A Smoking Cessation Trial in HIV-infected Patients in South Africa (JHU)

• Smoking status using a point of care test for measuring carbon monoxide (CO) [ Time Frame: 6 months from baseline ]
  A point of care test for measuring carbon monoxide (CO) will be conducted via the piCO Smokerlyzer from OPS Medical, designed specifically for smoking cessation programs and tobacco control programs. Carbon monoxide will be measured in an exhaled breath in parts-per-million (ppm). A reading of ≤ 8ppm will indicate abstinence.
  
  
• Smoking status using a point of care test for measuring cotinine [ Time Frame: 6 months from baseline ]
  A point of care urine test for measuring cotinine will also be conducted via the SmokeScreen® test from GFC Diagnostics Ltd. to verify smoking status. A color change to red/orange indicates a positive sample, with a darker color indicating greater nicotine intake.
  
  

• Smoking status [ Time Frame: 2 months from baseline and 12 months from baseline ]
  A point of care test for measuring CO will be conducted via the piCO Smokerlyzer from OPS Medical, designed specifically for smoking cessation programs and tobacco control programs. Carbon monoxide will be measured in an exhaled breath in parts-per-million (ppm). A reading of ≤ 8ppm will indicate abstinence. A point of care urine test for measuring cotinine will also be conducted via the SmokeScreen® test from GFC Diagnostics Ltd. to verify smoking status. A color change to red/orange indicates a positive sample, with a darker color indicating greater nicotine intake.
  
  
• Urges to smoke [ Time Frame: Baseline, 2-week visit, 2-month visit, 6-month visit, and 12-month visit ]

  Smoking Urge Questionnaire

  This scale consists of five items:

  1. "I have a desire for a cigarette right now"
  2. "If it were possible I would smoke now"
  3. "All I want right now is a cigarette"
  4. "I have an urge for a cigarette"
  5. "I crave a cigarette right now"

  Responses to each item are rated from 0 (not at all) to 100 (the strongest feeling possible); responses are averaged to produce a craving intensity score.

  
  
• Withdrawal symptoms [ Time Frame: Baseline, 2-week visit, 2-month visit, 6-month visit, and 12-month visit ]

  Wisconsin Smoking Withdrawal Scale

  The 28-item scale contains 7 reliable subscales tapping the major symptom elements of nicotine withdrawal syndrome (Anger, Anxiety, Concentration, Sadness, Hunger, Sleep, Craving). Cronbach's alpha for the subscales ranges from .75 to .93. The scale is sensitive to smoking withdrawal, and is predictive of smoking cessation outcomes.

  
  
• Reinforcing effects of smoking [ Time Frame: Baseline, 2-week visit, 2-month visit, 6-month visit, and 12-month visit ]

  Cigarette Evaluation Questionnaire

  The scale yields 3 subscales:

  1. Smoking Satisfaction (satisfying, taste good, enjoy smoking)
  2. Psychological Reward (calm down, more awake, less irritable, help concentrate, reduce hunger)
  3. Aversion (dizziness, nauseous).
  
  

Tobacco use is estimated to be responsible for over 5 million deaths globally every year and HIV/AIDS kills 2 million worldwide, with persons living in the developing world especially at risk. However, the association between tobacco use and HIV is not clearly understood. The introduction of highly active antiretroviral therapy (HAART) has led to longer duration of survival following HIV-infection in the developed world, and now that HAART is being rolled out in the developing world, survival will increase in these highly endemic regions as well. Given this increase in survival, more people will die of non-HIV related illnesses for which smoking plays an important causal role. Smoking cessation for HIV-infected persons has been studied in the US though these studies have had small numbers and limited follow-up. US based studies suggest that approaches that combine nicotine replacement therapy (NRT) and counseling interventions are most successful. Optimal approaches in resource-limited settings have not been determined.

This study will compare intensive counseling plus NRT versus intensive counseling only, comparing smoking cessation at 2, 6 and 12 months. At 6 months, patients who are still current smokers will be given a second opportunity to receive their group assigned intervention, either intensive counseling plus NRT or intensive counseling alone. We will relate smoking exposure and cessation to HIV progression as measured by immunologic and viral markers, risk of respiratory infections, including tuberculosis, and AIDS-related malignancies. The RCT will be performed at the Tshepong HIV Wellness Clinic in Klerksdorp, South Africa, associated with the Reproductive Health & HIV Research Unit of the University of the Witwatersrand, South Africa.