Abstract
Tobacco use has emerged as a leading cause of death among persons living with HIV (PLWH) who smoke cigarettes. In contrast to the general population where smoking prevalence in men exceeds that in women, large surveys have shown similar smoking rates among male and female PLWH. There are important behavioral and biological differences between male and female smokers, but little is known about the relationships between tobacco use and gender in PLWH. Herein, the authors present a detailed examination of gender differences in smokers living with HIV (N = 267; 54% male, 46% female) recruited in 2 tobacco treatment trials. The authors found higher rates of heavy smoking and other substance use in men. Women were more likely to have used pharmacotherapy during quit attempts. Asthma rates were markedly higher in female smokers. There were no significant differences in a range of psychobehavioral domains or in cessation rates between male and female smokers living with HIV.
Introduction
Cigarette smoking is not a gender-neutral behavior. In the United States, the proportion of adult men who smoke (20.5%) significantly exceeds that of women (15.8%), 1 and there are important behavioral and biological differences between male and female tobacco users. Males are more likely to be heavy smokers and are more nicotine dependent but are also more likely to succeed in quitting compared to women, especially when aided by nicotine replacement therapy (NRT). 2,3 Women more frequently report that smoking helps them to control stress and negative mood as well as to manage their weight. 2,4,5 Men are more likely to attempt to quit “cold turkey.” 6 Biological differences between the genders may also affect tobacco use behaviors and smoking outcomes. Women metabolize nicotine faster than men, 7 and their smoking patterns may be influenced by their menstrual cycles. 8 There are also gender-based differences in the effects of smoking on lipid profiles and thrombotic pathways. 9 These realities have provided the impetus for gender-specific smoking-cessation interventions. 4
There is a smoking epidemic embedded within the HIV epidemic, and with the advent of effective antiviral therapeutics, tobacco use has emerged as the leading killer of persons living with HIV (PLWH). 10 As the PLWH community ages, and age-related diseases such as cancers and cardiovascular disease assume greater importance as causes of morbidity and mortality, cigarette smoking occupies an ever greater role as a driver of these health outcomes. 11,12 Persons living with HIV as a group smoke at approximately 3 times the rate of the general population 13,14 ; and in the United States among those living with HIV, male smokers far outnumber female smokers since male PLWH outnumber female PLWH 3:1. 15 However, in contrast to the general population, both a statewide survey in New York 13 and a national survey 14 found that the proportions of male and female PLWH who smoke are virtually identical.
From the tobacco treatment standpoint, smokers living with HIV are complicated. They have very high rates of comorbid psychiatric disease and other substance use, both of which represent serious barriers to successful quitting. 16 There is a small but growing literature on tobacco treatment strategies for PLWH. 17 –23 Some proven approaches to tobacco treatment, such as motivational interviewing and intensive individual counseling, have failed to prove effective in PLWH. 18,22 In response to the public health import of this problem, the US Public Health Service has identified the optimization of tailored tobacco treatments for smokers living with HIV as a high priority goal. 24 The randomized controlled trials published to date have provided very limited gender-specific information on baseline characteristics of smokers living with HIV, and only 1 study noted a difference between genders in the abstinence outcome. 23 The latter trial suggested that women responded better to a Web-based cessation intervention than men did.
A clearer understanding of the role that gender plays in the smoking epidemic among PLWH may help to inform the development of more effective interventions. We therefore report on gender differences in a group of smokers living with HIV who were recruited in 2 tobacco treatment trials conducted in New York City.
Materials and Methods
Montefiore Medical Center’s Center for Positive Living provides comprehensive HIV care to over 2800 individuals in the Bronx, New York. Between 2009 and 2013, we conducted 2 randomized controlled trials of intensive behavioral cessation interventions, one consisting of live group therapy and the other a Web-based individual program versus standard care (all patients were offered transdermal nicotine patches [TNPs]). The inclusion criteria for the studies, published elsewhere, 19,23 were similar: documented HIV infection, receipt of care at the Center for Positive Living, current cigarette smoking, motivation to quit, and no contraindication to TNPs. In the second study, there were additional computer/Internet access and literacy requirements. Program content was summarized in detail in the prior publications, 19,23 but, in short, both programs consisted of 8 educational/motivational sessions, guided by social cognitive theory, and delivered over 7 weeks. The program content was thoroughly tailored to address the specific needs and concerns of smokers living with HIV. In both studies, subjects provided sociodemographic information, tobacco use history, and completed a range of behavioral scales (measuring depression, anxiety, self-efficacy, etc) at the time of enrollment. A complete list of the psychobehavioral scales used has been published elsewhere. 19 The primary smoking outcome for both trials was exhaled carbon monoxide-verified (ECO < 10 parts per million), seven-day point prevalence abstinence at three months.
For the purpose of the present study, we combined the patient samples from the 2 treatment trials. A small group of patients (n = 11) participated in both trials, and for these individuals only data were retained from the earlier study. Transgender participants were too few in number for any meaningful analysis (n = 5) and were therefore excluded from the sample.
For summary statistics, means and standard deviations were calculated. For comparisons of categorical variables, χ2 and Fisher exact tests were used as appropriate. For comparisons of means, we employed Student t test or the Mann-Whitney U test if normality or the common variance assumption was violated. Statistical analyses were completed using SPSS V18.0 (SPSS Inc.). All aspects of this research were approved by the Montefiore Medical Center Institutional Review Board.
Results
The final sample size was 267, including 144 (53.9%) men and 123 (46.1%) women. Over one-third of participants (34.8%) were Latino/a, 80.6% were black, 16.2% were white, and 3.2% reported other racial backgrounds. The most common reported route of HIV acquisition was heterosexual contact (51.1%), followed by male–male sex (22.3%), and injection drug use (9.8%). Baseline characteristics of the sample, according to gender, are summarized in Table 1. The demographic profiles of males and females were similar. There was a trend toward higher rates of marriage among women (P = .08). As expected, there was a higher rate of HIV acquisition through heterosexual contact for women and through same-sex contact for men. Consistent with prior observations, 25 the mean CD4 count was significantly higher among women. Men reported histories of myocardial infarction and stroke more commonly, whereas there was a marked increase in asthma among women.
Baseline Sociodemographic and Clinical Characteristics.
aResponse totals do not equal the cohort size for all items because of incomplete reporting.
Tobacco and other substance use behaviors according to gender are summarized in Table 2. More than a quarter of men smoked ≥1 pack per day compared to 14.8% of women (P = .03), and, consistent with this finding, men demonstrated a trend toward higher ECO level. Although numbers of quit attempts were similar across genders, women were more likely to have used NRT, varenicline, or acupuncture during a quit attempt. Although NRT usage was relatively high within the study cohort, utilization of quit lines, Web sites, and formal smoking cessation counseling was extremely low among both men and women.
Baseline Tobacco and Other Substance Use.
MDMA, 3,4-Methylenedioxymethamphetamine. aResponse totals do not equal the cohort size for all items because of incomplete reporting.
bFor participants who drank an alcoholic beverage in the last 30 days
Current (within the past 30 days) alcohol use and overall volume of alcohol consumed on days that drinking occurred did not differ significantly between genders. However, men were more likely to drink alcohol at least once per week. Men were also more likely to report histories of marijuana, heroin, and ecstasy use. Consistent with prior observations, 16 a history of other substance use was present in the overwhelming majority of study participants.
Measures of a range of psychobehavioral variables known to be important predictors of tobacco use and success at quitting were collected and findings are summarized in Table 3. There were no significant differences between genders in motivation to quit, nicotine dependence, anxiety, loneliness, decisional balance, or abstinence self-efficacy. Higher depression scores observed in female participants did not achieve statistical significance.
Baseline Psychobehavioral Measures.
aModified Abrams and Biener Readiness to Quit Ladder.
bModified Fagerstrom Tolerance Questionnaire.
cCenter for Epidemiologic Studies Depression Scale.
dGeneral Anxiety Disorder-7.
eUCLA Loneliness Index–10 item.
fSmoking Decisional Balance–Short Form.
gSelf-efficacy/Temptations Scale.
The primary abstinence endpoint for both trials was ECO-verified, seven-day point prevalence abstinence three months post-intervention. Across all study conditions, the aggregate abstinence rate for women was 13.0% versus 9.1% for men (P = .31). Differences in the abstinence outcome between men and women did not achieve statistical significance in any of the study conditions, although there was a trend favoring women over men in those randomly assigned to the Web-based intervention (17.9% versus 3.3% quit rates; P = .097). 23
Discussion
The relationship between gender and tobacco use is a complex one that is steeped in the Western cultural history of gender norms and influenced by the advertisement and marketing strategies of cigarette manufacturers. Cigarette smoking began, in the 19th century, as an almost exclusively male activity, with female smoking viewed as a deviant behavior. In the early 20th century, this changed with the realization by tobacco manufacturers that American women represented “a new gold mine right in our front yard.” 26 They began to aggressively market cigarettes to women as symbols of emancipation from societal strictures, as glamorous accessories, and as a means of staying slim and attractive. Women were encouraged to make a statement by smoking their “torches of freedom.” In his insightful review, Brandt commented that “for men, the cigarette evoked images of power, authority, and independence; for women, it represented rebellious independence, glamour, seduction, and sexual allure ….” 26 To this day, gender differences in smokers’ relationships to their tobacco products persist. Nicotine craving may play a greater role in male smoking patterns, 2 whereas stress control, regulation, and weight management are more common drivers of tobacco use among females. 2,4,5 The social aspect of smoking may be particularly important to gay men and lesbian women. 27 There are also biological differences in the gender–tobacco relationship, for example, more rapid nicotine metabolism in women, which have been reviewed in other publications. 2,7 –9 Moreover, studies suggest that there may be gender inequality in the medical management of tobacco use, with female smokers underdiagnosed and undertreated by their providers. 28 These observations are particularly concerning, given the overall low rates of tobacco use discussions occurring in PLWH interactions with their health-care providers. 29 Given this social and biologic backdrop, it is not surprising that there are important differences in the smoking behaviors of women and men, and efforts to combat tobacco use may benefit from a more sophisticated understanding of these distinctions.
The National Health Interview Survey (NHIS), last conducted in 2012, is a rich source of information about cigarette smoking trends in the United States, based on data collected from over 34,000 respondents. 1 In 2012, 20.5% of US adult males and 15.8% of US adult females were current smokers. 1 In contrast, recent surveys revealed current smoking rates of 42.9% and 41.5% for HIV-infected males and females nationally, 14 and New York statewide rates of 55.8% and 54.9% for HIV-infected males and females, respectively (percentages imputed from study tables). 13 These data suggest that the male predominance of cigarette smoking that prevails in the general population does not extend to PLWH. In comparison to the national NHIS sample, ethnic and racial minorities were overrepresented in our group of 267 urban, HIV-infected smokers. This reflects both the demographics of the Bronx and the disproportionate involvement of minorities in the HIV epidemic. Smokers of both genders in this trial reported daily cigarette consumption levels <14.6 cigarettes per day reported by NHIS. Thirty-eight percent of the national sample reported smoking ≥1 pack per day, compared to 25.9% of males and 14.8% of females in our study. However, the daily smoking (ie, every day smoking) rate in our sample of men and women (90.6% and 86.6%) exceeded the 78.4% in the national sample.
As summarized in Tables 2 and 3, there were far more similarities than differences between men and women relating to the patterns of cigarette and other substance use as well as psychobehavioral correlates of tobacco use. These data do not support the need for gender-segregated tobacco treatment strategies for smokers living with HIV. However, the differences that we report may be helpful in better tailoring cessation messages for men and women within this highly vulnerable group. Practitioners treating male smokers living with HIV should be aware of their higher rates of heavy smoking and comorbid substance use and address these issues accordingly. They should also strongly encourage an increased utilization of quit aides, especially pharmacotherapy. For their female smokers living with HIV, they should be mindful of the higher rates of depression. The women in our sample were more likely to have used various assistance strategies in their quit attempts. However, many of these strategies, even freely available ones, for example, quit lines, were dramatically underutilized in all participants. Over half of women smokers reported a history of asthma. Cessation efforts for women should emphasize the salutary effects that quitting can have on their bronchospastic lung disease and, by extension, their overall quality of life.
In the merged data set of 2 randomized controlled trials of targeted tobacco treatment for smokers living with HIV, there was no difference between genders in successful quitting. This finding is of interest since in the general population men are more successful than women in their quit attempts. 30 Quit rates were actually slightly higher among women in our sample, and this increase was driven by the higher abstinence rates observed among women randomized to the Web-based intervention in the later study. 23 We are not aware of any other randomized controlled trials that compared outcomes between men and women smokers living with HIV, although this may be a worthy subject for secondary and/or post hoc analyses in future research.
Certain limitations of the present study require mention. The trials were restricted to New York City residents and enrolled almost exclusively ethnic/racial minority participants. Findings may not be generalizable to other geographic or demographic populations. Although this was one of the larger study samples among published trials of tobacco treatment in PLWH, it was not specifically powered to assess the differences between genders, and it is possible that important gender associations were missed because of type II (β) errors. It is also possible that gender differences in motivation to participate in clinical trials could have introduced a selection bias prior to study entry. Finally, inclusion in the trials required certain enrollment criteria, such as motivation to quit, access to a computer (in the second study), and willingness to participate in research, which may have limited the generalizability of the study sample.
In summary, we found some noteworthy differences between male and female smokers living with HIV. Heavy smoking and other substance use were more common in men. Women were more likely to have asthma and to use assistance during their quit attempts. The psychobehavioral domains that we explored were more notable for their similarities than their differences across genders. Contrary to the observations made in the general population, we did not find any male advantage in achieving abstinence in our cohort of smoker living with HIV enrolled in tobacco treatment trials. Data such as these may be helpful in fine-tuning cessation treatments targeting this highly vulnerable group.
Footnotes
Authors’ Note
This work examines data derived from 2 previously published clinical trials NCT01106638 and NCT01570595 (
). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institute on Drug Abuse, the National Cancer Institute, or the National Institutes of Health
Acknowledgments
The authors would like to acknowledge the assistance of Ms Eileen Dolce and Ms Daniela Morales in the conduct of the studies. They would also like to acknowledge the support and cooperation of the staff and patients of the Center for Positive Living.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the National Institutes of Health/National Institute on Drug Abuse (Grant R21 DA023362) and the National Institutes of Health/National Cancer Institute (Grants # R21CA163100-01 and P30CA051008). It was also supported by the Clinical Core of the Center for AIDS Research at the Albert Einstein College of Medicine and Montefiore Medical Center funded by the National Institutes of Health (Grant AI-51519).