Having HIV is
associated with a greater likelihood of cigarette smoking and using smokeless
tobacco, according to research conducted in 25 sub-Saharan African countries
and published in Nicotine and Tobacco
Research
.  After taking into account
other factors associated with tobacco use, people living with HIV were approximately 12% more likely to
smoke cigarettes and over 34% more likely to use smokeless tobacco than their
HIV-negative peers. There was considerable variability in smoking prevalence
among patients with HIV between countries; several other demographic
characteristics were also associated with increased likelihood of tobacco use.

“Respondents who
were HIV-positive were significantly more likely to smoke cigarettes and to use
smokeless tobacco than those who were HIV-negative,” comment the authors.
“Overall, these findings highlight the importance of addressing tobacco use in
the HIV-positive population in sub-Saharan Africa. Existing HIV prevention and
treatment infrastructure in sub-Saharan Africa provides a unique opportunity
for implementing low-cost tobacco interventions, including cessation services,
community participation, and public health outreach to affected families.”

Research conducted
in Europe and North America has shown that people with HIV are more likely to smoke
tobacco
compared to HIV-negative individuals. Moreover, smoking has been
associated with increased rates of illness and death in the context of HIV
infection, even
when people are taking antiretroviral therapy
.

Little in known
about the intersection between HIV and tobacco use in sub-Saharan Africa, a
region with a low but increasing prevalence of smoking. To fill this gap in
knowledge, investigators analysed data from the the Demographic and Health Surveys (DHS) and AIDS Indicator Surveys (AIS) from 25 sub-Saharan African countries. Their main aim was to determine prevalence of cigarette smoking and use of smokeless tobacco according to HIV status.

Cross-sectional data were
collected between 2005 and 2015 from adults aged between 15 and 59 years. As well as HIV status, data were
also collected on gender, martial/relationship status, level of education,
income, area of residence (rural/urban) and employment status. These factors were taken into account in statistical analyses of the association between HIV status and tobacco use.

A total of 286,850
participants completed surveys. Most (79%) were aged 39 or younger, 62%
lived in rural areas, 48% were male, a third were not working, another third
had agricultural employment and half had no formal education.

Slightly fewer
than 6% of participants were HIV-positive, with prevalence higher among women
than men (6.9% vs. 4.7%).

The overall prevalence
of smoking and smokeless tobacco use was 8.3% and 1.9%, respectively. Rates
of cigarette smoking were far higher in men than women (16.5% vs. 0.8%). The
over-50s were the age group with the highest smoking prevalence (20.3%). Younger
participants smoked least, with only 1.8% of teenagers reporting the use of
cigarettes.

Whereas only 6.2% of wealthier individuals reported smoking, prevalence was much higher among the poorest participants (10.8%). Rural dwellers were more likely to smoke than urban residents, and the prevalence of tobacco use was also higher among participants engaged in manual labour or agricultural work than other employment groups.

Turning to HIV, the prevalence of
smoking was higher among HIV-positive than HIV-negative individuals (10.6% vs.
8.1%). Analysis by gender showed that 25.9% of HIV-positive men and 1.2% of
HIV-positive women smoked, significantly higher than the 16.1% and 0.7% prevalence seen in
HIV-negative men and women, respectively.

After taking into
account other factors associated with smoking, the investigators
found that HIV-positive individuals had significantly higher odds of smoking
compared to HIV-negative individuals (OR = 1.12; 95% CI, 1.04-1.21, p
0.001). Repeating the analysis according to gender produced almost identical
results. In addition, individuals with HIV also had significantly increased
risk of using smokeless tobacco (OR = 1.34; 95% CI, 1.17-1.53).

Poverty, manual
labour and living in rural areas were also associated with higher rates of
tobacco use.

Country-level analyses
showed considerable variability in tobacco use between individual countries. The prevalence of smoking ranged from 2.4% in Ghana to 19.9% in Lesotho. Over
half of countries (14 of 25) showed a higher smoking prevalence among people
with HIV. The difference was significant in five countries: Gambia, Niger,
Swaziland, Zambia and Zimbabwe. But in Ethiopia and Namibia, HIV-positive
participants were less likely to smoke than HIV-negative ones.

The prevalence of
smokeless tobacco use was higher among individuals with HIV in Lesotho,
Swaziland, Zambia and Zimbabwe.

“This study showed
that having HIV was associated with greater likelihood of smoking cigarettes as
well as with using smokeless tobacco in sub-Saharan Africa,” write the authors.
“These tobacco use modalities were also associated with male sex and lower
socioeconomic status.”

The investigators
acknowledge a number of limitations, including the cross-sectional design of
their study, failure to collect data on frequency and intensity of tobacco use
and a lack of data on use of antiretroviral therapy.

“Incorporating
smoking prevention and cessation strategies into existing global HIV control
infrastructure would help reduce the burden of disease caused by tobacco use,”
conclude the investigators. “By the same token, implementing tobacco control
measures such as the World Health
Organization’s Framework Convention on Tobacco Control
and MPOWER could reduce smoking
among the HIV-positive population.”