摘要：Objectives. We sought to determine smoking-related hazard ratios (HRs) and population-attributable risk percentage (PAR%) for serious clinical events and death among HIV-positive persons, whose smoking prevalence is higher than in the general population. Methods. For 5472 HIV-infected persons enrolled from 33 countries in the Strategies for Management of Antiretroviral Therapy clinical trial, we evaluated the relationship between baseline smoking status and development of AIDS-related or serious non-AIDS events and overall mortality. Results. Among all participants, 40.5% were current smokers and 24.8% were former smokers. Adjusted HRs were higher for current than for never smokers for overall mortality (2.4; P < .001), major cardiovascular disease (2.0; P = .002), non-AIDS cancer (1.8; P = .008), and bacterial pneumonia (2.3; P < .001). Adjusted HRs also were significantly higher for these outcomes among current than among former smokers. The PAR% for current versus former and never smokers combined was 24.3% for overall mortality, 25.3% for major cardiovascular disease, 30.6% for non-AIDS cancer, and 25.4% for bacterial pneumonia. Conclusions. Smoking contributes to substantial morbidity and mortality in this HIV-infected population. Providers should routinely integrate smoking cessation programs into HIV health care. Highly active antiretroviral therapy (HAART) for HIV has led to a decrease in AIDS-related events and deaths. 1 – 3 However, HIV-infected persons are also at risk for a variety of serious non–AIDS-defining diseases, including cardiovascular, renal, and hepatic disease, as well as certain cancers and infections not included in the AIDS case definition. 1 , 3 – 5 Studies conducted in the general population demonstrate that cigarette smoking increases the likelihood of many of these serious clinical conditions, including cardiovascular, pulmonary, and neoplastic diseases. 6 , 7 For example, smoking is a major risk factor for peripheral vascular and coronary artery disease, increasing the risk for cardiovascular disease (CVD) complications, including myocardial infarction and stroke. 6 – 8 Respiratory complications of smoking include chronic obstructive pulmonary disease and respiratory infections such as bacterial pneumonia or pulmonary tuberculosis. 6 , 7 , 9 Smoking increases the risk for many types of cancer, including cancers of the oral cavity, pharynx, esophagus, stomach, pancreas, larynx, lung, cervix, urinary bladder, and kidney. 6 , 7 , 10 Studying smoking-related morbidity and mortality among persons with HIV is especially important because their smoking prevalence is higher than that of the general population. Twenty-one percent of US adults are current cigarette smokers, 11 but many recent studies have reported rates 2 or 3 times as high (46%–76%) among HIV-positive persons. 12 – 18 HIV-infected current smokers are reported to smoke an average of 6 to 23 cigarettes daily and to have smoked for an average of 23 to 24 years. 15 , 16 , 18 , 19 Many smoking-related illnesses significantly affect HIV-infected persons. Lung cancer and other malignancies are important causes of death among persons with HIV. 20 , 21 HIV infection or use of antiretroviral drugs may contribute to CVD risk, 22 , 23 and use of effective HAART has resulted in increasing numbers of aging HIV-infected patients, who may develop metabolic syndrome, obesity, and other CVD risk factors. 24 , 25 HIV-infected patients may develop a variety of pulmonary diseases, including bacterial pneumonia 26 , 27 ; recurrent pneumonia is considered an AIDS-defining condition. 28 Because persons with HIV are at risk for these serious and life-threatening clinical syndromes, critical prevention questions are whether and to what extent smoking further increases the risk of developing these diseases, especially in the era of HAART. Because smoking is a modifiable risk factor, it is important to define the magnitude of smoking's effect on overall mortality among HIV-infected patients and its effect on development of specific adverse clinical conditions, including those that are not AIDS defining. It is also important to identify the proportion of disease among an HIV-infected population that is attributable to smoking. This information can be used to help estimate the effect of smoking cessation on reducing disease and improving survival for HIV-infected persons and to counsel individual patients about ways to optimize their health. We evaluated data from a large multisite international study of 2 HAART treatment strategies. We determined the relative risks associated with smoking for development of different serious clinical events and on all-cause mortality, with adjustment for a variety of important potential confounders. We also calculated the population-attributable risk percentage (PAR%) associated with smoking for these clinical syndromes and all-cause mortality.
