| |
PLWH who adhere to ART but smoke are substantially more
likely to die from lung cancer than from AIDS-related causes
|
| |
| |
Download the PDF here
Download the PDF here
"In this microsimulation model–based analysis, cumulative lung cancer mortality by age 80 years for men and women who entered HIV care in the United States at age 40 years and continued to smoke an average number of cigarettes daily was 23.0% and 20.9%, respectively.......Among 40-year-old men with HIV, estimated cumulative lung cancer mortality for heavy, moderate, and light smokers who continued to smoke was 28.9%, 23.0%, and 18.8%, respectively; for those who quit smoking at age 40 years, it was 7.9%, 6.1%, and 4.3%; and for never smokers, it was 1.6%. Among women, the corresponding mortality for current smokers was 27.8%, 20.9%, and 16.6%; for former smokers, it was 7.5%, 5.2%, and 3.7%; and for never smokers, it was 1.2%.
ART-adherent individuals who continued to smoke were 6 to 13 times more likely to die from lung cancer than from traditional AIDS-related causes"
-------------------------
Lancet HIV August 27, 2021
Getting people living with HIV who smoke cigarettes to quit is difficult, and most attempts end in failure. In the context of tobacco treatment, harm reduction is largely focused on reducing average daily cigarette intake (cigarettes per day [CPD]) or cutting down, or transitioning to an alternative tobacco or nicotine product believed to confer less harm.
Harm reduction is a sensible and needed approach for smokers living with HIV who are unable or unwilling to quit. In this Viewpoint, we take an expansive view of harm reduction to include not only cutting down on cigarette intake for persistent smokers, but also reducing smoking's downstream health effects by increasing lung cancer screening and by controlling concurrent cardiovascular risk factors, especially hypertension and hyperlipidaemia.
Population-based surveys suggest that approximately half of people living with HIV in the USA are current cigarette smokers, more than triple the prevalence in all US adults, and 15–20% of cigarette smokers living with HIV use other tobacco products as well, most commonly cigars. Cigarette smoking is a risk factor for a range of infectious (eg, bacterial pneumonia, tuberculosis, and Pneumocystis jirovecii pneumonia) and non-infectious diagnoses (eg, lung cancer, myocardial infarction, stroke, and emphysema), and tobacco use has emerged as a leading killer of people living with HIV in the USA and Europe in the past decade and the most influential factor perpetuating the survival gap between those living with and without HIV.
We suggest that practitioners, patients, researchers, and policy makers should take a more expansive view of tobacco treatment in smokers living with HIV, to encourage reduced cigarette intake in those who are unable or unwilling to quit completely, to increase screening of eligible individuals for lung cancer, and to aggressively control other cardiovascular risk factors, especially hypertension and hyperlipidaemia.
We have shown in two separate randomised controlled trials that most smokers living with HIV can reduce their CPD over 24 weeks of follow-up. Although we believe that encouraging smokers living with HIV who cannot or will not quit to cut down is a worthwhile endeavour, shortcomings of this approach require mention. Smokers who reduce their daily cigarette consumption might offset some or all of the potential benefit by compensatory smoking behaviours (eg, inhaling more deeply). Smokers might also under-report their daily cigarette consumption, and there is no readily available biomarker to verify their estimates.
-------------------------------------
"Applying model projections to the approximately 644 200 PLWH aged 20 to 64 in care in the United States, 59 900 (9.3%) are expected to die from lung cancer if smoking habits do not change."
Clinicians caring for PLWH should offer guideline-based behavioral and pharmacologic treatments for tobacco use.62 Lung cancer is now a leading cause of death among PLWH, but smoking cessation can greatly reduce the risk. Lung cancer prevention, especially through smoking cessation, should be a priority in the comprehensive care of PLWH.
Using a microsimulation model, we found that ART-adherent PLWH in the United States who smoke cigarettes are 6 to 13 times more likely to die from lung cancer than from AIDS-related causes. Even when accounting for reported rates of ART nonadherence and loss to follow-up, we found that nearly 10% of PLWH initially linked to HIV care (including both smokers and nonsmokers) are expected to die from lung cancer if smoking habits do not change. Smoking cessation could substantially reduce lung cancer risk for an individual and avert many lung cancer deaths at the population level.
Perhaps counterintuitively, lung cancer risk is linked to adherence to HIV therapy. Those who are not ART-adherent are more likely to die of AIDS-related causes before developing lung cancer. Nonetheless, even when accounting for reported rates of ART nonadherence and loss to follow-up from HIV care, we found that for male heavy smokers, the risk of dying from lung cancer is similar to the risk of dying from AIDS-related causes.
Much of the non-AIDS disease burden is tobacco-related. Over 40% of PLWH in the United States smoke cigarettes, more than double the smoking prevalence in the general population.3-7 Among PLWH undergoing ART, smoking now reduces life expectancy more than HIV itself.8-10
Tobacco use and HIV together may accelerate the development of lung cancer.11-14 The risk of lung cancer is increased by the presence of HIV through mechanisms likely involving chronic inflammation, immunomodulation, and other infections.11,15-19 Lung cancer is the leading cause of cancer death among PLWH undergoing ART and is among the leading causes of death overall in this population.13,20
Despite the high smoking prevalence and the risk of lung cancer and other tobacco-related diseases, smoking cessation programs generally have not been successfully implemented in HIV care.
JAMA Intern Med
Key Points
Question What is the risk of lung cancer death by smoking exposure for a person living with human immunodeficiency virus (HIV)?
Findings In this microsimulation model–based analysis, cumulative lung cancer mortality by age 80 years for men and women who entered HIV care in the United States at age 40 years and continued to smoke an average number of cigarettes daily was 23.0% and 20.9%, respectively;
if they quit smoking, the respective risks decreased to 6.1% and 5.2%. Those who continued to smoke were 6 to 13 times more likely to die from lung cancer than from traditional AIDS-related causes.
Meaning Smoking cessation should be a priority in the care of people living with HIV.
Abstract
Importance Lung cancer has become a leading cause of death among people living with human immunodeficiency virus (HIV) (PLWH). Over 40% of PLWH in the United States smoke cigarettes; HIV independently increases the risk of lung cancer.
Objective To project cumulative lung cancer mortality by smoking exposure among PLWH in care.
Design Using a validated microsimulation model of HIV, we applied standard demographic data and recent HIV/AIDS epidemiology statistics with specific details on smoking exposure, combining smoking status (current, former, or never) and intensity (heavy, moderate, or light). We stratified reported mortality rates attributable to lung cancer and other non–AIDS-related causes by smoking exposure and accounted for an HIV-conferred independent risk of lung cancer. Lung cancer mortality risk ratios (vs never smokers) for male and female current moderate smokers were 23.6 and 24.2, respectively, and for those who quit smoking at age 40 years were 4.3 and 4.5. In sensitivity analyses, we accounted for nonadherence to antiretroviral therapy (ART) and for a range of HIV-conferred risks of death from lung cancer and from other non–AIDS-related diseases (eg, cardiovascular disease).
Main Outcomes and Measures Cumulative lung cancer mortality by age 80 years (stratified by sex, age at entry to HIV care, and smoking exposure); total expected lung cancer deaths, accounting for nonadherence to ART.
Results Among 40-year-old men with HIV, estimated cumulative lung cancer mortality for heavy, moderate, and light smokers who continued to smoke was 28.9%, 23.0%, and 18.8%, respectively; for those who quit smoking at age 40 years, it was 7.9%, 6.1%, and 4.3%; and for never smokers, it was 1.6%. Among women, the corresponding mortality for current smokers was 27.8%, 20.9%, and 16.6%; for former smokers, it was 7.5%, 5.2%, and 3.7%; and for never smokers, it was 1.2%.
ART-adherent individuals who continued to smoke were 6 to 13 times more likely to die from lung cancer than from traditional AIDS-related causes, depending on sex and smoking intensity. Due to greater AIDS-related mortality risks, individuals with incomplete ART adherence had higher overall mortality but lower lung cancer mortality. Applying model projections to the approximately 644 200 PLWH aged 20 to 64 in care in the United States, 59 900 (9.3%) are expected to die from lung cancer if smoking habits do not change.
Conclusions and Relevance Those PLWH who adhere to ART but smoke are substantially more likely to die from lung cancer than from AIDS-related causes.
|
|
| |
| |
|
|
|
