Interventions for tobacco use cessation in people living with HIV

Noreen Dadirai Mdege, Sarwat Shah, Omara Dogar, Erica R.M. Pool, Peter Weatherburn, Kamran Siddiqi, Cosmas Zyambo, Jonathan Livingstone-Banks

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The prevalence of tobacco use among people living with HIV (PLWH) is up to four times higher than in the general population. Unfortunately, tobacco use increases the risk of progression to AIDS and death. Individual-/group-level and system change interventions that are effective in helping PLWH stop using tobacco can markedly improve the health and quality of life of this population. However, clear evidence to guide policy and practice is lacking, which hinders the integration of tobacco cessation interventions into routine HIV care. This is an update of a review that was published in 2016. We include 11 new studies.

To assess the benefits, harms and tolerability of interventions for tobacco use cessation among PLWH. To compare the benefits, harms and tolerability of interventions for tobacco use cessation that are tailored to the needs of PLWH with that of non‐tailored cessation interventions.

Search methods:
We searched the Cochrane Tobacco Addiction Group's Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and PsycINFO in December 2022.

Selection criteria:
Randomised controlled trials (RCTs) of individual-/group-level behavioural and/or pharmacological interventions for tobacco use cessation delivered directly to PLWH aged ≥ 18 years who use tobacco were included. RCTs, quasi-RCTs, other non-randomised controlled studies (e.g., controlled before and after studies), and interrupted time series studies of system change interventions for tobacco use cessation among PLWH were also included. For system change interventions, participants could be PLWH receiving care, or staff working in healthcare settings and providing care to PLWH; but studies where intervention delivery was by research personnel were excluded. For both individual-/group-level and system change interventions, any comparator was eligible.

Data collection and analysis:
We followed standard Cochrane methods, and used GRADE to assess certainty of the evidence. The primary measure of benefit was tobacco use cessation at a minimum of six months. Primary measures for harm were adverse events (AEs) and serious adverse events (SAEs). We also measured quit attempts/quit episodes, the receipt of a tobacco cessation intervention, quality of life, HIV viral load, CD4 count, and the incidence of opportunistic infections.

Main results:
We identified 17 studies (16 RCTs and one non-randomised study) with a total of 9959 participants; 11 studies are new to this update. Nine studies contributed to meta-analyses (2741 participants). Fifteen studies evaluated individual-/group level interventions, and two evaluated system change interventions. Twelve studies were from the USA, two from Switzerland, and there were single studies for France, Russia and South Africa. All studies focused on cigarette smoking cessation. All studies received funding from independent national- or institutional-level funding. For three of the studies, study medication was provided by a pharmaceutical company, free of charge. Of the 16 RCTs, three were at low risk of bias overall, five were at high risk, and eight were at unclear risk.

Behavioural support or system change interventions versus no or less intensive behavioural support: Low-certainty evidence from seven studies (2314 participants) did not demonstrate a clear benefit for tobacco use cessation rates in PLWH randomised to receive behavioural support compared with brief advice or no intervention: risk ratio (RR) 1.11, 95% confidence interval (CI) 0.87 to 1.42, with no evidence of heterogeneity. Abstinence at ≥ six months in the control group was 10% (number (n) = 108/1121) and in the intervention group it was 11% (n = 127/1193). There was no evidence of an effect on tobacco use cessation from one study on system change interventions: calling the quitline and transferring the call to the patient whilst they are still in hospital (warm handoff) versus fax referral (RR 3.18, 95% CI 0.76 to 13.99; 25 participants; very low-certainty evidence). None of the studies included in this comparison assessed SAE.

Pharmacological interventions versus placebo, no intervention, or another pharmacotherapy: Moderate-certainty evidence from two studies (427 participants) suggested that varenicline may help more PLWH to quit than placebo (RR 1.95, 95% CI 1.05 to 3.62) with no evidence of heterogeneity. Abstinence at ≥ six months in the placebo control group was 7% (n = 14/215) and in the varenicline group it was 13% (n = 27/212). There was no evidence of intervention effects from individual studies on behavioural support plus NRT versus brief advice (RR 8.00, 95% CI 0.51 to 126.67; 15 participants; very low certainty evidence), behavioural support plus NRT versus behavioural support alone (RR 1.47, 95% CI 0.92 to 2.36; 560 participants; low-certainty evidence), , varenicline versus NRT (RR 0.93, 95% CI 0.48 to 1.83; 200 participants; very low-certainty evidence), and cytisine versus NRT (RR 1.18, 95% CI 0.66 to 2.11; 200 participants; very low-certainty evidence). Low-certainty evidence from two studies (427 participants) did not detect a difference between varenicline and
placebo in the proportion of participants experiencing SAEs (8% (n = 17/212) versus 7% (n = 15/215), respectively; RR 1.14, 95% CI 0.58 to 2.22) with no evidence of heterogeneity. Low-certainty evidence from one study indicated
similar SAE rates between behavioural support plus NRT and behavioural support only (1.8% (n = 5/279 versus 1.4% (n = 4/281), respectively; RR 1.26, 95% CI 0.34 to 4.64). No studies assessed SAEs for the following: behavioural support plus NRT versus brief advice; varenicline versus NRT and cytisine versus NRT.

Authors' conclusions:
There is no clear evidence to support or refute the use of behavioural support over brief advice, one type of behavioural support over another, behavioural support plus NRT over behavioural support alone/brief advice, varenicline over NRT, or cytisine over NRT for tobacco use cessation for ≥ six months among PLWH. There is also no clear evidence to support or refute the use of system change interventions such as warm handoff over fax referral, to increase tobacco use cessation or receipt of cessation interventions among PLWH who use tobacco.
However, the results must be considered in the context of the small number of studies included. Varenicline likely helps PLWH to quit smoking for ≥ six months compared to control. We did not find evidence of difference in SAE rates between varenicline and placebo, although the certainty of the evidence is low.
Original languageEnglish
JournalCochrane Database of Systematic Reviews
Publication statusAccepted/In press - 30 May 2024

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