HIV & smoking in India

Indian Journal of Medical Research, July, 2009 by S. Ramesh Kumar, Soumya Swaminathan, Timothy Flanigan, K.H. Mayer, Raymond Niaura

There are approximately 2.5 million people living with HIV/AIDS (PLWI-IA) in India--the young being particularly vulnerable. The prevalence of smoking has increased in India especially among rural, lower socio-economic and illiterate men. Studies have shown that HIV-infected smokers may be at additional risk for several infectious and non-infectious complications, including malignancies and cardiovascular events. Smoking alters immunological mechanisms and suppresses host defenses in the alveolar environment. HIV-infected smokers have also been found to have a poorer response to antiretroviral therapy and a higher risk of death. HIV-infected individuals who smoke could be at a greater risk for developing TB and subsequently suffer higher morbidity and mortality than those who do not smoke. Currently available smoking cessation interventions like physician's advice, nicotine replacement therapy and pharmacological agents like bupropion and varenicline have had varying degrees of success. Smoking cessation intervention in the HIV-infected population might be more complex because of associated psychosocial problems like drug addiction, alcoholism, depression, etc. More research including clinical trials testing the efficacy of smoking cessation interventions in HIV-infected persons is required in India. In addition to public health measures like banning smoking in public places and raising tobacco tax, comprehensive guidelines for health workers can help address this problem. Counselling on smoking cessation should be one of the main components of primary care, especially in the management of HIV-infected persons. This review highlights the importance of smoking cessation among HIV-infected persons in India.

Key words HIV--India--smoking cessation--tobacco--tuberculosis

Introduction

Tobacco consumption is currently the single leading preventable cause of death (1); over 500 million people may die due to tobacco by 2030 (2). Cigarette smoking is associated with a ten-fold increase in the risk of dying from chronic obstructive lung disease (3). About 90 per cent of all deaths from chronic obstructive pulmonary diseases (COPD) are attributable to cigarette smoking (3). Environmental tobacco smoke is a leading asthma trigged. Cigarette smoking increases the risk for cancers of the lip, oral cavity, pharynx, oesophagus, pancreas, larynx, lung, uterine cervix, urinary bladder, and kidney (5). Cigarette smokers are 2-4 times more likely to develop coronary heart disease than non smokers and cigarette smoking approximately doubles a person's risk for stroke (6). Smoking cessation has received little attention in HIV-infected persons. Yet smoking contributes significantly to the pulmonary complications of HIV (COPD, pneumonia) (7).

Smoking prevalence in India

Of the estimated 1.1 billion smokers worldwide, about 182 million (16.6%) are in India and by 2020 it is predicted that tobacco will account for 13 per cent of all deaths (8). The National Family Health Survey (NFHS) is a large scale multi-round survey conducted in a representative sample of households throughout India. According to NFHS-3 conducted in 2005-06, which collected data on tobacco use directly by asking respondents to report on their own tobacco use, the percentage of women and men aged 15-49 yr who smoked cigarettes or bidis, in India was 1.4 and 32.7 per cent respectively (9). Bidis are thin, often flavoured and are made of tobacco wrapped in a tendu (or temburini; Diospyros melonoxylon) leaf. Bidis have higher concentrations of nicotine, tar, and carbon monoxide than conventional cigarettes (10). Prevalence of cigarette/bidi smoking in different States was variable with a low of 14 per cent of men in Goa to a high of 74 per cent in Mizoram. Four in 10 male smokers reported that they smoked 10 or more cigarettes/bidis in the previous 24 h. Two per cent of rural women smoke cigarettes or bidis, while less than 1 per cent of urban women smoke. The lower prevalence of smoking rates in women in India compared to men is presumed to be due to social and cultural factors. In NFHS-2 done in 1998-99, the smoking prevalences in males and females were 29.3 and 2.3 per cent respectively (11). Comparing NFHS-2 and NFHS-3, we found that the prevalence of smoking among males (both rural and urban) has increased. Further, the rates among illiterates, rural and lower socio-economic groups were consistently higher in both the surveys (Table I). The same groups were also more vulnerable to HIV, suggesting that smoking is likely to be an important co-morbidity among HIV-infected individuals in India.

A multicentric study in four districts (Bangalore, Chandigarh, Delhi and Kanpur) showed that the prevalence of smoking was 15.6 per cent (male 28.5%, female 2.1%), that significant respiratory morbidity was associated with smoking and that quit rates were low (10%) (12). In a study of smoking habits among medical students, 46 per cent of the medical students smoked (all were male and no female smoked) (13). In recruits enrolled for military training (in the age group 17 to 23 yr), 43 per cent were smokers (15). In the Global Youth Tobacco Survey (GYTS) reported from the northern region of India (14), among school going children aged 13 to 15 yr, the prevalence of ever used tobacco was 2.9 to 8.5 per cent in boys and 1.5 to 9.8 per cent in girls although the majority of them reported desire to quit. In the GYTS conducted in Tamil Nadu, 10 per cent of the students had ever used tobacco and a significantly higher percentages of current tobacco users (one in three students) compared to never tobacco users thought smoking or chewing tobacco made a boy or girl more attractive (15). These rates of tobacco use in the school going age group is a cause for alarm. In most studies from India, prevalence of smoking in the female population was generally very low. However, in a study in Bihar, smoking prevalence in females was reported to be 23.4 per cent (17).