For Those with HIV, Cigarettes Have Become More Dangerous Than the Actual Virus

In 1982, when the CDC first began using the term AIDS, Philip Morris was in its 29th year of record-breaking profits. Despite decades of ever-increasing doomsaying, smoking was still pretty normal—a fact of life on airplanes and buses and in restaurants. Much of the world still bore a grody yellow tinge.

An HIV infection then was a death sentence. HIV would certainly lead to AIDS, which would in turn open the body to catastrophic encounters with opportunistic infections. This picture began to change dramatically in mid-1990s with the advent of antiretroviral therapy (ART). HIV is now a manageable condition, requiring maintenance on par with, say, diabetes (as oft remarked), but otherwise allowing a pretty normal life. Cigarettes, meanwhile, are still cigarettes. They are about as deadly now as they were then.

According to a study out this week in the the Journal of Infectious Diseases, those with HIV infections who are also smokers are now more likely to die from smoking than anything related to HIV itself. In fact, among European populations smoking was found to reduce life expectancies among those with HIV by about twice as much HIV itself. In the US, where rates of HIV treatment adherence are generally worse, HIV and smoking are about equal in terms of (indirect) causes of death.

The new results come courtesy of Krishna Reddy and colleagues at Harvard Medical School and Massachusetts General Hospital. They are based on computer simulations projecting the lifespans of HIV patients with respect to whether or not they smoke. Generally, rates of smoking are much higher among those with HIV—approaching 40 percent—compared to the the overall US smoking rate, which is is closer to 15 percent. Couple this disparity with the higher rates of cardiovascular disease and cancer found in HIV-infected smokers compared to non-infected smokers and we have a pretty severe public health problem.

Men and women entering HIV treatment above the age of 40 that smoked were found to lose 6.7 and 6.3 years of life, respectively, compared to non-smokers with HIV. If the same group were to quit smoking at age 40, they could be expected to regain 5.7 and 4.6 years, respectively. Even those that quit at age 60 can expect a "substantial" increase in lifespan (about two and a half years for men and women), according to Reddy and his team. All told, if 10 to 25 percent of HIV-infected smokers kicked the habit, we could expect a total gain nearly a quarter-million years of life expectancy.

"In persons with human immunodeficiency virus (HIV) infection, smoking is a scourge," writes Keri Althoff, an epidemiologist at Johns Hopkins Bloomberg School of Public Health, in a commentary accompanying the new study. "This study makes clear that we must prioritize smoking cessation among adults with HIV if we want them to have an increase in the quantity (and likely quality) of life."

It's a reminder that treating HIV, as with any chronic illness really, is a holistic endeavor. We can get so far with drugs—and controlling HIV is one of the more amazing things we've accomplished with those drugs—but Reddy's study makes it clear just how easy it is to erase those gains if we try to look at diseases in isolation.