Optimizing Tobacco Treatment Delivery for People Living with HIV

With advances in antiretroviral therapy (ART), people living with HIV (PLWH) are living longer, are more likely to die from non-AIDS-related causes, and are less likely to die from AIDS-related complications. In fact, lung cancer is now the leading cause of cancer death among PLWH. Tobacco use is a major contributing factor to lung

cancer incidence and mortality among PLWH since smoking rates among PLWH are approximately 40-50%. Indeed, this is more than double or triple the 15.5% rate of smoking in the general United States population. With several evidence-based tobacco treatment approaches at the patients' disposal, including pharmacotherapy and

behavioral counseling, optimizing how those treatments are delivered to patients requires an empirical approach. Routine clinical care through the healthcare system may not be optimized to reach this patient population. Prior research has shown that proactive tobacco treatment increases the likelihood of treatment engagement and

downstream cessation. Beyond the method for engaging in the initial contact session, prior studies have demonstrated that there are optimal ways for framing how the tobacco treatment is being provided. That is, presenting smoking cessation in an opt-out fashion results in increased patient reach and likelihood of

abstinence. Despite the evidence in support of a proactive, opt-out method for smoking cessation intervention delivery, this strategy has not been evaluated in the context of tobacco treatment for PLWH. Further, because this approach can connect patients with available, evidence-based interventions that can be delivered remotely,

it holds promise for implementation in the context of healthcare settings across the country. In the proposed study, we will conduct a type 1 hybrid effectiveness-implementation trial to evaluate the impact of a proactive, opt-out smoking cessation intervention on smoking cessation outcomes and advance understanding of key

barriers and facilitators of implementation processes. We propose a comparison of Treatment As Usual [TAU; reactive, opt-in smoking cessation treatment delivered through Infectious Diseases clinical pathways] to Proactive Outreach with Medication Opt-out for Tobacco Treatment Engagement (PrOMOTE) and

characterization of key determinants of PrOMOTE implementation outcomes. The intervention will consist of a tobacco treatment specialist proactively and remotely contacting a patient to assess smoking status, provide a brief motivational interview and counseling, and provide a mail-order prescription for varenicline (or dual NRT if

indicated) in an opt-out fashion. This proposed study will examine this novel approach to optimizing delivery of smoking cessation care for PLWH. Integrating effectiveness and implementation results will help define best practices for engaging PLWH with existing evidence-based smoking cessation interventions. This hybrid

effectiveness-implementation trial presents on opportunity to optimize tobacco treatment delivery, and identify barriers and facilitators towards future implementation and dissemination to ambulatory HIV clinics across the country.