Volume 21, Issue 1 , Pages 1-2, January 2010
Things Change…Eventually
Article Outline
What you leave behind is not what is engraved in stone monuments, but what is woven into the lives of others.
—Perecles
Perhaps you remember a scene like this one: An HIV-infected patient shows up in your clinic. You look at his chart and note that at his last clinic appointment 4 months ago his weight was 164 pounds, which was appropriate for his height. Today his weight is documented at 144 pounds. He tells you that he has not been trying to lose weight and that he eats as much as he always did. He also tells you that his friends are concerned about him “getting skinny.” You tell him that he needs to eat calorie-dense foods. You tell him to put butter or gravy on everything and to have ice cream every day. You make an appointment for him to see a dietitian. You also see a pack of cigarettes in his pocket. His chart says that he has smoked two packs a day for 20 years. You don't say anything to him about smoking. What year was that? 1988? 1998? 2008?
In 1988 things were different—at least as far as nutrition and HIV were concerned. We didn't worry about high cholesterol and triglycerides or diabetes or cardiovascular disease in people living with HIV infection (PLWH) because we didn't expect them to live long enough to suffer from the detrimental effects of those problems. We were just trying to keep people alive. They had acute issues. People who lost weight died (Kotler, Wang, & Pierson, 1985) and, without effective treatment, we just wanted to prevent wasting. Chronic disease was as far from our thoughts as it could possibly be. Things had changed by 1998—better HIV treatments, longer life expectancies, and greater risks of problems related to high-calorie high-fat diets—and wasting was no longer the common problem that it had been. By 2008, PLWH were getting healthy-diet messages that resembled the information given to the rest of the population. Fruits, vegetables, and low fat had become the mantra.
But what about smoking? In 1988, once again on the presumption that people with HIV would not live that long anyway, cigarette smoking was ignored. Why encourage someone to go through the pain and frustration of trying to break an addiction? After all, we didn't think it would make a difference in survival, and the process would just increase the patient's discomfort.
I don't want you to think I equate smoking with nutrition. PLWH have to eat. We didn't know the right nutrition messages in 1988, or more likely the right messages changed over time and clinicians adjusted. As care improved, so did the messages about what to eat. Cigarette smoking has never been good for your health—a fact acknowledged by the United States more than 50 years ago (Samet & Wipfli, 2009). Unfortunately, the messages we gave to PLWH about cigarettes didn't change much by 1998, and we hadn't seen any real progress in decreasing PLWH smoking behaviors by 2008 either.
Whether it was addressed or not, cigarette smoking has always been a problem in HIV care. For whatever reason, PLWH smoke more than people without HIV, often at rates estimated as high as 50% to 70% (Reynolds, 2009) or about 3 times higher than in uninfected people. Smoking is a primary contributor to the increasing incidences of bacterial and inflammatory lung diseases, lung and cervical cancers, fungal and inflammatory problems in the oral cavity, peripheral artery disease, renal disease, and cardiometabolic syndromes in PLWH (Reynolds, 2009).
During the past decade, cigarette smoking cessation has become a major target of federal and state regulation, health care providers, behavior change research, and pharmaceutical product development. Overall, smoking rates have been cut in half. And now that the U.S. Food and Drug Administration has regulatory control over tobacco, we should expect to see more progress and lower smoking rates (Magee, 2009).
Despite all of this, PLWH continue to smoke in frightening numbers. Granted, addiction is a difficult issue to address in the midst of caring for PLWH, who often have complex chronic disease and psychosocial and economic concerns. In addition, cigarette smoking is an especially difficult addiction to kick. My friend Edith Springer once told me, “I was addicted to heroin and I got off it by using methadone. Then I decided to get off methadone, and it was hard, but I did it. So I've had a lot of success dealing with addictions. But I've tried, and I just can't quit smoking.” I suspect many PLWH have had similar experiences. They may feel like this poet did:
Tobacco is a dirty weed. I like it.
It satisfies no normal need. I like it.
It makes you thin. It makes you lean.
It takes the hair right off your bean.
It's the worst darn stuff I've ever seen.
I like it.
(Graham Lee Hemminger, “Tobacco”)
The time has come for HIV care providers to pay attention. It's time to talk about smoking constructively; it needs to be more than, “You know you should quit smoking don't you?” It's time to use the skills you have developed to enhance adherence and to promote prevention with positives. Risk assessment, harm reduction, motivational interviewing, and effective prescriptions can all be used to make a difference. Smoking is the focus of several articles in this issue of JANAC. I hope you find them helpful as you move forward to address this critical issue with your patients.
References
- . Body composition studies in patients with the acquired immunodeficiency syndrome. American Journal of Clinical Nutrition. 1985;42:1255–1265
- Magee, M., (2009). Tobacco control in the U.S.: There is still work to be done. Retrieved from http://healthcommentary.org/public/item/243637.
- Reynolds, N.R., (2009). Cigarette smoking and HIV: More evidence for action. AIDS Education and Prevention, 21(Suppl. A), 106–121. Retrieved from http://www.atypon-link.com/GPI/doi/pdfplus/10.1521/aeap.2009.21.3_supp.106. doi:10.1521/aeap.2009.21.3_supp.10
- . Unfinished business in tobacco control. Journal of the American Medical Association. 2009;302:681–682doi:10.1001/jama.2009.1155
PII: S1055-3290(09)00175-7
doi:10.1016/j.jana.2009.10.002
© 2010 Published by Elsevier Inc.
Volume 21, Issue 1 , Pages 1-2, January 2010
