Effectiveness of a smoking cessation algorithm integrated into HIV primary care

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Smoking remains the leading cause of preventable death and disability in the United States. Whereas smoking has declined significantly among individuals in the general population, it is clustered in populations of vulnerable individuals such as people living with HIV/AIDS (PLWH) in whom smoking prevalence rates and resulting comorbidity rates remain high. Medical advances in the treatment of HIV have resulted in substantial increases in life expectancy among PLWH and as a consequence PLWH smokers are now, more than ever, at heightened risk for tobacco-related illnesses and death. In fact, PLWH smokers engaged in treatment lose more years of life due to smoking now than to HIV disease. Although PLWH smokers engaged in HIV care typically see a medical provider every 4-6 months, smoking cessation treatment and referral is often not part of routine HIV care. While 94% of HIV treatment providers indicated that they would be willing to provide smoking cessation services to their patients, few have received training in how to provide smoking cessation services. With seven first line pharmacotherapies available for smoking cessation, development of algorithms to assist providers in selecting the most appropriate pharmacotherapy is an important but untested strategy to increase smoking cessation in PLWH. Our pilot work has provided initial support for this approach and our intervention has resulted in increased abstinence, higher use of pharmacotherapy, increased 24-hour quit attempts, and enhanced in motivation to quit, compared to those receiving standard of care. The purpose of this proposal is to conduct a mixed efficacy/effectiveness trial comparing an algorithm treatment with prescription cost off sets and quit line referral (AT) to an enhanced Treatment as Usual (quit line referral only; eTAU) group. Six hundred PLWH smokers will be recruited at the University of Alabama at Birmingham, University of Washington, and Fenway Health HIV clinics and will be randomized to receive AT or eTAU. All AT smokers will receive active treatment for twelve weeks regardless of stated motivation or intention to quit. eTAU smokers will be referred to quit line services and HIV providers may elect to treat smoking as part of standard of care. Participants will remain in the study for 12 months. The primary outcome will be point prevalence smoking abstinence at 6 months. Other smoking-related outcomes of interest include 24-hour quit attempts and reduction in cigarettes smoked per day. Effectiveness outcomes of interest include cost effectiveness analyses, number of smoking pharmacotherapy prescriptions written, and change in provider knowledge and confidence to treat smoking. If successful, this algorithm could provide an important tool that could be easily sustained and available for use through the electronic medical record or transferred to a mobile device to aid health care professionals in providing smoking cessation treatment to PLWH smokers.