Gus Cairns investigates the fatal attraction between people with HIV and cigarettes – and tries to kick the habit himself.
I had this great idea last year. I was going to give up smoking – and use this article to do it.
An on-off smoking habit I’d had since my student days had spiralled into 20 Marlboro Reds a day. I was sick and tired of smelling like an ashtray, of not being able to taste my food, and of colds prolonging into chesty coughs. Having survived AIDS, it seemed perverse to have a habit that would hasten my death. Besides which, I was ashamed of being controlled by an addiction.
So, I thought, I’ll go on a stop-smoking course, and write up my experience as a reborn non-smoker as an article. So I signed up for the once-a-week stop-smoking course run by the gay men’s health charity GMFA. It was going to be easy.
After a couple of evenings bonding as a group and being given the kind of data on smoking that will follow in this piece, our ‘Stop Smoking Day’ happened in the third week. Participants recite a pledge that they will, from then on, be a non-smoker.
For the next four weeks we were supported in staying off, assisted by whatever medication we chose to use (some use none). Every week we took a ‘breathalyser’ test that measures the amount of carbon monoxide in the body (see below); it can tell if you’ve had a cigarette in the last 24 hours.
One way we prepared to stop was to look at our smoking ‘triggers’: what makes us light up. Smokers tend to be one of three types:
I’m the third type. I don’t smoke regularly, but when I do I binge. Apparently my type finds it hard to stop because we’re psychologically, rather than physically, addicted. I could cheat the breathalyser because I don’t smoke every day.
You know what’s coming – going ‘cold turkey’ didn’t work. After seven weeks of the course, I was smoking more than ever, though at least I had the bottle to go back and admit it. Having tried and failed my first attempt, I went off to the doctor for a prescription for an anti-smoking pill called Champix (varenicline).
This helped. My consumption has gone way down and I managed a three-week period without a single puff. But it’s far from being an unqualified success. I still smoke, though less often.
I probably needed to be reminded at first hand of exactly why it has proved so hard to reduce what the US Centers for Disease Control call “the single most important preventable cause of death in our society”.1
Nicotine is the addictive substance in tobacco. An oft-quoted surveyperiodically asks addiction experts to rate various drugs in terms of their addictiveness, and nicotine has consistently come top – ahead of crystal meth, cocaine and heroin.2
Nicotine is only moderately physically addictive: but it’s fiercely behaviourally addictive, due to a unique combination of effects.
Firstly, nicotine is a stimulant drug. It causes the release of the neurotransmitter dopamine, also associated with cocaine and crystal meth, which creates a sensation of confidence and alertness.3
Secondly, and unlike other stimulants, it increases the brain’s sensitivity to another neurotransmitter, glutamate.4 Glutamate improves alertness and concentration.
Thirdly, when you burn nicotine you create a substance called harman,5 which is an antidepressant drug.
Fourthly, most addictive drugs induce tolerance: habitual users need more to have the same effect. But with nicotine the brain cells develop more nicotine receptors as time goes by, which means the ‘hit’ keeps on getting better.6 This increased number of receptors persists for months or even years after people quit smoking, prolonging cravings and ‘priming’ ex-smokers to relapse.
And lastly, there’s the way you take it. Because they can have control over how much drug they inhale, smokers can achieve the optimum balance between reward and side-effects. As users of nicotine replacement therapies know, other delivery methods don’t feel so good.
Nicotine itself has harmful effects. The dopamine it creates causes your system to flood with adrenaline, which increases heartbeat and blood pressure and raises the amount of cholesterol in the blood.7 It also increases the amount of clotting agents, making thrombosis more likely.8
Nicotine also raises blood sugar (which is why it suppresses appetite) and decreases insulin production.9 It causes sexual dysfunction: a study in Chinese men (China has one of the world’s highest smoking rates in men, and is predicted to suffer an epidemic of lung cancer in the next 20 years) found that smoking raised the risk of erectile dysfunction by 65%.10
However it’s not the nicotine that causes the majority of harm: if it did, the health service wouldn’t prescribe nicotine patches. The most harm is caused by two other chemicals.
Firstly, tobacco smoke is full of carbon monoxide, a killer gas that stops your blood cells being able to take up oxygen. Heavy smokers have about ten times as much carbon monoxide in their blood as a non-smoker living in a city, and will be deficient in oxygen for eight hours after their last cigarette. This makes the heart work harder and damages blood vessels.11 Carbon monoxide is also the most important pollutant affecting passive smokers, who may inhale 25% of active smokers’ intake of the gas.12
In pregnant women, carbon monoxide from smoking, or from passive smoke, also restricts the oxygen supply to the baby, which can affect its development in the womb and result in premature birth and low birth weight. Smokers are also more likely to experience complications during their pregnancy and during the birth, including eclampsia and placental abruption.13
Secondly, smoking causes the formation of tar, and tobacco tar contains at least 20 of the most potent carcinogens (cancer-causing chemicals) known.14
Lung and other cancers are not the only diseases caused by these carcinogens: the cellular disruption causes inflammation, leading to chronic obstructive pulmonary disease (COPD; i.e. bronchitis and emphysema).15
Cigarette smoke also includes a whole number of other toxic chemicals, including formaldehyde, cyanide, ammonia and arsenic.
Imagine three jumbo jets crashing every day, 365 days a year, killing everyone on board. That’s the number of deaths caused by tobacco in the USA alone. Each cigarette shortens the average smoker’s life by eleven minutes.16
The seminal studies on tobacco and mortality were conducted in the UK in the 1950s by the pioneering epidemiologist Sir Richard Doll.
His first study17 was stimulated by a 15-fold increase in lung cancer in the UK, between 1920 and 1940. This had been preceded 20 years earlier by a quadrupling in smoking.
Knowing that tar causes cancer, Doll first thought that the increase in tarred roads was to blame for the epidemic. But instead he found that 90% of lung cancer cases occurred in smokers, and heavy smokers (25+ cigarettes a day) were 50 times more likely to develop lung cancer than non-smokers.
At this point Doll was a smoker himself. “I gave up two-thirds of the way through the study”, he later remarked.
He followed this with a study of 35,000 male British doctors. Starting in 1951, this assessed their smoking habits, then monitored their deaths for half a century.18
Doll found that the smokers died, on average, ten years younger than non-smokers, were three times more likely to die before they were 70 and were at least 15 times more likely to die from lung cancer, 14 times more likely to die of COPD, and 50% more likely to die from heart disease or a stroke.
If they’d stopped smoking before 30, they avoided all the extra risk of dying, and stopping at 50 halved it.
At the time of Doll’s original study, half the men in the UK smoked. Smoking rates declined to 24% by 1990, but then seemed to get stuck. However, due to a comprehensive national tobacco control programme, which included legislation like banning smoking in public places and support for smokers to quit, it started declining further in 1998 and now stands at 19% in the general population.
However, it has not declined in a number of vulnerable groups, such as people with psychiatric diagnoses, and 40% of UK teenagers have smoked. Although deaths due to smoking have declined, it still caused 18% of all deaths in England and Wales and 24% of those in Scotland in 2000.19
One group in which smoking remains at high levels is people with HIV. A study from the HIV clinic at London’s Royal Free Hospital in 2004 found that 45% of its patients smoked an average of 15 cigarettes a day and that two-thirds had smoked at some point.20
The majority of the survey respondents were gay men, and the smoking rate among gay men is, at 38%, higher than in the general population. Smoking among Africans has historically been lower, at about a third of the rate of people born in the UK, but rates in Africa have increased faster than anywhere else since 1990, as has the incidence of COPD.21
Why do so many people with HIV smoke? According to Barrie Dwyer, who runs the GMFA stop-smoking courses, for gay men it’s largely a question of lifestyle.
“Gay culture is more accepting of behaviours like smoking, recreational drugs, open relationships and so on. Starting to smoke may be part of socialisation, becoming accepted in the group. And there’s that eternal pick-up line – ‘Can I offer you a light?’”
He’s less keen to automatically attribute psychological factors like stress to gay, HIV-positive smokers – “Not everyone who smokes a lot is gay” – but acknowledges that “messages directed at us are internalised and may result in stress and low expectations of ourselves”.
Imagine three jumbo jets crashing every day, killing everyone on board. That's the number of deaths caused by tobacco in the USA alone.
Carolina Herberts is the smoking cessation worker at the Royal Free Hospital. She advises and helps everyone from patients hospitalised with COPD to HIV clinic attendees and even hospital staff who want to stop.
“I think the stress of dealing with HIV may certainly be a factor,” she says. “So is stigma: people may blame themselves for poor health choices generally, as well as HIV, and may feel they have no control over giving up. That’s why it’s so important to acknowledge how hard it is to stop and not to nag people.”
What is clear is that having HIV exacerbates the harm smoking can do, and vice versa.
HIV increases the risk of lung and other smoking-related cancers. Studies have found that between 2.6 and 5.3 times as many cases of lung cancer occur in HIV-positive smokers than in their HIV-negative counterparts.22, 23
A 2003 survey from London’s Chelsea and Westminster Hospital found that the annual incidence of lung cancer in their patients rose from one in 12,500 patients a year before 1996 to one in 1500 a year after 1996.24 So it’s still relatively rare: but if you do get it, you only have a 33% chance of surviving a year.
In terms of cardiovascular disease, a study has found that HIV infection and smoking both roughly contribute equal amounts to the risk of hardening of the arteries and to heart attacks – doubling an already increased risk.25
People also worry about the cardiovascular effects of HIV drugs, but these raise the risk less than uncontrolled HIV infection: one study found their contribution was the equivalent of smoking about one to four cigarettes a day, so even if you are a smoker, it’s better to be on HIV treatment than not.26
The bottom line is that if you have HIV, smoking could double your risk of premature death. A study in HIV-positive women in 2006 found that smokers had a 53% increased chance of dying during the study period:27 and one in US army veterans (mainly men) in 2005 found that it raised the risk by 99%.28
However, it is possible to come off, and stay off, cigarettes. A French study of 233 smokers with HIV found that about 7% stopped within the next two years.
This quit rate is approximately what Carolina Herberts sees at the Royal Free.
“We know that about 3% of patients a year, who simply decide to stop and have no other help, manage to quit permanently after any one attempt.
“If they also use medication such as nicotine replacement therapy or the anti-smoking drugs Zyban (bupropion) or Champix, the one-year success rate is 7%. But if they get medication and support, such as an anti-smoking course, the success rate is 20%.”
Short-term success is much greater: a month after stopping smoking 60% of smokers have still stopped. But, as I found, the addictiveness of nicotine means that there’s a high relapse rate.
Vince knows about relapse. He’s 64, has had HIV for 23 years, and used to smoke 30 a day. A tough proposition for a stop-smoking course.
“I started smoking at 17, and was smoking for 38 years before I stopped in 2000,” he says. “I managed to stay smoke-free till last year when I was having a bad time.
“I started again in June and was soon up to 30 a day. I was coughing again within a month. A friend said: ‘You’re already sounding like you did ten years ago’.”
The first time round he had attended a stop-smoking course at the Royal London Hospital. He initially tried nicotine replacement therapy but, finding it didn’t work, started taking Zyban.
It’s still not clear exactly how Zyban works. It has tended to become less popular over time – in favour of Champix – because a lot of people complain of side-effects, including Vince. “I felt really spaced out, like I was unpleasantly drunk and had a woolly mind. However they halved the dose and I then felt much better.”
This may have been because anti-HIV drugs, including both protease inhibitors and non-nucleoside (NNRTI) drugs, increase the amount of Zyban in the body.
This time round he tried the GMFA stop-smoking course and Champix. This is the first drug specifically designed as an anti-smoking medication. It works by blocking the nicotine receptors on nerve cells, so smokers experience fewer cravings when they stop. It doesn’t interact with HIV drugs.
The most common side effect is mild nausea in the first couple of weeks. Vince also experienced disturbing dreams and disrupted sleep, though he says “it was hard to tell if it was part of the mental process of giving up.” And he says it has not entirely abolished cravings. But at the time I interviewed him, five weeks after the stop-smoking course, he only admitted to once having a puff on a tobacco-free marijuana joint.
Only a minority take an anti-smoking pill; the most popular choice is still to use nicotine replacement therapy (NRT), which gives you a hit of nicotine without filling you full of the tar and carbon monoxide you would get from smoking a cigarette.
NRT comes in a variety of different guises, tailored to smokers’ individual habits. Habitual smokers who light up first thing in the morning might use patches, which deliver a regular supply of nicotine. Occasional smokers might benefit more from gum, fast-acting lozenges, or a nicotine nasal spray to tackle cravings.
Milo is another GMFA course graduate. He’s 35 and HIV-negative and saw his cigarette consumption increase to about 15 a day since he started smoking eleven years ago. He had tried to give up three times before he decided to try a course.
Most smokers need a lot of attempts before they quit successfully. If it doesn't work this time, come back!
Barrie Dwyer, GMFA
“I think the course really helped; sharing experiences, going through something similar to everyone else. If you relapse you’re letting others down as well as yourself – though I liked the honesty of it too, and people feeling able to admit their slip-ups. It’s the first group therapy thing I’ve ever done.”
Vince chose the GMFA course because “courses are the only thing that have ever worked for me. It’s the ego thing, being able to come back the following few weeks and tell people you’re smoke-free.”
He wants to stay a non-smoker “because it’s the one thing in my life I can control. I need meds for my HIV, and I take antidepressants too. At least I can bloody well stop cigarettes. And I want to stay alive for my partner Ray.”
Barrie Dwyer emphasises there is no disgrace in relapse. “Most smokers need a lot of attempts before they quit successfully. If it doesn’t work this time, come back!”
I’m already thinking of it…
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28. Crothers K et al. The impact of cigarette smoking on mortality, quality of life, and comorbid illness among HIV-positive veterans. Journal of General Internal Medicine 20 (12), 1142-1145, 2005.
