Discussion
The harms of smoking and the beneficial effects of smoking cessation on health are well-established. All healthcare staff coming into contact with patients at risk have a role to play in helping smokers to quit, mainly through triggering quit attempts by asking about smoking, delivering VBA on smoking and referring to stop smoking services.
The simple intervention of asking HIV-positive people about smoking when they attended HIV ambulatory care appointments and offering referral to stop smoking services to identified people who were current smokers, allowed VBA advice to be given and 40% of smokers accepted referral to smoking cessation services. This suggests that this intervention was acceptable to people with HIV and there is a demand for such services.
As with other interventions attempting to increase uptake of stop smoking services,13 most individuals offered referral did not take this up. The model of service provision in which dedicated smoking cessation services are not provided within HIV care, but instead individuals are referred to local services or primary care (depending on local commissioning decisions) may represent a barrier to their uptake for PLWH. Specifically targeted interventions in other groups with high smoking prevalence or risk of harm from smoking, such as individuals with peripheral vascular disease,14 diabetes15 or mental health problems,16 have been shown to improve uptake of stop smoking services. We believe that interventions tailored to the needs of PLWH should be evaluated. These might include personalised information about risk of harm from smoking,13 better communication between HIV care and stop smoking services or minimising barriers to access to such services within HIV care.
In the UK NHS setting, smoking cessation services have been shown to be cost-effective.17 The cost associated with the brief intervention we evaluated (estimated to be £55.77 for each person attending stop smoking clinic) was similar to that estimated in an evaluation by Wu et al of a personalised invitation from primary care to stop smoking clinic and appointment for a taster session, with an estimated mean cost of £54 per person. This was found to be cost-effective from an NHS perspective in the long-term.18 Although few studies have comprehensively evaluated the economic impact of smoking cessation across a lifetime, available data suggest that there may be net savings from investing in smoking cessation.19 How this differs in HIV-positive groups in resource-rich settings has not been formally assessed, though the higher prevalence of smoking and greater risk of smoking-related illness is likely to increase these benefits—suggesting that this is a population who should be targeted specifically within smoking cessation policy.
The current means by which smoking cessation interventions are delivered, with few formalised links between HIV and smoking cessation services, may not be suited to the medical, social and psychological needs of PLWH. As a consequence, HIV services could miss this important opportunity to improve health outcomes. Alternative models of care, for instance, facilitating communication between services, training of HIV care providers to deliver smoking cessation assistance or specialist services directly linked to HIV care, should be evaluated. More importantly, asking about smoking and helping smokers to quit must become a core part of the care provided by all healthcare professionals involved with PLWH. Such an approach (described as ‘Making Every Contact Count’) can be a powerful means of generating lifestyle and behaviour change.20
The provision of smoking cessation interventions by the health service in England and Wales has undergone significant changes in recent years: responsibility for preventative public health interventions has moved from healthcare services to local authorities following the Health and Social Care Act 2012. Funding provided to local authorities from central government for public health interventions has subsequently been reduced and smoking cessation services have been one of the targets for cuts.21 At the same time, changes, such as the increased availability of e-cigarettes, have altered the way that some people consume nicotine and may be a means for some individuals to stop smoking, although this remains controversial.22 These changes have been associated with a significant reduction in the number of people accessing NHS stop smoking services.23 Within this changing landscape, HIV services must ensure that appropriate support for their patients is available.
This analysis has limitations which should be considered. Data collection was undertaken as part of clinical service evaluation and for a proportion of referrals made to stop smoking services so we could not establish the outcome of the referral, either because the service had no record of the referral or its outcome, or the smoking cessation service had been decommissioned since the time of referral. This illustrates the current deficiencies in communication between HIV and local smoking cessation services and the reduction in provision of universal smoking cessation services in the UK, as documented by recent national surveys.24 The proportion of HIV-positive individuals identified as current smokers by this intervention (25%) is lower than that found in other recent studies of PLWH in London, where around 30% were current smokers3 8—suggesting that not all smokers disclosed this when asked. Finally, the identification of smokers relied on self-report, rather than being objectively confirmed (for instance with exhaled carbon monoxide measurements) and no objective measurement of quit rates (such as saliva cotinine levels) was performed. Despite these limitations, we believe that our report describing the potential benefit of low-cost smoking cessation interventions for the UK HIV-positive populations and the difficulties highlighted in the management of those smokers who wish to quit highlights the need for joined-up working to improve personal and public health within the NHS.