New publications from K•A•C discuss the challenge of smoking in treatment services caring for those who are HIV positive or coping with drug problems.
Smoking rates among those who are HIV positive and those who use drugs (as well as those with mental health problems where there may well be overlap) are anything from two to four times higher than the general adult smoking rates of most developed countries. One study of those receiving opiate substitute treatment recorded a smoking prevalence rate of 85%. Why should this be?
K•A•C's two new GSTHR Briefing Papers highlight underlying correlations such as poverty, discrimination, incarceration, and marginalisation, but behavioural and social aspects of smoking are also powerful drivers which are not confined to vulnerable groups but do have extra potency here.
At an individual level, smoking is a way of dealing with stress, anxiety and depression. Some studies demonstrate that nicotine can enhance the effect of some drugs and there is a comforting ritualistic aspect to both drug use (especially where drugs are injected) and the act of cracking open a packet of cigarettes, taking a cigarette out, putting it to the lips and lighting up.
When those who smoke decide to quit, a significant part of what they report missing isn't just the nicotine, it's having something to do with their hands in moments of anxiety, boredom, or social awkwardness.
And from a social aspect, the offer of a cigarette within a group under pressure helps build a certain level of trust – it’s a friendly act in a dangerous world. Smoking as a shared experience often finds its way into drug treatment services where workers who themselves might be former drug users, but are still smoking, quite naturally want to show empathy with their clients. There is a real challenge here, but one that should no longer be ignored. It is also the case that safer alternatives mean there are positive steps that can be taken short of total abstinence.
But for those with compromised immune systems, there is a further price to pay. Those living with HIV and/or serious drug problems are likely to have multiple co-morbidities which can only be made worse by smoking. For people with hepatitis B and hepatitis C, smoking is associated with worse liver outcomes and more severe disease progression. People who smoke drugs such as crack cocaine or methamphetamine often have poor respiratory health, worsened by smoking and strongly associated with chronic obstructive pulmonary disease (COPD). It is often older drug users who succumb to opiate overdose where years of smoking have severely compromised the ability to breathe and so reduce the chances of survival.
Those living with HIV and who smoke, are more likely to succumb to pneumocystis pneumonia than those with HIV who don’t smoke, and generally the effects of HIV on the immune system and inflammatory responses renders an individual at risk of a whole basket of diseases including cancer, heart disease and stroke.
How can agencies respond? The problem is potentially easier to manage in higher income countries with decent health infrastructure combined with legislation that bans smoking inside public buildings and workplaces, which removes smoking as an option during counselling. (But see below).
Yet even in higher income countries, drug and HIV treatment agencies are often not fully engaged with delivering smoking cessation treatment. This may be because funding shortages limit what might be regarded as ancillary services or because there is no referral option to a bespoke stop smoking service or because, while everybody knows the health impact of smoking, somehow this doesn’t translate into structured intervention with clients.
In many LMICs, ‘services’ for vulnerable groups hardly warrant the name and are exponentially worse. The dominant model of drug treatment is not remotely evidence-based. Compulsory rehabilitation centres, essentially detention facilities, are widespread across Asia, Latin America, and parts of Africa, where people are held without consent, subjected to forced labour, religious programming, or physical punishment, and receive no medication-assisted treatment. These have been repeatedly condemned by the UN and the WHO but persist because they are politically convenient and cheap.
But where drug and HIV treatment services are part of a national health infrastructure, there are ways that agencies can move people away from smoking. Indeed, many clients express an interest in quitting when the subject is raised. The papers explain how workers can move from initial assessment through to positive action towards switching clients away from smoking.
Tobacco harm reduction is the key here. Workers will be familiar with the idea as it relates to drugs and HIV but may not be aware of it in relation to smoking. Moreover, due to the avalanche of misinformation spread about vaping and similar products, they may have a very negative view and be wary about encouraging clients to switch.
But as all the most rigorous studies show, vaping, for example, delivers the nicotine without the dangers inherent in smoking. Therefore, having ensured staff undergo credible, evidence-based training (including debunking the myth of second-hand vaping), agencies may consider allowing vaping on premises. At the other end of the care spectrum, even some brief intervention work can be valuable, for example, delivered by community workers via a mobile phone in areas where health-based structured services are non-existent.
The idea behind the most recent GSTHR publications is not to deliver a counsel of perfection: what a service can offer by means of tobacco harm reduction interventions will entirely depend at the very least on resources, national regulations and product access. Presented instead are some ideas of how tobacco harm reduction within a service framework can help those who cannot or don’t want to quit nicotine. Clients may well appreciate the acknowledgement of the value nicotine plays in their life, but they too will need reassurance from well-informed staff that they are not jumping from one danger to another as the ‘mood music’ would have you believe. Otherwise, why not carry on smoking?
Check out these three new GSTHR publications exploring the stark impact of smoking in two high-risk communities:
What is the impact of smoking on people living with HIV and how could tobacco harm reduction help?
Smoking among people facing problems with drug use
Integrating tobacco harm reduction into drug treatment and harm reduction services