetime useaOR = 2.13, 95% CI = 1.05–4.29).

. Discussion

This study identified individual- and social-level characteris-ics associated with an interest in quitting smoking and lifetimeRT/medication use among smokers with HIV. The individual-levelharacteristics of older age and use of NRT/medications were asso-iated with an interest in quitting smoking. Older age and Whiteace were associated with lifetime NRT/medication use.

Both associations (i.e., older age, NRT/medication use) withnterest in quitting are consistent with literature in other popula-ions (Clarke et al., 2001; Nahvi et al., 2006). The finding concerningifetime NRT/medication use and interest in quitting, is congruent

ith prior research (Nahvi et al., 2006), and not surprising; actual

uit attempts are associated with prior quit attempts (Zhou et al.,009; Hagimoto et al., 2009; Vangeli et al., 2011). It logically fol-

ows that quit attempts correlate with an interest in quitting. Bothndividual-level findings associated with lifetime NRT/medications

Covariate was not included in final adjusted model.

use (i.e., older age, White race) are consistent with prior researchin other populations (Li et al., 2010, 2011; Fu et al., 2005; Zhuet al., 2000). Older smokers likely have a longer smoking historythan younger smokers, allowing for more time to use cessationaids, and may also be more likely to have smoking-related healthsequelae that prompt cessation attempts. Racial disparities werenot explained by factors measured in this study. Research has foundracial disparities in use of services and physician treatment amongMedicare recipients (Gornick et al., 1996) and others with accessto health care (Bach et al., 2004). Additional research is neededto explore racial/ethnic disparities in uptake of NRT/medications,

particularly where socioeconomic status factors are concerned.

A novel outcome includes finding that Index participants witha main Supporter with lifetime NRT/medication use were more

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ikely to have used NRT/medications themselves. This points tohe potential importance of social characteristics in influencingmoking behaviors among people with HIV. Coupled with the highnterest in cessation modalities involving a social component, thisnding has implications for the development of novel social cessa-ion interventions.

This study has several limitations: it utilizes cross-sectional,elf-report data, and did not contain questions about quit attemptssing other cessation aids, unassisted attempts, or success of pastuit attempts. Additionally, the survey did not assess the degree of

nterest, or intentions to quit within a specified time frame. Thistudy has a number of strengths to note as well. Most prior workas focused on characteristics associated with current smoking sta-us; we focused on two additional smoking behaviors: interest inuitting and lifetime NRT/medication use. This study extends the

iterature by also investigating social environmental variables asso-iated with smoking behaviors. Multiple imputation minimizedeasurement biases arising from missing data and allowed for

reater statistical power that would have been lost with a completease analysis.

Findings from this study corroborate research among otheropulations showing that individual-level characteristics are asso-iated with smoking behaviors. Results extend existing researchy demonstrating that social-level characteristics are also associ-ted with smoking behaviors among a sample of smokers with HIV.indings suggest that members of an individual’s social networkay influence their smoking behaviors. Ultimately, characteris-

ics traditionally associated with smoking cessation attempts aressociated with attempts among smokers with HIV. Strategies suc-essfully employed in other populations may be of utility amongeople with HIV and should be tailored to smokers with HIVEncrenaz et al., 2010), accounting for factors such as substancese/disorders and mental health comorbidities that are highlyrevalent among this group, as well as varying types and qual-

ty of social support that members of this group may possess.dditionally, although findings from cessation interventions that

ncorporate a social support component have been somewhatixed (May and West, 2000; Westmaas et al., 2010), social inter-

entions may be attractive to this population and should bexplored in future investigations.

ole of funding source

This work was funded by the following National Institute onrug Abuse (NIDA) grants: F31 DA033873 (Pacek), R01 DA032217-2S1 (Latkin), and R01 DA019413 (Knowlton).

ontributors

Author Pacek conceptualized the research question and wrotehe first draft of the manuscript. Authors Pacek and Stuart under-ook the statistical analyses. Authors Pacek, Latkin, Crum, Stuart,nd Knowlton contributed to subsequent drafts of the manuscript.ll authors have contributed to and have approved the finalanuscript.

onflict of interest

The authors have no conflicts of interest to declare.

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