HIV and Smoking: 5 Reasons Why You Need to Stop Today

Consequences Are Far Worse for People Living With HIV

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Photograph © Kruscha

While the hazards of smoking are well known for anyone who lights up a cigarette, they are arguably far worse for people living with HIV.

Consider, on the one hand, that HIV itself causes a persistent inflammation that translates into higher rates of both HIV- and non-HIV associated illnesses. Now add to the burden of smoking and its impact on the lungs, heart, and other organs systems, and it’s easy to see why cigarettes are today considered the single greater contributor to ill health and premature death in HIV-infected individuals—even those on fully suppressive antiretroviral therapy.

What makes this all the more concerning is the fact that the rate of smoking among people with HIV in the U.S. is twice that of the general population. And while the reasons for this are many, one of the main causes is the failure to treat HIV as a facet of primary care.

Too often HIV is treated in isolation, with both patients and doctors often putting all other preventive health measure to one side. So instead of incorporating smoking cessation alongside the treatment and management of HIV infection, we focus on getting one’s viral load down to undetectable levels and leave the issue of smoking to another date.

We can no longer do that. Today, study after study has shown that smoking not only profoundly decreases life expectancy in people with HIV, it increases the risk of illness and even disease transmission.

1. People With HIV Lose More Life Years to Smoking than to HIV

Irrespective of whether you are on HIV therapy or not, research from the University of Copenhagen has concluded that smoking as an independent risk factor is associated with loss of life of more than 12.3 years when compared to smokers in the general population.

The research, which included 2,921 people with HIV and 10,642 non-infected individuals, further concluded that the mortality rate in smokers with HIV was more than thrice that that of their non-infected counterparts.

When comparing smoking and non-smoking individuals with HIV, the disparity becomes even greater.

According to the study, the median life expectancy for a 35-year-old smoker with HIV was 62.6 years compared to 78.4 years for a non-smoker with HIV—a loss of over nearly 16 years.

2. Smoking Greatly Increase Lung Cancer Risk in People With HIV

Emphysema and lung cancer have long been associated with cigarette smoking, and its impact on people with HIV is seen to be far more dangerous than earlier imagined.

A large-scale study conducted by the U.S. Department of Veteran’s Affairs looked at the rates of lung cancer among 7,294 smokers with HIV and 75,750 smokers without HIV. In their report, the researchers concluded that the rate of lung cancer was nearly twice in the smoking HIV population when compared to smoking general population, and that there was an astonishing, 14-fold increase in lung cancer risk among smokers with HIV.

What makes the figures all the more dismaying was the fact that these increases occurred irrespective of a person’s CD4 count, viral load, disease history, or whether or not the person was on antiretroviral therapy.

Death rates among smokers with HIV were also higher, with only a 10% lung cancer survival rate compared to 40% among smokers in the general population.

3. Risk of Heart Attack and Stroke Is Doubled If You Smoke and Have HIV

Whether smoking or not, heart disease remains a serious concern in persons with long-term HIV infection. According to the U.S. Veterans Administration, smoking as an independent risk factor is associated with a two-fold increase in the risk of heart attack in people with HIV when compared to the general population.

This appears to be true even for persons on successful antiretroviral therapy (ART), with a 2016 study from researchers at Massachusetts General Hospital concluding that ART alone was not sufficient in reducing elevated arterial inflammation associated with heart disease.

If you are a person with HIV who smokes, the outcomes are even worse, with more than twice risk of a heart attack or stroke when compared to persons with HIV who never smoked.

That doesn’t mean, however, that things can’t be turned around. The same study has shown that by stopping cigarettes, the risk of acute heart disease dropped by nearly half within the course of three years.

4. Smokers With HIV Are Disproportionately Affected by Cervical and Anal Cancers

Cervical cancer, specifically invasive cervical cancer (ICC), has long been classified as an AIDS defining illness by the Centers for Disease Control and Infection. Similarly, anal cancer, infrequently seen in the general population, occurs at astonishingly higher rates among HIV-positive men who have sex with men (MSM).

The human papillomavirus (HPV) is associated with both of these cancers, with certain "high risk" strain promoting the development of pre-cancerous lesions—which, in turn, can advance to ICC and anal tumors.

Not only does smoking appear to alter the natural course of HPV and increase the risk of both of these diseases, it compounds the rate of these cancers in HIV-infected individuals—with as high as a 15-fold increase in the risk of cervical cancer in women and a 40-fold increase in the risk of anal cancer in MSM when compared to the general U.S. population.

Furthermore, the risk of developing symptomatic HPV (e.g., anal warts, pre-cancerous lesions) appears to be exacerbated by smoking in people with HIV. A 2013 study from researchers at the University of Washington in Seattle has suggested that there may be as high as a 3-fold increase in HPV acquisition among HIV-infected MSM who smoke versus HIV-infected MSM who never smoked.

5. Smoking Increases the Risk of Transmitting HIV During Pregnancy

Both in the developed and developing world, medical interventions to prevent mother to child transmission of HIV (PMTCT) have been enormously effective.

In the U.S., the incidence has dropped to around 100 new cases per year, while even in South Africa—the country with the highest number of HIV infections in all of the world—we’ve seen the incidence rate drop from 30% before the initiation of PMTCT in 2001 to just 2.7% by 2010.

However, the success seen on a population scale does not necessarily reflect what happens on an individual basis if an HIV-positive mother smokes.  A large-scale investigation conducted by researchers at the Mothers and Infants Cohort Study (a four-year, study conducted in Brooklyn and the Bronx, New York) investigated the implications of smoking in prenatal HIV transmission rates.

What they found was that pregnant mothers with HIV who smoked after the first trimester had a three-fold increase in the risk of transmitting HIV to their babies when compared to counterparts who did not smoke after the first trimester.

These increases were associated with the pre-term rupture of membranes. Particularly in mothers who have not been treated for HIV prior to delivery (or haven’t a fully suppressed viral load while on treatment), such ruptures can dramatically can increase the likelihood of transmission to the unborn child.


U.S. Centers for Disease Control and Prevention (CDC). "Cigarette smoking among adults - United States, 2011." Morbidity and Mortality Weekly Report (MMWR). November 9, 2012. 61(44):889-894.

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Sigel, K.; Wisnivesky, J.; Justice, A.; et al. "HIV Infection Is an Independent Risk Factor for Lung Cancer." 17th Conference on Retroviruses and Opportunistic Infections (CROI 2010). San Francisco; February 16-19, 2010: Abstract 30.

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Schwartz L.; Castle, P.; Follansbee, S.; et al. "Risk factors for anal HPV infection and anal precancer in HIV-infected men who have sex with men." Journal of Infectious Diseases. August 1, 2013; online edition.

CDC. "HIV Among Pregnant Women, Children, and Infants." Atlanta, Georgia; accessed June 16, 2016.

Goga, A.; Dinh, T.; Jackson, D.; et al. "Impact of the national prevention of mother-to-child transmission of HIV (PMTCT) program on perinatal mother-to-child transmission of HIV (MTCT) measured at six weeks postpartum, South Africa (SA)."  XIX International AIDS Conference; Washington, D.C.; July 22-27, 2012; abstract WEPE173.

Burns, D.; Landesman, S.; Muenz, L.; et al. "Cigarette Smoking, Premature Rupture of Membranes, and Vertical Transmission of HIV-1 Among Women With Low CD4+ Levels."Journal of Acquired Immune Deficiency Syndrome. July 1994; 7(7); online publication.

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