Researchers look for the best ways to help people with HIV quit smoking

Human immunodeficiency virus (HIV) treatment has gotten so good that people can take a pill once a day to achieve viral suppression that lets them live much longer than anyone could have imagined just a few decades ago.

“But what if I were to tell you that smoking cigarettes nearly eradicates the survival benefit of taking these medications?” asked Seth Himelhoch, MD, MPH, Chair of the Department of Psychiatry and Behavioral Neuroscience at the University of Chicago Medicine. “That would make it very important to find the best ways to help people with HIV stop smoking cigarettes.”

Himelhoch is the lead author of a recently published study tackling this very question. In a large randomized trial conducted in Kenya, he and his colleagues found that combining medication with a specialized counseling program dramatically increased long-term quit rates among people with HIV who smoked — an outcome that could significantly reduce tobacco-related deaths in this vulnerable population.

HIV and smoking: a deadly combination

Around the world, people living with HIV smoke tobacco at two to three times the rate of the general population. To make the problem worse, this population appears uniquely vulnerable to the substance’s well-known negative effects.

“There's something about living with HIV that seems to amplify the risk associated with smoking, such that they die much more rapidly from cardiovascular disease and smoking-associated cancers like lung cancer,” Himelhoch said.

The research team carried out the project in Kenya because of a longstanding partnership with local experts and clinical researchers in Nairobi. Sub-Saharan Africa also has the highest prevalence of HIV in the world, and at the same time, smoking rates in the region are rising steadily. That combination, according to Himelhoch, makes it critical to test and refine interventions specifically for people who face this “perfect storm” of risk factors.

“I have a very vivid memory of sitting in a focus group in Nairobi and having our translators turn and say to us: ‘People are saying tobacco is the absolute worst thing that has ever happened to their community, and they see this study as an unbelievable opportunity to get help.’ It was a deeply compelling description of how people view the work we’re trying to do,” Himelhoch said.

Putting interventions to the test

The researchers tested two interventions, separately and in combination. The first was a medication called bupropion, which can help reduce nicotine cravings and withdrawal symptoms, ultimately making it easier to resist the urge to smoke. The other intervention was Positively Smoke Free, a behavioral program tailor-made for smokers living with HIV. The intervention involves eight one-hour sessions that teach participants to identify smoking triggers, strategize for high-risk situations, build social support and develop a “nonsmoker” identity. Each participant receives a workbook that reinforces learning and serves as an ongoing resource after the sessions end. Because participants in Nairobi came from diverse backgrounds and had varying levels of English fluency, the team worked with local research staff to translate program materials into Swahili and adapted the materials, questions and overall approach to be culturally sensitive and relevant.

The study enrolled 300 adults living with HIV in Nairobi, each of whom wanted to quit smoking. They were randomly split into four groups: half took the medication bupropion while the other half took placebo pills, and half of each medication group also received either the Positively Smoke Free program or just a brief “quit smoking” advice session. Over the course of 36 weeks, the researchers checked everyone’s progress by asking about their smoking habits and measuring carbon monoxide levels in their breath — an objective way to tell who’s actually quit. By comparing the groups, the team could see whether medication alone, counseling alone, or the two combined worked best.

The quit rates were striking. Overall, only 6.6% of those who received the placebo and “quit smoking” advice session were able to quit smoking by the 36-week mark, but that number more than doubled for individuals who received just one of the two interventions — either bupropion plus the “quit smoking” advice or Positively Smoke Free plus the placebo — reaching quit rates around 20-25%. Most impressively, nearly 40% of participants who received both bupropion and Positively Smoke Free successfully quit smoking for the long term.

“Looking at data from studies in America, it’s clear that we’re finding it really challenging to get people to quit smoking, so it’s good to see evidence that these interventions are efficacious in a population at very high risk for tobacco-associated mortality,” Himelhoch said.

Looking to a healthier future

The researchers’ next study, which is already underway, will tackle the connection between smoking and alcohol use. People living with HIV often face multiple health challenges, and alcohol use can further compound the risks of smoking—particularly when it comes to cancers and cardiovascular disease. Himelhoch’s new project aims to find ways to help those who drink at moderate-to-severe levels cut back on alcohol while also quitting smoking.

Himelhoch said the most important takeaway from the recent study for the general public is the belief that smoking cessation is possible.

“So many people think there’s no way to get people to quit smoking,” he said. “But with the right tools and the right resources, we can help people — including those living with a historically stigmatized disease — quit smoking and extend their lives meaningfully.”

“Efficacy of Smoking Cessation Interventions among People with HIV in Kenya” was published in NEJM Evidence in October 2024. Co-authors include Seth S. Himelhoch, Emily Koech, Angela A. Omanya, Patience Oduor, Walter Mchembere, Tina W. Masai, Melanie E. Bennett, Lan Li, Wendy Potts, Sylvia Ojoo and Jonathan Shuter.