Tackling Barriers to Smoking Cessation The Ottawa HIV Quit Smoking - - PowerPoint PPT Presentation

Tackling Barriers to Smoking Cessation The Ottawa HIV Quit Smoking Study

Stephanie Wiebe PhD Louise Balfour PhD Paul MacPherson PhD, MD, FRCPC Ottawa Hospital University of Ottawa

Presenter Disclosure

• Presenter Name: Stephanie Wiebe
• Relationships with commercial interest

Grants and research support:

• University of Ottawa Dept of Medicine
• Canadian Foundation for AIDS Research
• Bristol-Myers Squibb, Janssen
• CIHR

Current Health Issues among People Living with HIV

• With advances in anti‐retroviral medications people

living with HIV are living into older age

• People living with HIV are now facing diseases of
• lder age such as cardiovascular disease and cancer
• Addressing cardiovascular disease in the population
• f people living with HIV has become a front and

center issue

Detels et al., 1998

High Rates of Cardiovascular Disease among People Living with HIV

• HIV+ individuals across all age groups are 2‐4 times

more likely to suffer an acute myocardial infarction.

• HIV+ individuals are more likely to suffer a myocaridal

infarction at a younger age.

(Furber et al., 2007)

• DAD cohort: 41.3% of HIV+ individuals are at high risk
• f cardiovascular disease.

(Friis‐Moller et al., 2003)

Smoking Rates among People Living with HIV are VERY High

• Smoking rates among people with HIV: 40‐70%

(Mamary et al., 2002; Stein et al., 2008)

• Smoking rates in the general Canadian population:

19%(Health Canada, 2007)

• Smoking rate in Ottawa’s HIV clinic: 43‐49%

(Balfour et al., 2006)

• Smoking rate in Ottawa: 12%

And it’s a big problem…

• D:A:D cohort: after pre‐existing CVD, smoking was identified as

the most significant predictor of CVD in the HIV+ population.

(Friis‐Moller et al., 2003)

• Compared to HIV+ non‐smokers, HIV+ smokers have a three‐fold

higher mortality rate, 30% higher rate of hospital admission, higher rates of COPD, and lower CD4 improvement when on anti‐retroviral therapy.

(Crothers et al., 2005; Stein et al., 2008)

• People living with HIV lose more life years to smoking related

complications than complications related to HIV

(Helleberg et al., 2013)

THE CHALLENGE: Helping People Quit Smoking

• Given that smoking leads to significant health problems

among people living with HIV

• AND given that the smoking rates are so high among

people living with HIV

• Helping people with HIV quit smoking is a top priority

for HIV clinical care right now

The Problem: It’s hard to Quit!

• The majority of people who smoke want

information about quitting (Robinson et al., 2012)

• Successful quit rates among people living with HIV

are low and relapse rates are high

• Estimates are 10‐40% stay quit more than 6 months

in the general population

• Among people with HIV, 9‐12%

stay quit past 6 months

Especially When You’re Depressed

• Smoking relapse rates are high among those with

depression in the general population

• Smoking rates are high among those with depression
• Smoking can be a way to self‐medicate low mood
• The prevalence of depression among people living

with HIV is high (40‐60%)

So, what can we do?

• Smoking cessation treatments for people living

with HIV need to address depressive symptoms as a barrier to quitting

• Interpersonal/social factors are also important
• Relapse prevention needs to be top priority

Smoking Cessation Program

• We developed a program tailored for people living

with HIV

• Addressing mood, and other barriers to staying quit

for people living with HIV

• HIV specific health‐related benefits of quitting as

motivating factors

Smoking Cessation Program: The Focus

• Internal motivation
• reasons for quitting, feelings about quitting, goals
• Tackling Barriers (i.e., social isolation, low mood)
• Coping with Withdrawal symptoms

Smoking Cessation Program The Structure

• Session 1: Preparation for Quitting
• Session 2: Quit Day Counselling Session
• Session 3: Week 4
• Session 4: Week 12
• Session 5: Six Month Follow‐up

Smoking Cessation Program Session 1: Preparation for Quitting

• Open dialogue about feelings about quitting
• Reasons for quitting are explored
• Health specific: improved immune functioning, reduced

cardiovascular risk

• General reasons: “the house will smell better”
• Barriers are explored and named
• Social isolation, withdrawal symptoms, mood
• Withdrawal symptoms are discussed and strategies

are discussed

• Information about NRT patch is provided

Smoking Cessation Program Session 2: Quit Day Counseling

• What to expect in the first few weeks of quitting
• withdrawal symptoms
• dealing with cravings
• changes in mood
• managing weight
• Coping with stress and depression
• Managing smoking lapses: “lapse” and a “relapse”
• Normalize how difficult it is to quit smoking in order

to reduce feelings of guilt/shame

• Information about smoking cessation medication

Smoking Cessation Program Session 3: Week 4

• Review the experience including challenges and

successes

• Assess adherence to and experience with smoking

cessation medication

• Normalize struggles – review “lapse” vs. “relapse”
• Discuss barriers associated with staying smoke free
• coping with cravings and triggers for smoking
• problem‐solving around any potential barriers

Smoking Cessation Program Session 4: Week 12

• Discuss barriers to staying smoke free now
• Coping with stress – strategies for relaxation

and anxiety reduction

• Coping with depression
• Cognitive distortions, negative self‐talk, and their relation

to mood

• Assertiveness skills for improving relationships

Coping with Stress

Smoking Cessation Program Session 5: Six Month Follow‐up

• Review of previous topics as needed
• Feelings about completing the HIV Quit Smoking

intervention, and continuing the quit attempt without the added support of the counsellor ‐ fears or concerns are explored

• Challenges that may interfere with staying quit are were

reviewed, identified, discussed

• Coping strategies are reviewed, discussed
• Triggers, managing cravings, reducing anxiety
• Review of successes and processing the end of the

relationship

Pilot Study

• 50 people living with HIV who smoke were

recruited from the clinic at the Ottawa Hospital

• All participants received 5 counseling sessions
• AND received Nicotine Replacement Therapy

Pilot Study: Measures

Depression: Center for Epidemiological Studies Depression Scale (CES‐D; Radloff, 1977)

• Cut off score for depression >16

Smoking status: (1) self‐reported smoking (2)

• bjective smoking status measured by CO levels

Pilot Study Results: Smoking

• 17/50 (34.69%) participants attended the 24 week

follow‐up session.

• 14/50 (28%) remained abstinent from smoking at

24‐week follow‐up.

• This is significantly better than previous studies (9‐

11.9%) quit rates with medication plus counselling at 6 month follow‐up

Pilot Study Results: Mood

• At the start of the study 52% had clinically

significant symptoms of depression (clinical cut off > 16; Radloff, 1977)

• Depressive symptoms at the start of the study did

not predict relapse

• Those who had significant symptoms of depression

at the start of the study demonstrated significant drops in depressive symptoms at follow‐up

Successful Quitters Study

• 50 HIV+ smokers were recruited from HIV clinic

visits at the Ottawa Hospital

• 14 HIV+ participants successfully quit smoking (28%
• f original sample) and completed the program to

24 week follow‐up.

Successful Quitters: Questionnaires

Depression: Center for Epidemiological Studies Depression Scale

(CES‐D; Radloff, 1977)

• Cut off score for depression >16

Smoking Self‐Efficacy Questionnaire

(Etter, Bergman, Humair & Perneger, 2000)

• Internal self‐efficacy to avoid smoking (e.g.,

confidence in one’s ability to refrain from smoking when nervous, angry or depressed)

• External self‐efficacy to avoid smoking (e.g.,

confidence in one’s ability to refrain from smoking when having drinks with friends)

Change across smoking cessation counseling sessions

5 10 15 20 25 Pre Quit date 6w 12w 24w

Depression (CESD) Self‐efficacy: External Self‐efficacy: Internal

Pilot Study

• The program was relatively effective (28% compared to 9‐

12%)

• Those with depression had significant reductions in

symptoms Successful Quitters

• Improvements were made in mood and self‐efficacy
• These changes may be part of the process of quitting for

those who successfully stay quit and should be considered as part of smoking cessation counseling programs for HIV+ smokers

Summary

What does this mean?

• A tailored smoking cessation counseling program

may be helpful to increase quit rates for people living with HIV

• Addressing depressive symptoms as part of

smoking cessation programs is key, at least for those who are depressed

So…..

Next Steps

• Randomized controlled trial to test the efficacy of

the program

• Compare those who receive the program to those who

receive usual care

• Process research: what are the key ingredients?

Can we tailor the program for individuals’ specific concerns? (i.e., depression, motivation, barriers)

• Qualitative research: participant feedback, what

happened for those who relapsed?

Thank you!!

• Supported by:
• University of Ottawa Dept of Medicine
• Canadian Foundation for AIDS Research
• Bristol-Myers Squibb, Janssen
• CIHR
• The University of Ottawa Heart Institute
• The Division of Infectious Diseases
• HIV Patients

This study was supported by the CIHR Canadian HIV Trials Network (CTN 008).