Integrating Tobacco Treatment in HIV Care

Modern HIV treatment is one of medicine’s great success stories. With today’s therapies, many people living with HIV can expect long, full lives. But as patients age, a new reality has emerged: The biggest threats to their health are often the same ones facing the general population—heart disease, cancer, and chronic lung conditions. For many, smoking is a major contributor to those risks. Yet tobacco use can be overshadowed by other urgent medical and social concerns.

E. Jennifer Edelman, MD, MHS, professor of medicine (general medicine) at Yale School of Medicine (YSM), has spent years studying the intersection of HIV and substance use. In her latest study, conducted with Steven L. Bernstein, MD, of the Geisel School of Medicine at Dartmouth, and other collaborators, she tested an adaptive, team-based strategy to better integrate tobacco treatment into HIV clinics. The findings were published in JAMA Network Open.

In an interview, Edelman discusses why smoking must become a higher priority in HIV care—and how more flexible, team-based strategies can help patients live longer, healthier lives.

Fortunately, we have effective medications to treat HIV, and individuals with HIV are living longer, healthier lives. But tobacco use is a major driver of comorbidity and mortality in this population. It contributes to cardiovascular disease, cancer, and lung disease, and it has a profound impact on quality of life. In many ways, smoking has become one of the most significant health threats facing people living with HIV—even though HIV itself is well controlled.

There are multiple layers to that. In the clinic setting, both patients and providers are often focused on other pressing issues—viral suppression, medication adherence, housing instability, and mental health concerns. Tobacco use can fall down the list.

At the same time, the smoking cessation treatments we have aren’t perfect. They don’t work for everyone, and tobacco use disorder is a chronic, relapsing condition. On a broader level, there are societal and community factors that complicate things, including targeted marketing of menthol cigarettes in certain communities. All of these factors make it harder to address tobacco use consistently and effectively.

It mirrors what we do in clinical practice. Not all cessation treatments work for everyone. If something isn’t working, you adjust. We wanted to build that flexibility into the design itself. An adaptive approach allows us to tailor care based on how someone responds. That’s much closer to real-world medicine. It acknowledges that behavior change is complex and that patients need options and adjustments over time.

One of the most remarkable aspects of HIV care is its team-based model. In our clinics, we have physicians, advanced practice providers, clinical pharmacists, social workers, psychiatrists, nurses, medical assistants, and others working together in an integrated setting. Embedding clinical pharmacists into this work is critical. They are incredible partners in delivering smoking cessation treatment—from counseling patients to managing medications like nicotine replacement therapy and varenicline to helping implement behavioral strategies like contingency management. More broadly, this kind of integrated, team-based structure makes it easier to address health behaviors like smoking more meaningfully—rather than treating them as an afterthought.

I think there are several important next steps. We need more sustainable models for delivering contingency management and smoking treatment in HIV clinics. We should also provide patients with more upfront choices—whether that’s nicotine replacement therapy or other medications—and think more flexibly about how we support behavior change. We need to better understand factors that impact communication between patients and clinical pharmacists and how it translates into outcomes.

The study’s other authors include Yanhong Deng, MPH; James Dziura, PhD; Inbal Nahum-Shani, PhD; June-Marie Weiss, MA, MEd; Lydia Aoun-Barakat, MD; Krysten Bold, PhD; Dini Harsono, MSc; Colleen Mistler, PhD; Erika Payne, PharmD; Sherry Aiudi, MS; Keith Sigel, MD, PhD; Jessica Yager, MD, MPH; and David Ledgerwood, PhD.