Introduction
Smoking of tobacco is a world wide phenomenon. According to About.com between 80,000 and 100,000 children start to smoke each day^1,2.  The World Health Organisation³ compiled statistics on smoking in 2002 and found that:

• About one third of the total male population smokes.
• Smoking related diseases kill one in every 10 adults globally. If the current trend continues, smoking will kill one in every six people by 2030.
• Every eight seconds, someone dies from tobacco use.
• Smoking is on the rise in the developing world but falling in developed nations. Among Americans, smoking rates shrunk by nearly half in three decades (from the mid-1960s to mid-1990s), falling to 23% of adults by 1997. In the developing world, tobacco consumption is rising by 3.4% per year.
• About 15 billion cigarettes are sold daily - or 10 million every minute.
• Among young teens (aged 13 to 15), about one in five smokes worldwide.
• Evidence shows that around 50% of those who start smoking in adolescent years go on to smoke for 15 to 20 years.

Another disturbing fact that was discovered is that people did not perceive smoking to be harmful to their health⁴:

• One British survey found that nearly 99% of women did not know of the link between smoking and cervical cancer⁵.
• One survey found that 60% of Chinese adults did not know that smoking can cause lung cancer while 96% were unaware that it can cause heart disease.

The truth is that smoking poses a real threat to our health:

• Half of long-term smokers will die from tobacco. Every cigarette smoked cuts at least five minutes of life on average - about the time taken to smoke it.
• Smoking is the single largest preventable cause of disease and premature death. It is a prime factor in heart disease, stroke and chronic lung disease. It can cause cancer of the lungs, larynx, oesophagus, mouth, and bladder, and contributes to cancer of the cervix, pancreas, and kidneys.
• More than 4,000 toxic or carcinogenic chemicals have been found in tobacco smoke.
• At least a quarter of all deaths from heart diseases and about three-quarters of world's chronic bronchitis are related to smoking.

What is the situation in South Africa?
South African adolescents have the highest reported smoking prevalence amongst African health surveys. Amongst these youth, 30% report ever having smoked a cigarette in their lifetime, 21% are current smokers (smoked cigarettes on one or more days in the past month), nearly 7% are frequent smokers (on 20 or more days in a month), and 6% had smoked their first cigarette before the age of 10 years. Of the current smokers, 47% had tried to stop smoking within the past year.  Smokeless tobacco use within the previous month was also reported by 11% of learners^6,7,8.

It brings us to the question: “What effect does smoking has on HIV and AIDS?”

Smoking, HIV and AIDS
In the United States, the prevalence of cigarette smoking is estimated to be 50-70% among HIV-infected persons and 75% among substance abusers, compared to 25% in the general population⁹. Although smoking has no direct association with these illnesses, it is associated with reduced health-related quality of life in HIV-infected persons, increased incidence of bacterial pneumonia and other AIDS defining illnesses, increase incidenced of malignancies, and increased mortality risk compared to HIV-positive non-smokers¹⁰.

Indeed, emerging evidence now suggests that tobacco smoking may actually be an independent risk factor for HIV infection^11,12. Some studies also suggest that nicotine smoking may be associated with faster progression to AIDS and/or neurological complications of AIDS¹³. Furthermore, smokers taking Highly Active Antiretroviral Therapy (HAART) are at increased risk for lipodystrophy and cardiac disease compared to non-smokers.

New data also suggests that women smokers on HAART have poorer viral responses, poorer immunologic response, greater risk of virologic rebound, more frequent immunologic failure, and have higher risk of developing AIDS¹⁴.

Some studies also suggest that nicotine smoking may be associated with faster progression to AIDS and/or neurological complications of AIDS. The study¹⁵, which appears in the journal Sexually Transmitted Infections, says it is not clear why smokers would be more likely to become infected with the HI virus, , than non-smokers. But the authors pointed to growing evidence that smoking increases the risk of all types of infections, perhaps by changing the structure of the lung or weakening the immune system. They also noted that tobacco use tended to be higher among people most likely to get AIDS, like prostitutes¹⁶.

The study reported that AIDS and tobacco use are the only two major causes of death that are on the rise, with tobacco projected to play a role in perhaps eight million deaths in a little over a decade.

Conclusion
The obvious answer to the problem of smoking is easy: stop smoking. However, this is easier said than done. As soon as a person stops smoking his/her body will have withdrawal symptoms. It is nevertheless interesting to take note of the advice offered to smokers by Nancy Wongvipat who is a health education specialist in AIDS Project Los Angeles' Education Division¹⁷:

• Ex-smokers will usually tell you it takes three to four attempts before successfully quitting smoking. More than 3 million Americans quit smoking permanently every year. And you can, too! Don't despair, even if you have tried and failed in the past. By choosing the right approach and keeping a positive attitude, you'll see that there is still hope to kick the habit. Some people are successful quitting "cold turkey," while others slowly decrease the number of cigarettes per day until they quit. Some even need the assistance of medical professionals. Choose the method that best suits you and your lifestyle. Nicotine addiction is 95-percent psychological and about 5-percent physiological. No one ever died of nicotine withdrawal. In fact, most people make it through the withdrawal symptoms but start smoking again due to boredom, stress or peer pressure.
• Since nicotine is eliminated from the body in two weeks, the "pressures" you feel to start again aren't from the nicotine, they're from the psychological stressors in your life.
• Many resources for helping smokers quit are available. Most resources can be categorised as either smoking cessation programs or methods used to treat withdrawal from nicotine. By offering ongoing counselling and coping strategies that help with the psychological stressors that are often the reasons for relapse, a formal smoking cessation class increases your chances of quitting tremendously. Methods used to treat nicotine withdrawal, such as gums, patches, inhalers, nasal sprays and medications, alleviate the symptoms of withdrawal only. While acupuncture, hypnosis and biofeedback work for some, there is no formal evaluation validating their success rates.

A good starting point seems to be to advise children at a very young age not to start smoking. But imparting knowledge alone is no guarantee that they will adhere to the advice. However, an innovative tobacco curriculum for schools in South Africa has been developed and is currently under evaluation in 36 schools in conjunction with Departments of Health and Education, and the MRC, directly in response to the government legislation¹⁸. One can only hope that this ‘window of hope’ will make a substantial difference.

For further reading on the SA Medical Research Council’s response visit the following websites:

• http://www.mrc.ac.za/chronic/healthykids.pdf
• http://www.mrc.ac.za/healthpromotion/GYTS2002part1.pdf
• http://www.mrc.ac.za/healthpromotion/GYTS2002part2.pdf
• http://www.mrc.ac.za//policybriefs/polbrief1.htm
• http://www.sahealthinfo.org/lifestyle/heinsmoking.pdf
• http://www.sahealthinfo.org/lifestyle/onlinedocs.htm

Sources

1. Cigarette Smoking and HIV Prognosis Among Women in the HAART Era
2. Worldwide Smoking Statistics
3. Global Smoking Statistics
4. Ibid.
5. Global Smoking Statistics
6. Healthy Active Kids South Africa 2007
7. GYTS2002part1.pdf (application/pdf Object)
8. GYTS2002part2.pdf (application/pdf Object)
9. NIDA - What's New - Past Meetings - "Current Issues in Cigarette Smoking and HIV/AIDS" Workshop
10. Ibid.
11. Ibid.
12. Is smoking tobacco an independent risk factor for HIV infection and progression to AIDS? A systemic review -- Furber et al. 83 (1): 41 -- Sexually Transmitted Infections
13. ScienceDirect - Alcohol : Chronic cigarette smoking and heavy drinking in human immunodeficiency virus: consequences for neurocognition and brain morphology
14. Is smoking tobacco an independent risk factor for HIV infection and progression to AIDS? A systemic review -- Furber et al. 83 (1): 41 -- Sexually Transmitted Infections.
15. Smoking may increase risk of contracting AIDS virus - International Herald Tribune
16. Ibid.
17. Smoking: It Doesn't Make Living with HIV Any Easier - The Body
18. Healthy Active Kids South Africa 2007.

Author: Pieter Visser
Reviewed by: Joyce M Tsoka
Contact: afroaidsinfo@mrc.ac.za
Date: May 2008