Smokers with HIV/AIDS find quitting easier with cell phone counseling
MD Anderson Cancer
Dr. Michael Fish: Welcome to Cancer Newsline, a podcast series from University of Texas, MD Anderson Cancer Center. Cancer Newsline helps you stay current with the news on cancer research, diagnosis, treatment and prevention providing the latest information on reducing your family's cancer risk. I'm your host Dr. Michael Fish, I'm the chairman of the Department of General Oncology and today we're talking with Dr. Damon Vidrine, associate professor of behavioral science and Dr. Ellen Gritz, professor and chair of behavioral science. Welcome and congratulations on your study showing that counseling via cell phone helps smoker with HIV/AIDS quit and this research was recently published online in clinical infectious diseases and I would tell you that the topic of tobacco use is much on our mind at MD Anderson Cancer Center after this year's ASCO meeting where we learned that 44 million smokers are still out there in the United States and I was wondering why you decided to conduct this study in an HIV/AIDS population and I wonder Dr. Vidrine if you can tell us how this got going.
Dr. Damon Vidrine: Sure. This study is actually the, the latest in the long line of research that we've been conducting starting and, we believe 1999, this study was informed by the, the previous research and basically we've observed incredibly high rates of smoking in the HIV positive population, rates that range anywhere from 45 to 70%, so two to three times higher than in the general US population. It's also a population that suffers from the adverse effects of smoking much more so than the general US population. So only responds to antiretroviral treatments but also the traditional smoking related diseases such as lung cancer, head and neck cancer.
Dr. Michael Fish: Well Dr. Gritz why is there such a big group of smokers in this population? What is it about the population that enriches them for this?
Dr. Ellen Gritz: Well that's a really interesting question Dr. Fish and I think it has multiple answers. First of all, many of the individuals who are affected with HIV/AIDS are in the lower socioeconomic classes which tend to have much higher smoking rates than those who are more highly educated and are in higher financial status categories. Secondly, many of these individuals are substance users. In addition to tobacco, they use alcohol, they use other substances and many have high rates of depression and other mental disorders and those are traditionally and especially now conditions that are associated with very high rates of smoking. So they all go together in a synchronistic type of way and I think I'd like to add to Dr. Vidrine's earlier response that one our, my close colleagues Dr. Roberto Arduino who is a professor of infectious disease at the UT Health Science Center and Medical School has been our collaborator in this study and it was through conversations with him and myself many years ago that we learned and mutually discovered that the patients whom he was treating had these very high rates of tobacco use of smoking and that's when we decided to embark on this collaboration which Dr. Vidrine was a part of from the very beginning.
Dr. Michael Fish: Well so when you take the approach of trying to improve the quit rates with smokers, tell me about how that's ordinarily done in typical population say at cancer centers and whether your approach here was similar or different.
Dr. Damon Vidrine: Sure. Most of the treatments are based on the public health service guideline. It's a big collection, it's a meta analysis basically that has been updated several times over the years, but the treatments consist of evidence based counseling, in our case we use cognitive behavioral treatment as well as pharmacotherapy such as nicotine replacement therapy, Zyban, Gentex, so what we did when we were coming up with our treatments were to, to look at the literature, see what worked for other populations, but then we dove a lot deeper. I mentioned some of our previous where much of these efforts were designed to understand the barriers at place within the HIV positive population. Dr. Gritz mentioned a few such as the substance use, the, the alcohol use and the psychiatric co-morbidity, but we also found basic barriers such as lack of phone service, household instability that's a population that moves around a lot, so expecting and also a population that depends on public transportation. So where many treatments might rely on smokers to come to a central location for treatment, it wasn't really feasible with the HIV positive population, so we had to understand these barriers that lack of phone service, lack of transportation to come up with our idea and that's when we settled on cell phones.
Dr. Michael Fish: That makes sense. When I think about some of the barriers, I also think about cost of getting treatment and, and also maybe peer pressure when there is enough of the people around you that are acculturated to smoking. Are those issues in this population?
Dr. Ellen Gritz: Very much so. So when we talked about the issue of cost, we actually gave them our participants the cell phones preloaded with calls, so we made them available to them for free treatment in a sense and we called them proactively again to stimulate motivation and willingness to engage with the counselor. There's a great deal of peer pressure, there still is a great deal of tobacco use and other substance use in the population which is a barrier not only to quitting but to staying quit which is part of what we learned in our study. You've mentioned before the cancer center I think we need to point out that in the general population, individuals are usually healthy, they have more economic freedom, they have other kinds of support systems, both personally and socially and in this population individuals are much more challenged on all levels both medically and socially and so the most support and this, this our intervention relied heavily on social support through the peer counseling to try to stimulate the desire to quit and to stay quit and the same kinds of issues arise in the cancer patient population which we're not talking about today but which we have a very strong and intensive program here at MD Anderson.
Dr. Michael Fish: Dr. Vidrine did the age of this population tend to be a bit younger than the general population or what were there any specific age related aspects?
Dr. Damon Vidrine: No, for this trial, this treatment trial we had an average age, I believe it was in the mid 40s and that's pretty much what you see in most smoking cessation studies. So even though there might a popular perception of, of HIV positive individuals being a bit younger, it's really an ageing population with, with the advent of effective antiretroviral, it's a population that's living longer and longer and I'd believe that we saw that in our data.
Dr. Michael Fish: Fair enough. Now Dr. Gritz when I think about cell phone interventions, I'm always thinking about texting and so many people choose to text. Was that a component of this study or was it just using the cell phone for voice exchange.
Dr. Ellen Gritz: So at the time that this particular study was funded, I'm not sure the texting even existed. You know how fast the electronic world is developing, so we were, we call this a novel intervention, it was even in the title of our grant application and it worked very well, but now we see with texting and all sorts of smartphones of various kinds that we have to be even more novel and faster, so the next generation studies that Dr. Vidrine is heading up those will have all those features.
Dr. Damon Vidrine: And in fact some of them are already underway, so we have an ongoing study that will compare the voice based intervention that we did in the past with the purely text based intervention. So one of our questions will be to see if health literacy which appears to be limited in this population to see if that will impact the effectiveness of the text based intervention, but again we're, we're working on those answers right now.
Dr. Michael Fish: Good to hear. Well, Dr. Vidrine when I think about successful quit rates, we learned that it tends to be 6 or 7% at one year and in your study you did a lot better than that at least early on. Why do you think this was effective, this counseling via cell phone?
Dr. Damon Vidrine: Well, you, you say effective and we did have a nice treatment effect, but we did see those steep relapse rates that you just mentioned, so by six months and a year we were down there below 10%. I believe early on we were able to increase the social support, we were able to provide coping skills to bring about quit attempts and get people to quit at least temporarily and I think that we see that in other smoking cessation trials as well, maybe not population based trials but at least in clinical trials we see this. I think our steep relapse curves really speak to all of these other problems that are present in this population that Dr. Gritz mentioned before. And I believe that the next generation of interventions will have to actively take on the depression, the substance abuse and the alcohol use to really find a, a way to sustain the cessation rates over and beyond a three month period.
Dr. Ellen Gritz: I also want to add that this is very typical for all smoking cessation clinical trials that the highest quit rates are found at short-term follow up and then there is a decline over time in terms of relapse, but as Dr. Vidrine pointed out, we feel that our population is at much greater risk of relapse because all of the personal and social and other barriers that we have discussed in addition to which this next time in future trials we want to be able to assure that all participants have active access to pharmacotherapy and nicotine replacement or whatever other agents we may design because those also help deal with the craving and the nicotine addiction part of the behavior and this is a chronic relapsing disorder. We are asking a lot of individuals to quit and stay quit when in the general population permanent cessation sometimes takes up to 14 attempts.
Dr. Michael Fish: Well that seems awfully challenging because the cost of the, those interventions is not trivial and I know that in the county health systems and in other systems it's not necessarily part of the care plan for these more expensive interventions and I wonder whether you, Dr. Gritz would think that, that changing healthcare environment and pay for performance type approaches could come into play to improve the investment in some of the effective smoking cessation treatments.
Dr. Ellen Gritz: We think this is a critical point and a major point because while you may say that the treatment is expensive, smoking cessation treatment is perhaps the single most cost effective intervention in medicine that I know of today. I can't site you the, specific dollar amounts, but compared to mammography or many other prevention interventions, smoking cessation has huge cost savings in terms of disease incidents and disease treatment treating lung cancer and treating other cancers, heart disease, pulmonary diseases which are chronic conditions cost hundreds and thousands if not millions of dollars versus you might talk about a few hundred dollars to help somebody quit smoking.
Dr. Michael Fish: Well Dr. Vidrine this is exciting work and I know a lot people would be interested to know what the implications of this work might be for the general public not just HIV population. What have we learned that the general public can take home?
Dr. Damon Vidrine: Well I, I think some of the big lessons that we've learned is no matter how underserved the population is, no matter what the competing healthcare needs are such as we observed in the HIV positive population that people who smoke, want to quit smoking and they prioritize that and they participate in smoking cessation trials, they can quit, they want to quit and they want to keep it rolling, they keep in trying to quit, so I think that among the most positive outcomes of this study was the just positive endorsement that we received from our participants and I think with that's often the case among smokers, smokers want to quit, so I, I found that very reassuring.
Dr. Ellen Gritz: And I think this is a very important take home message to the general public that very often people want to give up on individuals who are facing serious diseases and they say their life isn't going to be that long or they don't really want to quit, they have so many other problems, they're not thinking about their tobacco, their tobacco is the only thing that helps them and reinforces them to keep going, but it isn't true and we learned in one of the those earlier studies that Dr. Vidrine mentioned too that there was very high motivation to enroll and seek treatment, that wasn't one of our feasibility trials. And again I'm going to make the same statement with regard to cancer patients whom we often think oh once they have cancer what's the point in their stopping smoking, but we've learned here in the tobacco treatment program, a very parallel lesson that people really do want to stop and when we emphasize to them, it's the single most important personal thing that you can do to participate in your healthcare. They become more empowered and, and it becomes very rewarding to work with them under those circumstances.
Dr. Michael Fish: That's such as critical point and I'm so glad you're able to make that and I was, I was shocked to learn that only 29% of NCI trials assess tobacco use and I wonder whether the trial list have just not had that point well understood.
Dr. Ellen Gritz: Thank you Dr. Fish for bringing that up because I was one of the authors on that paper and what we did was we assessed almost 160 NCI supported clinical trials that are operated through the clinical trials cooperative groups and it was to our great shock to see that 79% of those trials made no assessment whatsoever, so 21% did, 79% didn't and mostly it was to ask whether people smoked at the beginning of the trial and mostly that was in trials that had to do with smoking related cancers, none of them assessed nicotine dependence, none of them assessed follow up of smoking status throughout the trial and this is very important because smoking has adverse effects on treatment, on cancer treatment and on medical outcomes and on survival, quality of life, I could go on and on even though this particular interview is about HIV.
Dr. Michael Fish: Well I think you made the point very well and I wonder for the HIV trials, do they assess tobacco better? How is that going Dr. Vidrine?
Dr. Damon Vidrine: It's another good point and we've seen quite a change in the years that we've been doing this. When Dr. Gritz and I first started work and Dr. Arduino first started working on this topic, we found a lot of resistance about assessing smoking, about doing anything about it, I think recent data has really indicated just how bad smoking is for individuals with HIV. There was some big Danish cohort study that came out talking about the, the population attributable risk of smoking, basically HIV positive individuals lose far more years of life to smoking than they do HIV and when they're HIV positive and smoking it's a synergistic relationship so it's especially bad. I believe that the, the people who run the clinical trials and as well as treating physicians realize this now. So we're as years ago we got resistance, now Dr. Gritz and I probably get phone calls weekly to advise on how to assess smoking and what we can do to, to help HIV positive patients quit, so it's been quite a turnaround, a very positive.
Dr. Michael Fish: Well congratulations. I think things are changing and we look forward to a new landscape in this regard. So Dr. Gritz I wonder if you have any final thoughts about resources people should know about or what they should anticipate for the future with this work.
Dr. Ellen Gritz: Well we are certainly continuing our research. We have a study ongoing now at the legacy foundation, the federally qualified health agency and we are planning continued improved efforts to boost cessation rates to tailor and intensify the treatment to link individuals to other sources of assistance in the community and in their health agencies and to really normalize this behavior and to help people realize that tobacco is a seriously addicting substance and that even individuals with any sort of chronic illness can benefit from quitting.
Dr. Michael Fish: I want to thank Dr. Vidrine and Dr. Gritz for being with us today. If you have any questions about anything you've heard today on Cancer Newsline, contact Ask MD Anderson at 1-877-MDA-6789. We're online at www.mdanderson.org Thank you for listening to this episode of Cancer Newsline. Tune in for the next podcast in our series.