This article first appeared in Bob’s column on The Body here.
It's time, I'm afraid, to turn a critical gaze on those with HIV who smoke -- but more importantly those service providers who ignore that life-threatening issue. Because where we are now as a community on this issue, a community who should be leaders in promoting healthy choices is, frankly, third-rate.
There, I've said it. Stop reading, unfriend me. Call me a bore. But no matter, I'm joining the painfully thin ranks of those who say our community's lack of action has to be addressed. Simply put, we need to put smoking cessation programs front and centre. Turning a blind eye on smoking is destroying prospects of healthy living. Let's be big boys and girls. Let's be brave, be strong, acknowledge our vulnerabilities, individually and collectively, and care for each other and our community in ways we haven't tried before.
At one time I was more tolerant. We had excuses, lots of them. But some of those excuses seem weaker now. So I've become tired of AIDS service providers -- your local ASO may be one of them -- whose wellness problems ignore the biggest threat to wellness of all. There may be a place for acupuncture, massage therapy, wellness retreats and the A-Z range of therapies that crop up on the agenda of most ASO's, but don't include smoking cessation programs, or routine referrals to same, and ASO credibility suffers.
It's well known that smoking rates in people who live with HIV are high. A 2010 study of 1,094 people living with HIV in New York found an alarming 59% smoking prevalence rate. Interestingly, three quarters of those HIV+ smokers wanted to quit. But less than half of the 193 AIDS service providers surveyed indicated intake processes that include tobacco use questions, nor provided cessation programs or even referrals.
Why are smoking cessation issues so often ignored by ASOs? The same study suggests 65% of those agencies surveyed "perceived client resistance as a barrier to services." That's lame! I concur with the study authors who say "HIV/AIDS service providers are inadequately addressing the high smoking rate among PLWHA, despite being uniquely suited to do so. Efforts are needed to educate providers about the need for, and interest in, tobacco cessation." The need is described as "urgent."
It's important to contextualize all this and try to understand why smoking rates amongst people living with HIV are so high, though. One can't ignore, for instance, that smoking incidence in gay men is twice that of the national average, a consequence in part of bar culture which used to position smoking as a cultural norm. Everybody smoked in bars once, and some of us got addicted. I did.
The pressures of living with HIV which sometimes enhance the appeal of smoking can't be ignored too. Many HIVers perhaps need a crutch of some kind to get them through, to make the hurt feel less bad, to lower their stress levels, to provide pleasure in a world short of pleasurable experiences. One could argue that with advances in treatment and improving heath generally, that crutch is less of an essential for some. One way or another, HIVers are too often left with an unwelcome addiction to deal with -- and a strong one at that.
I know about nicotine addiction. I smoked two packs a day for years, including the first decade or so of my diagnosis. At first it didn't seem to matter -- I was going to die anyway. But things changed, and I wanted to quit. My early efforts were unsuccessful .But it's possible, I found, to learn from your mistakes. I found once I analyzed where my quitting efforts went wrong -- in my case it was the mistaken belief that "just one is OK" wouldn't result in more -- and omitted that behavior from my next attempt at quitting, it was in fact much, much easier. I quit cold turkey. So yes, I absolutely know that quitting can be hard, but with the right learned behaviors, tools and mindset, eminently do-able. My take -- and this is where we started -- is that AIDS service providers need, at the very least, to provide an entry point to the variety of programs available.
I'll be brutally honest. I'm alarmed by support workers who smoke along with their clients outside their building. Commitment to client wellness includes, I think, being a bit of a role model. Demonstrating to clients that smoking is OK just doesn't seem right.
I mean aren't agencies supposed to be sex positive? When was impotence -- a common side effect of smoking -- sex positive?
Wellness programs for HIVers should, I'm suggesting, always include smoking cessation. But look at most ASO websites and smoking cessation programming is largely missing in action. So we should laud the few shining exceptions, like the UK's GMFA where a clickable banner "Stop Smoking Help" is right there on their front page.
I think the solution lies in part with us. ASOs aren't providing these services, the research suggests, because they think we don't want them. Tell them -- smokers and non-smokers alike -- we DO want them.
We need hardly mention why and I'm not going to dwell on it. Let me just repeat what CATIE says: "Addiction to tobacco can cause devastating health problems, including cardiovascular disease, lung disease and cancer. Also, smoking harms nearly every organ in the body." Stopping smoking is often quoted as the best thing an HIVer can do for their health. If that argument isn't powerful enough, perhaps it's the social factors that will tip the scale -- the stigma of smoking today, for instance (why deal with more stigma?), or the cost, which I think was the tipping factor for me. But everybody is different and programs need to reflect that.
TheBody.com has had a large number of articles on smoking in the past. You can access a selection of them here.
In any event, it really is time to get serious about our response to smoking in our community. No ifs ands and definitely no butts.