HIV Won't Kill You, but Smoking Will

When the Centers for Disease Control and Prevention announced in 2017 that new HIV diagnoses had dropped 18 percent in 2014, it was a call for celebration. After all, many of us had spent the better part of the last two decades trying to get people to use condoms consistently in order to bring those numbers down. Thanks to strategies like PrEP and treatment as prevention (TasP), we finally saw what the beginning of “Ending the Epidemic” could look like once people were offered respectful, culturally appropriate, and sexually satisfying safer choices.

Yet, despite all of our well-earned kudos and congratulations, there is still shockingly little attention being paid to the fact that more than 30,000 LGBT adults die each year from smoking-related deaths, according to the CDC. Furthermore, according to a study in the Journal of the American Medical Association Internal Medicine, people living with HIV who smoke are far more vulnerable to side effects than people not living with HIV, and are now more likely to die from lung cancer than HIV. Indeed, researchers found, “those who continued to smoke were six to 13 times more likely to die from lung cancer than from traditional AIDS-related causes.”

According to the JAMA report, over 40 percent of people living with HIV in the U.S. smoke cigarettes, so a significant number of poz lives could be saved if we reduced the prevalence of smoking. We have the resources, wisdom, talent, and experience to make the numbers of smoking-related deaths decline just as we have with HIV and AIDS-related deaths. But we will not get there by embracing one approach alone. The only way we will see healthy outcomes and lives saved from smoking reduction is to understand there are several equally viable ways to prevent tobacco illnesses and mortalities.

Prevention: The goal of this strategy is to prevent people from ever smoking in the first place. Reducing tobacco advertising, putting age restrictions on sales, and raising costs on cigarette packs are all tools of a prevention framework. In the United States, this is the primary strategy implemented, and the focus of much legislation currently being proposed and debated. In California, for example, the cost of cigarettes went up an additional $2 per pack and $20 per carton following the passage of Proposition 56 in 2016. According to Time magazine, Chicago has the highest cigarette costs: state and local taxes add an additional $6.16 per pack, and in New York a pack costs at least $13. Unfortunately, studies — including a 2011 report in ScienceDaily — show higher costs don’t necessarily make smokers stop smoking.

Cessation: The goal of this strategy is to help people who have already started smoking, and developed an addiction to nicotine, take steps toward quitting. This may include prescribed medications, gums, patches, inhalers, or any intervention one uses with the intention of quitting permanently. This is the primary intervention that smokers are used to receiving from healthcare providers when the issue is discussed. Unfortunately, a 2011 report by the CDC found that only about six percent of smokers succeed in trying to quit. (However, 68 percent of those in the study tried to quit “without using evidence-based cessation counseling or medications.”) In a 2012 study by Harvard School of Public Health and University of Massachusetts, researchers found just as many of those who quit using patches relapsed as those who did not.

Harm-Reduction: The goal of this strategy is to provide smokers with a plethora of options and decisions they can use to reduce harm if they can’t or won’t stop using nicotine. The goal here may not be cessation or abstinence, but instead helping the individual satisfy cravings, stay comfortable, maintain a locus of control, and yet improve the quality of their health and the length of their life. Electronic nicotine delivery systems — a.k.a. electronic cigarettes and vape pens — offer an immediate harm reduction option, and can satisfy the consumer’s need for both the nicotine and the smoking ritual. A 2015 U.K. review of evidence found that e-cigarettes are 95 percent safer to the throat, lungs, and heart than that of smoked tobacco — and they can help smokers ultimately quit altogether.

Unfortunately, there continues to be a pervasive anti-nicotine ideology in the U.S. that often prohibits harm-reduction dialogues from occurring. The dogmatic approach treats tobacco-free nicotine delivery systems as if they are as dangerous as the products they replace. San Francisco’s Board of Supervisors, for example, has sought to prohibit sales of vaping products by including e-cigarettes in a ban on flavored tobacco products, despite the fact that e-cigarettes have no tobacco. The prohibition would not include the sale of regular tobacco cigarettes, only flavored tobacco products (like menthol) and vaping products. While banning menthol makes sense — considering a 2014 study showed menthol smokers have a 29 percent higher risk of severe lung disease — tobacco-free vape products actually save lives. This confusing hypocrisy continues to fuel public debate and voter referendums.

That means that people living with HIV (and their loved ones) are rarely offered harm-reduction information and tools from healthcare providers or service agencies. Prevention by itself hasn’t stopped new people from picking up smoking. Cessation by itself hasn’t helped long-term smokers quit. But if providers and legislators considered integrating harm reduction into their toolkit of interventions it would allow the consumer a variety of ways to satisfy desire while reducing harm. We would also see improved trust of health organizations, more consistent adherence to treatment, better health outcomes, and — most importantly — reduced death rates.

We learned from the HIV epidemic the value of prioritizing science over stigma, data over dogma, innovation over ideology. Isn’t it time we apply these tools to smoking?