High rates of smoking in people with HIV in sub-Saharan Africa

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Having HIV is associated with a greater likelihood of cigarette smoking and using smokeless tobacco, according to US research conducted in 25 countries in Sub-Saharan Africa and published in Nicotine and Tobacco Research, writes Michael Carter for AidsMap.

After taking into account other factors associated with tobacco use, people living with HIV were approximately 12% more likely to smoke cigarettes and over 34% more likely to use smokeless tobacco than their HIV-negative peers.

There was considerable variability in smoking prevalence among people with HIV between countries; several other demographic characteristics were also associated with increased likelihood of tobacco use.

“Respondents who were HIV-positive were significantly more likely to smoke cigarettes and to use smokeless tobacco than those who were HIV-negative,” comment the authors at the National Cancer Institute, Epidemiology and Genomics Research Programme and the University of North Carolina at Chapel Hill in the US.

“Overall, these findings highlight the importance of addressing tobacco use in the HIV-positive population in Sub-Saharan Africa. Existing HIV prevention and treatment infrastructure in Sub-Saharan Africa provides a unique opportunity for implementing low-cost tobacco interventions, including cessation services, community participation, and public health outreach to affected families.”

Research conducted in Europe and North America has shown that people with HIV are more likely to smoke tobacco compared to HIV-negative individuals. Moreover, smoking has been associated with increased rates of illness and death in the context of HIV infection, even when people are taking antiretroviral therapy.

Little is known about the intersection between HIV and tobacco use in sub-Saharan Africa, a region with a low but increasing prevalence of smoking. To fill this gap in knowledge, investigators analysed data from the Demographic and Health Surveys (DHS) and AIDS Indicator Surveys (AIS) from 25 sub-Saharan African countries. Their main aim was to determine prevalence of cigarette smoking and use of smokeless tobacco according to HIV status.

Cross-sectional data were collected between 2005 and 2015 from adults aged between 15 and 59 years. As well as HIV status, data were also collected on gender, marital/relationship status, level of education, income, area of residence (rural/urban) and employment status. These factors were taken into account in statistical analyses of the association between HIV status and tobacco use.

A total of 286,850 participants completed surveys. Most (79%) were aged 39 or younger, 62% lived in rural areas, 48% were male, a third were not working, another third had agricultural employment and half had no formal education.

Slightly fewer than 6% of participants were HIV positive, with prevalence higher among women than men (6.9% vs 4.7%).

The overall prevalence of smoking and smokeless tobacco use was 8.3% and 1.9%, respectively. Rates of cigarette smoking were far higher in men than women (16.5% vs 0.8%). The over-50s were the age group with the highest smoking prevalence (20.3%). Younger participants smoked least, with only 1.8% of teenagers reporting the use of cigarettes.

Whereas only 6.2% of wealthier individuals reported smoking, prevalence was much higher among the poorest participants (10.8%). Rural dwellers were more likely to smoke than urban residents, and the prevalence of tobacco use was also higher among participants engaged in manual labour or agricultural work than other employment groups.

Turning to HIV, the prevalence of smoking was higher among HIV-positive than HIV-negative individuals (10.6% vs 8.1%). Analysis by gender showed that 25.9% of HIV-positive men and 1.2% of HIV-positive women smoked, significantly higher than the 16.1% and 0.7% prevalence seen in HIV-negative men and women, respectively.

After taking into account other factors associated with smoking, the investigators found that HIV-positive individuals had significantly higher odds of smoking compared to HIV-negative individuals (OR = 1.12; 95% CI, 1.04-1.21, p < 0.001). Repeating the analysis according to gender produced almost identical results. In addition, individuals with HIV also had significantly increased risk of using smokeless tobacco (OR = 1.34; 95% CI, 1.17-1.53).

Poverty, manual labour and living in rural areas were also associated with higher rates of tobacco use.

Country-level analyses showed considerable variability in tobacco use between individual countries. The prevalence of smoking ranged from 2.4% in Ghana to 19.9% in Lesotho. Over half of countries (14 of 25) showed a higher smoking prevalence among people with HIV. The difference was significant in five countries: Gambia, Niger, Swaziland, Zambia and Zimbabwe. But in Ethiopia and Namibia, HIV-positive participants were less likely to smoke than HIV-negative ones.

The prevalence of smokeless tobacco use was higher among individuals with HIV in Lesotho, Swaziland, Zambia and Zimbabwe.

“This study showed that having HIV was associated with greater likelihood of smoking cigarettes as well as with using smokeless tobacco in sub-Saharan Africa,” write the authors. “These tobacco use modalities were also associated with male sex and lower socioeconomic status.”

The investigators acknowledge a number of limitations, including the cross-sectional design of their study, failure to collect data on frequency and intensity of tobacco use and a lack of data on use of antiretroviral therapy.

“Incorporating smoking prevention and cessation strategies into existing global HIV control infrastructure would help reduce the burden of disease caused by tobacco use,” conclude the investigators. “By the same token, implementing tobacco control measures such as the World Health Organisation’s Framework Convention on Tobacco Control and MPOWER could reduce smoking among the HIV-positive population.”

Background: In high-income countries, being HIV positive is associated with higher rates of smoking. This is important to public health because evidence suggests that HIV/AIDS patients who smoke have poorer treatment and survival outcomes. Moreover, both smoking and HIV are risk factors for comorbidities such as tuberculosis, which is highly prevalent in some low-and middle-income countries. The HIV-smoking relationship is understudied in sub-Saharan Africa, where tobacco use patterns and HIV prevalence differ greatly from other world regions. This study is an effort to fill this gap in the literature.
Methods: This study examined cross-sectional data from the Demographic Health Surveys (DHS) and AIDS Indicator Surveys. Data from 25 sub-Saharan African countries were pooled (n=286,850), and the association between cigarette smoking and HIV status was analysed through hierarchical logistic regression models. As a secondary aim, this study also examined the relationship between smokeless tobacco use (chew and/or snuff) and HIV status.
Results: Overall, men who had HIV/AIDS had a significantly (p < 0.0001) higher smoking prevalence (25.90%) than men who did not (16.09%), as did women who had HIV/AIDS compared with women who did not (1.15% vs. 0.73%; p < 0.001). Multivariate logistic regression analysis revealed that people living with HIV/AIDS were 12% more likely to smoke than people living without (OR = 1.12, 95% CI=1.04, 1.21; p < 0.001) when adjusting for socioeconomic, demographic, and sexual risk factors. Similarly, multivariate logistic regression revealed that HIV-positive individuals were 34% more likely to use smokeless tobacco than HIV-negative individuals (adjusted OR = 1.34, 95% CI = 1.17, 1.53).
Conclusions: This study complements evidence from other world regions showing that HIV infection is associated with a higher likelihood of cigarette smoking as well as smokeless tobacco use in sub-Saharan Africa, even when controlling for demographic, socioeconomic, and sexual risk factors.

John Murphy, Benmei Liu, Mark Parascandola

Aidsmap material
Tobacco Induced Diseases abstract

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