HIV Symptom Distress and Smoking Outcome Expectancies Among HIV+ Smokers: A Pilot Test

Abstract

Smoking occurs at high rates among people with HIV/AIDS, but little attention has been paid to understanding the nature of tobacco use among HIV+ smokers, especially the role that HIV symptoms may play in cognitive smoking processes. Accordingly, the present investigation examined the relation between HIV symptom distress (i.e., the degree to which HIV symptoms are bothersome) and smoking outcome expectancies. Fifty-seven HIV+ adult smokers (82.50% male; M _age=47.18; 45.6% White, 28.1% Black, 17.5% Hispanic) were recruited from AIDS service organizations and hospital-based clinics. On average, participants reported knowing their HIV+ status for 16 years and the majority of participants reported that they acquired HIV through unprotected sex (66.6%). Participants completed measures pertaining to HIV symptoms, smoking behavior, and smoking outcome expectancies. HIV symptom distress was positively related to negative reinforcement, negative consequences, and positive reinforcement smoking outcome expectancies after accounting for relevant covariates. The present research suggests that HIV symptom distress may play an important role in understanding smoking outcome expectancies for smokers with HIV/AIDS. Clinical implications for HIV+ smokers are discussed, including the importance of developing effective smoking cessation treatments that meet the unique needs of this group of smokers.

Introduction

HIV+ smokers represent a common, albeit understudied, segment of the smoking population who are at high risk for nicotine dependence and its associated morbidity and mortality. Specifically, smoking occurs among HIV+ persons at high rates (45–74%)¹ and HIV+ smokers have significant difficulty quitting.² Additionally, HIV+ smokers compared to HIV+ nonsmokers are more apt to die sooner, be susceptible to medical disease,^3
–5 and be nonadherent to their antiretroviral medication and derive less benefit from those medications.^6

–9 Yet, the factors that facilitate smoking among persons with HIV are not well understood.¹⁰ The current investigation sought to examine the role of HIV symptom distress in HIV+ smokers' beliefs about smoking (i.e., smoking outcome expectancies).

Smoking outcome expectancies reflect anticipated consequences of smoking.^11
–13 Specifically, smoking outcome expectancies include beliefs about positive reinforcement (e.g., “I enjoy the taste sensations while smoking”), negative reinforcement (e.g., “Smoking helps me calm down when I feel nervous”), negative consequences (e.g., “The more I smoke, the more I risk my health”), and appetite control (e.g., “Smoking helps me control my weight”).¹⁴ These expectancies are clinically relevant in terms of explaining various aspects of smoking behavior.¹⁵ For example, positive reinforcement smoking expectancies are related to greater smoking behavior,^16,17 and expectancies for negative reinforcement and negative consequences predict poor cessation success.¹⁸ Research has not yet examined smoking outcome expectancies among an HIV+ smoking population.

One HIV-specific factor that may be related to smoking outcome expectancies among HIV+ smokers is HIV symptom distress.¹⁰ HIV+ persons experience a wide range of bodily sensations and related discomfort as a result of their disease and medication regimens (e.g., fatigue, nausea, dizziness, pain, and nervousness).¹⁹ HIV symptom distress is clinically relevant given its associations with lower quality of life,²⁰ greater anxiety and depressive symptoms,¹⁹ and lower adherence to HIV medications.^21,22 Yet it is not clear if, or to what extent, HIV symptom distress relates to smoking expectancies among HIV+ smokers.

Building from self-regulation and coping theories for tobacco,^23,24 we hypothesize that HIV+ smokers with higher levels of HIV symptom distress may come to learn that smoking can lessen experiential discomfort. Specifically, HIV+ smokers with higher relative to lower HIV symptom distress may experience a greater degree of negative affect reduction from smoking (e.g., via attention reallocation, the pharmacological effects of nicotine, or both). It also is possible that HIV+ smokers may misattribute some of their HIV symptoms to nicotine withdrawal because of symptom overlap (e.g., dizziness, nausea, shortness of breath), and consequently may use smoking to alleviate these symptoms. Thus, even in the absence of any genuine stress-reducing properties of nicotine, HIV symptom distress may be related to negative reinforcement expectancies for smoking.

Higher HIV symptom distress also may be related to greater worry about smoking leading to negative health consequences. That is, because HIV symptom distress may elicit greater degrees of or attention to bodily sensations, HIV+ smokers with heightened levels of HIV symptom distress may expect smoking-related bodily symptoms to lead to negative health outcomes (e.g., death at an early age due to smoking). Thus, higher degrees of HIV symptom distress also may be related to negative consequences smoking expectancies.

Based on recent non-HIV research that found that depressed smokers endorse smoking to increase positive mood states,²⁵ higher HIV symptom distress also may be related to greater positive reinforcement smoking expectancies. Because HIV symptom distress is associated with a number of negative mood states (e.g., depression, anxiety) in addition to physical agitation,^19,26 HIV+ smokers who are high in HIV symptom distress may smoke, in part, to enhance their mood.

The present study was a pilot investigation that aimed to test two inter-related sets of hypotheses involving HIV symptom distress and outcome expectancies among HIV+ smokers. First, it was hypothesized that HIV symptom distress among HIV+ smokers would be significantly associated at the bivariate level with negative reinforcement, negative consequences, and positive reinforcement smoking expectancies. As an index of specificity, it also was expected that HIV symptom distress would not be associated with smoking expectancies for appetite control. Second, it was hypothesized that HIV symptom distress would predict negative reinforcement, negative consequences, and positive reinforcement (but not appetite control) smoking expectancies above and beyond the effects of recruitment site, most recent CD4 t-cell count, alcohol consumption, and smoking rate.

Methods

Participants

Participants were 57 adult smokers living with HIV (43.9%) or AIDS (52.6%; 3.5% did not specify their current disease status) who were recruited from AIDS service organizations (ASOs) and hospital-based clinics in Vermont (VT) and New Hampshire (NH) and an ASO in New York City (NYC), as part of a larger study (N=164) on HIV/AIDS, psychopathology, and substance use.^26,27 All tobacco smokers from the larger study who completed measures of HIV symptom distress and smoking outcome expectancies (described below) were included in the present study. The majority of the sample was male (82.5%) and the mean age of participants was 47.18 years (SD=8.21). The racial/ethnic distribution of the sample was 45.6% White, 28.1% Black, 17.5% Hispanic, and 8.8% mixed/other. Although the majority of the sample reported at least a high school degree (70.20%), more than half of the sample (59.60%) reported an annual income of ≤ $10,000.

On average, participants reported knowing their HIV+ status for 16 years (M=16.42, SD=5.27). The majority of participants reported that they acquired HIV through unprotected sex with a man (52.6%), followed by sharing needles (19.3%), unprotected sex with a woman (14.0%), other or unknown (12.3%), and blood transmission (1.8%). The average CD4 t-cell count for participants at the time of the study was 441.54.

Measures

Demographic (e.g., sex, race/ethnicity) and medical (e.g., HIV/AIDS status, most recent CD4 t-cell count) information were self-reported by participants. To reduce error in reporting, participants were told ahead of time that they would be asked to report their most recent CD4 t-cell count during the appointment.

The Alcohol Use Disorders Identification Test²⁸

The Alcohol Use Disorders Identification Test (AUDIT) is a 10-item self-report screening measure developed by the World Health Organization to identify individuals with alcohol problems. There is a large body of literature attesting to the reliability and validity of the AUDIT.²⁹ In the present study, the frequency and quantity items from the AUDIT were used to index current alcohol consumption (an average frequency-by-quantity composite score).³⁰

The Fagerström Tolerance Questionnaire³¹

The Fagerström Tolerance Questionnaire (FTQ) was administered and scored as the Fagerström Test for Nicotine Dependence (FTND). The FTND is a 6-item scale commonly used to assess gradations in tobacco dependence.³² The FTND has shown good internal consistency and positive relations with key smoking variables (e.g., saliva cotinine).³²

Smoking History Questionnaire³³

Smoking history was assessed with the well-established Smoking History Questionnaire (SHQ), which includes items pertaining to number of cigarettes smoked per day during the past week, age of smoking onset, and years of regular smoking. The SHQ was used as a descriptive measure of smoking behavior.

Smoking Consequences Questionnaires¹⁴

The Smoking Consequences Questionnaires (SCQ) was used to measure smoking outcome expectancies. Participants rate, on a 10-point Likert-type scale (0=completely unlikely, 9=completely likely) the extent to which they expect to experience 50 common consequences of smoking. The SCQ includes 4 subscales: negative reinforcement/negative affect reduction, negative consequences, positive reinforcement, and appetite control. The SCQ subscales demonstrated good internal consistency in the current study (range of observed αs=0.84–0.94).

AIDS Clinical Trials Group Symptoms Distress Module (ACTG-SDM; Justice et al., 2001)¹⁹

The ACTG-SDM was used to measure HIV symptom distress. Participants indicate on a 5-point Likert-type scale (0=I do not have this symptom, 4=It bothers me a lot) the extent to which they are bothered by 20 commonly experienced physical symptoms of HIV (e.g., dizziness, nausea). The ACTG-SDM evidenced good internal consistency in the current sample (α=0.90).

Procedure

Potential participants contacted the research clinic in VT or the ASO in NYC, and after confirming that they had a diagnosis of HIV or AIDS and were 18 years or older (the only eligibility criteria), were scheduled for an in-person appointment. Upon arriving at the research clinic or their ASO, participants read and signed a consent form. They then completed a battery of self-report questionnaires and were compensated $25 for participating. All participants who indicated that they smoked tobacco were included in the present analyses. This study was approved by the institutional review board at The University of Vermont.

Data analytic approach

Bivariate correlations between HIV symptom distress and smoking expectancies were first examined. Next, hierarchical multiple regression was used to test the predictive value of HIV symptom distress. Recruitment site, most recent CD4 t-cell count, alcohol consumption, and smoking rate were entered as covariates into step 1 of the regression model. These covariates were chosen on an a priori basis based on past research indicating that they may be related to the criterion variables.^34,35 HIV symptom distress (ACTG-SDM) was entered as the predictor variable into step 2 of the model. The criterion variables, which were examined in separate regression models, included individual smoking expectancies (i.e., the subscales of the SCQ).

Results

Descriptive statistics

On average, participants reported becoming regular smokers at age 17 (M=17.39, SD=6.13), smoking 14 cigarettes per day during the past week (M=13.54, SD=9.49), and relatively low levels of nicotine dependence (M=3.76, SD=1.70, possible score range=0–10) according to the Fagerström Test for Nicotine Dependence. Participants reported moderate HIV symptom distress (M=33.82, SD=16.48, possible score range=0–80) and moderate levels of negative reinforcement (M=5.31, SD=2.00), negative consequences (M=5.85, SD=1.55), positive reinforcement (M=5.23, SD=1.64), and appetite control (M=4.52, SD=2.17) smoking expectancies (possible score range=0–9).

Bivariate correlations

As expected, HIV symptom distress was positively related at the bivariate level to the negative reinforcement (r=0.44, p=0.001), negative consequences (r=0.32, p<0.02), and positive reinforcement (r=0.35, p<0.01) subscales of the SCQ. Also as expected, HIV symptom distress was not significantly related to the appetite control (r=0.06, p=0.66) subscale of the SCQ. All of the SCQ subscales were positively related to one another (all r's>0.30, p's<0.05).

Regression analyses

See Table 1 for the coefficient estimates for the regression analyses. For SCQ-Negative reinforcement, step 1 of the model accounted for a marginally significant portion of the variance (19%). Smoking rate was the only significant contributor at this step of the model. As hypothesized, in step 2, HIV symptom distress accounted for an additional 13% of variance and was positively related to negative reinforcement smoking expectancies.

Table 1.

Associations Between HIV Symptom Distress and Smoking Outcome Expectancies

	ΔR ²	β	t	p
Dependent variable: negative reinforcement ^a
Step 1	0.19			0.03
Recruitment site^b		0.04	0.27	0.79
CD4 t-cell count^c		0.15	1.14	0.26
Alcohol consumption^d		0.09	0.67	0.51
Cigarettes per day (past week)^e		0.43	2.95	0.01
Step 2	0.13			0.00
HIV symptom distress^f		0.38	3.05	0.00
Dependent variable: negative consequences ^a
Step 1	0.14			0.08
Recruitment site		−0.37	−2.49	0.02
CD4 t-cell count		−0.01	−0.10	0.92
Alcohol consumption		0.21	1.64	0.11
Cigarettes per day (past week)		−0.12	−0.78	0.44
Step 2	0.06			0.05
HIV symptom distress		0.27	2.01	0.05
Dependent variable: positive reinforcement ^a
Step 1	0.11			0.17
Recruitment site		0.09	0.59	0.56
CD4 t-cell count		0.03	0.19	0.85
Alcohol consumption		0.15	1.10	0.28
Cigarettes per day (past week)		0.33	2.16	0.04
Step 2	0.07			0.04
HIV symptom distress		0.29	2.14	0.04
Dependent variable: appetite control ^a
Step 1	0.11			0.18
Recruitment site		0.27	1.82	0.07
CD4 t-cell count		0.21	1.56	0.13
Alcohol consumption		−0.05	−0.34	0.74
Cigarettes per day (past week)		0.28	1.83	0.07
Step 2	0.01			0.47
HIV symptom distress		0.10	0.72	0.47

Smoking Consequences Questionnaire; ^bRecruitment site coded as 0=VT/NH, 1=NYC; ^cCD4 t-cell count self-reported by participants; ^dAlcohol Use Disorders Identification Test; ^eCigarettes per day (past week) self-reported by participants; ^fAIDS Clinical Trials Group Symptoms Distress Module.

For SCQ-Negative consequences, the covariates did not account for a significant portion of variance at step 1; however, recruitment site was a significant contributor to the model at this step. HIV symptom distress accounted for an additional 6% of variance at step 2 and was positively related to negative consequences smoking expectancies.

For SCQ-Positive reinforcement, the covariates, again, did not account for a significant portion of variance at step 1; however, smoking rate was a significant contributor to the model at this step. HIV symptom distress accounted for an additional 7% of variance at step 2 and was positively related to positive reinforcement smoking expectancies.

Neither the covariates nor HIV symptom distress were significantly related to SCQ-Appetite control.

Discussion

As hypothesized, HIV+ smokers with higher relative to lower levels of HIV symptom distress were more apt to expect smoking to relieve emotional distress (negative reinforcement), to cause physical harm (negative consequences), and to enhance positive mood. These effects were evident above and beyond the effects of recruitment site, most recent CD4 t-cell count, alcohol consumption, and smoking rate, suggesting that they are not better accounted for by other factors known to co-vary with HIV and tobacco use. These findings are broadly consistent with previous theory and research that has suggested that individual difference factors linked to emotional vulnerability are associated with affect-related smoking (e.g., neuroticism)³⁶ and extends it to an HIV-specific index of distress. The fact that HIV symptom distress is related to multiple types of smoking expectancies may help to explain the high rates of smoking among HIV+ individuals and why this group has difficulty quitting smoking.^37,38 By further clarifying the nature of HIV-related symptom distress and smoking outcome expectancies, it may be possible to further refine therapeutic approaches for this high-risk population.

Several limitations of this pilot investigation should be noted. First, the present study utilized a cross-sectional design and therefore cannot shed light on processes over time or isolate causal relations between variables. Second, self-report measures were utilized as the primary assessment tool, which does not fully protect against reporting errors and may be influenced by shared method variance. Future studies could build upon the present work by utilizing alternative assessment instruments such as tasks from cognitive science that tap implicit and automatic types of smoking-based motivational processes. Third, smoking status and level were not biochemically verified, so we cannot be fully certain that respondents' reports of smoking were entirely accurate. Fourth, participants only reported tobacco and alcohol use, so we were unable to control for other types of substance use. Rates of substance use are elevated among HIV+ smokers,^39,40 and recent research indicates that using substances to cope with negative affect (a behavior that exemplifies negative reinforcement outcome expectancies) mediates the relationship between substance use and decreased HIV medication adherence.⁴¹ Thus, future research should examine the effects of concurrent substance use in regard to HIV symptoms distress and smoking processes. Fifth, because of the relatively small sample size, we were not able to include every potential covariate of the relationship between HIV symptom distress and smoking outcome expectancies; we limited the covariates to those that were most relevant to the primary variables of interest. Future studies with larger samples should be conducted to examine other potential factors that may explain this relationship. Finally, future research should examine how HIV symptom distress relates to motivation to quit smoking and cessation rates, and whether smoking outcome expectancies mediate these relations.

Overall, the present findings have potentially important clinical implications for HIV+ smokers, particularly for the development of effective smoking cessation treatment based on the unique needs of this group of smokers. Specifically, smoking cessation interventions should consider the role of HIV symptom distress in increasing expectancies for smoking, which may affect smoking rates and cessation success. Decreasing symptom distress by helping HIV+ smokers develop adaptive strategies for coping with this distress may be one effective approach to treatment. Additionally, nicotine replacement therapy and other medical regimens (e.g., Chantix) that have been shown to facilitate abstinence⁴² may be useful for decreasing nicotine withdrawal symptoms and for helping individuals differentiate between nicotine withdrawal symptoms and HIV-related symptoms that may be alleviated in other ways.⁴³ Ultimately, developing effective smoking cessation treatment will be important for helping HIV+ individuals quit smoking and for decreasing their risks for medical disease, premature death, and reduced mediation adherence and effectiveness.^3

–9

Footnotes

Acknowledgments

Funding for this study was provided by a McNeil Prevention and Community Psychology Fund grant and a University of Vermont Undergraduate Research Endeavors Competitive Award. The authors wish to thank Justin Parent and Michael Hickey for their data collection efforts.

Author Disclosure Statement

No competing financial interests exist.

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HIV Symptom Distress and Smoking Outcome Expectancies Among HIV+ Smokers: A Pilot Test

Abstract

Introduction

Methods

Participants

Measures

The Alcohol Use Disorders Identification Test 28

The Fagerström Tolerance Questionnaire 31

Smoking History Questionnaire 33

Smoking Consequences Questionnaires 14

AIDS Clinical Trials Group Symptoms Distress Module (ACTG-SDM; Justice et al., 2001) 19

Procedure

Data analytic approach

Results

Descriptive statistics

Bivariate correlations

Regression analyses

Discussion

Footnotes

Acknowledgments

Author Disclosure Statement

References

The Alcohol Use Disorders Identification Test²⁸

The Fagerström Tolerance Questionnaire³¹

Smoking History Questionnaire³³

Smoking Consequences Questionnaires¹⁴

AIDS Clinical Trials Group Symptoms Distress Module (ACTG-SDM; Justice et al., 2001)¹⁹