Vol.2, No.8, 913-918 (2010)
Copyright © 2010 SciRes. http://www.scirp.org/journal/HEALTH/
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Smoking behavior of HIV-infected patients
Till Neumann1*, Nico Reinsch1, Stefan Esser2, Peter Krings1, Thomas Konorza1, Tanja
Woiwoid1, Michael Miller3, Norbert Brockmeyer4, Raimund Erbel1
1Department of Cardiovascular Medicine, Essen University, Medical School, Essen, Germany; *Corresponding Author:
2Department of HIV-Medicine & Dermatology, Medical School, Essen University, Essen, Germany
3Department of Gastroenterology, Medical School, Essen University, Essen, Germany
4Department of Dermatology, Medical School, Bochum University, Bochum, Germany
Received 10 March 2010; revised 2 April 2010; accepted 5 April 2010.
Recent reports describe an increased rate of
cardiovascular events in smoking HIV-infected
subjects. However, a lot is still unknown about
smoking in this patient population. The purpose
of the study was to analyze smoking behavior in
HIV-infected subjects as a risk factor of coro-
nary atherosclerosis and determine its effect on
the probability of coronary events. We analyzed
the cardiovascular risk factors of 294 HIV-infected
adults (age: 42.1 10.1 years; 77% males). An
elevated tobacco abuse was observed in 63.6%
of the HIV-infected patients. Tobacco use was
much more common in HIV-infected males than
in females (67.8% vs. 49.2%; p < 0.01). Even
elderly HIV-infected subjects had elevated rates
of pack-years, the daily tobacco consumption
does not seem to change at different ages (p >
0.2). Analysing the way of infection and the
status of smoking, patients with HIV-infection
acquired by heterosexual contact exhibited sig-
nificantly lower rates of smoking compared with
patients with HIV-infection acquired by MSM
(man having sex with man) or by intravenous
drug abuse (52.7% vs. 67.4%/82.1%, p < 0.01).
The effect of smoking on the 10yrs. probability
of coronary events determined by Framingham-
equation was superior compared with all other
classic cardiovascular risk factors. HIV-infected
patients exhibited an increased tobacco use.
Knowledge about smoking behavior in this pa-
tient population is essential to evaluate the risk
of cardiovascular events and to implicate pre-
vention strategies for HIV-infected subjects.
Keywords: Human Immunodeficiency Virus;
Atherosclerosis; Smoking; Tobacco Consumption
Since the development of effective antiretroviral therapy
concepts, the replication of the human immunodefi-
ciency virus (HIV) could be decreased and its coincident
deleterious effects on the immune system be diminished.
Therefore, the HIV-infection has become a chronic dis-
ease with a potential for long-term survival.
However, the spectrum of HIV-related diseases has
shifted from opportunistic infections towards long-term
complications of HIV-infection and the antiretroviral
therapy. Based on an increased rate of coronary events in
HIV-infected patients, a variety of investigators are cur-
rently focusing on metabolic disorders as a long-term
effect of the highly antiretroviral therapy (HAART) and
their risk for premature atherosclerosis [1,2]. In particu-
lar, a rising number of case reports on myocardial infarc-
tion in HIV-infected patients in recent years implicated
an association between HAART and coronary heart dis-
ease [3-8]. However, the results of register analyses of
coronary heart disease in HIV-infected patients, which
display a correlation between an increased rate of car-
diovascular events and antiretroviral therapy, are still
controversially discussed [9,10].
Therefore, in HIV-infected subjects further patho-
physiological mechanisms may participate to premature
atherosclerosis. In particular, classic cardiovascular risk
factors, including smoking, are suspected to play a rele-
vant role in the development coronary events. The pre-
sent study was performed to assess smoking behavior as
a cardiovascular risk factors in HIV-infected subjects
and to determine its effects on the probability of coro-
nary heart disease.
Patient population: All HIV-infected patients being
T. Neumann et al. / HEALTH 2 (2010) 913-918
Copyright © 2010 SciRes. http://www.scirp.org/journal/HEALTH/Openly accessible at
treated in the Internal Medicine HIV-out patient depart-
ment over a time period of 5 years were included into
analysis. Of these 294 HIV-infected patients one hun-
dred seventy three (58.9%) acquired HIV-infection by
homosexual contact of man having sex with man, 83
(28.2%) by heterosexual contact, 28 (9.5%) by intrave-
nous drug abuse and 10 (3.4%) by blood transfusion.
A medical history was taken and a physical examina-
tion performed by a physician. Of each patient, demo-
graphic data, state of infection, antiretroviral medication
and cardiovascular risk factors including personal history,
lipid disorders, and smoking behaviors were analysed. If
subjects were smokers, further information including the
amount of cigarettes per day as well as the frequency
and the time period of smokingresulting in pack years
data were recorded and analysed. Resting systolic
blood pressure (SBP) and diastolic blood pressure (DBP)
were measured by oscillometric sphygmo-manometry.
A total of 28 patients (9%) were on lipid-lowering
therapy. Of these patients the lipid values were included
before the start of the lipid-lowering therapy. The study
was in agreement with the Local Council on Human
Research and the Declaration of Helsinki.
Calculation of the probability of coronary events:
The prediction of coronary events was determined by the
Framingham algorithm [11]. As major cardiovascular
risk factors age, gender, total cholesterol, LDL choles-
terol, blood pressure, smoking and diabetes were fea-
tured into the calculation. The result of the Framingham
prediction algorithm determines the 10-year probability
of coronary events and gives information about the im-
pact of each cardiovascular risk factor.
Statistical Analysis: Variables that described demo-
graphic data and data of smoking behavior were ex-
pressed as mean values SD. The comparison of these
variables was performed between distinct groups by
one-way ANOVA and Bonferroni test. Nominal vari-
ables were expressed as frequencies and comparisons
performed by using Fishers exact test. Skewed variables
such as variables describing the probability of coronary
events were expressed as median and comparisons were
done by Wilcoxon rank sum test and Dunn´s test (indis-
tinct groups were compared by Wilcoxon signed rank for
paired observations adjusted according to Bonferroni-
Holm). A p < 0.05 was considered significant.
Overall, HIV-infected patients exhibited an increased
tobacco use. Of all 294 HIV-infected patients in the pre-
sent study, 187 (63.6%) were regular smokers, nearly all
of them consuming cigarettes (only one patient smoked
pipe). The demographic data of smokers and non-
smokers are presented in Table 1. There were no sig-
nificant differences between smoking and non-smoking
HIV-infected subjects concerning age, height, weight or
body mass index in our analyses. Moreover, there was
no significant difference in HIV-RNA concentration,
CD4-count and antiretroviral therapy.
In both groups, about one third of patients were in
stage A, B and C of the disease, without significant dif-
ferences due to the rate of smoking (smokers: 31.7%/
33.3%/35.0%; non-smokers: 33.7%/26.9%/39.4%, res-
pectively). Further cardiovascular risk factors, including
systolic and diastolic blood pressure and elevated lipid
or glucose concentration did not differ significantly be-
tween the two groups (Table 2).
Tobacco use was much more common in HIV-infected
males than in females. While more than two thirds of
HIV-infected males were smokers, the smoking rate in
HIV-infected females was less than 50 percent (67.8% vs.
49.2%; p = 0.008). Even gender differences in HIV-
infected patients were particularly assessed concerning
the rate of smoking, no significant difference were pre-
sent between these two groups in the time interval of
smoking and the amount of cigarettes consumed includ-
ing pack-years and cigarettes per day). Only 2.0% of
HIV-infected males and 3.0% of females showed a daily
cigarette consumption that was less than 5 cigarettes. In
contrast, 44.1% of males and 33.4% of females smoked
each day more than 20 cigarettes (Table 3).
Table 1. Demographics and Antiretroviral Therapy.
Non-Smoker Smoker p-value
N (male/female)107 (73/34) 187 (154/33)
Age [y] 42.9 11.6 41.7 10.9 0.38
Height [cm] 174.0 9.9 175.7 8.3 0.11
Weight [kg] 70.6 11.6 70.313.5 0.84
BMI [kg/m²] 23.4 3.7 22.7 3.7 0.11
(50, 7000)
(50, 10500) 0.22
CD4 [cells/µl] 438 247 466 304 0.42
NRTIs 91 (85.0%) 160 (85.6%)1.00
NNRTIs 48 (44.9%) 69 (36.9%) 0.22
PIs 49 (45.8%) 89 (47.6%) 0.81
Demographics data are presented as mean values SD, Antiretroviral
therapy in percentage; NRTIs: nucleosidal reverse transcriptase inhibi-
tors; NNRTIs: non-nucleoside reverse transcriptase inhibitors; PIs:
protease inhibitors
T. Neumann et al. / HEALTH 2 (2010) 913-918
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Table 2. Cardiovascular Risk Factors.
Non-SmokerSmoker p-value
SBP [mmHg] 122.8 17.3120.3 16.5 0.23
DBP [mmHg] 79.6 11.3 78.2 11.6 0.33
Total cholesterol
[mmol/L] 5.59 1.47 5.49 1.40 0.56
[mmol/L] 1.20 0.49 1.14 0.45 0.34
[mmol/L] 3.52 1.69 3.50 1.38 0.93
[mmol/L] 2.88 2.96 2.76 3.19 0.76
[mmol/L] 5.5 (4.9, 6.3)5.3 (5.0, 6.3) 0.53
HbA1c [%] 5.3 0.9 5.1 1.1 0.10
Data are mean values SD or median (lower quartile, upper quartile);
SBP: systolic blood pressure; DBP: diastolic blood pressure.
The majority of smoking HIV-infected were 31 to 40
years old and consumed 11 to 40 cigarettes per day. No
significant differences were found in our study between
the rate of smoking at different ages (18-30 yrs: 58.4%,
31-40 yrs: 64.6%, 41-50 yrs. 69.8%, > 50 yrs. 55.3%).
As expected, elderly HIV-infected subjects of more than
40 years had a significantly higher amount of pack-years
compared with younger HIV-infected subjects. Even the
smoking period of elderly subjects was increased, no
significant differences were found in respect of daily
tobacco consumption (Table 4).
Analysing the way of infection and the status of smo-
king, also significant differences were present (Table 5).
In particular, the group of patients with HIV-infection
acquired by heterosexual contact exhibited significantly
lower rates of smoking compared with patients with
HIV-infection acquired by MSM (man having sex with
man) or by intravenous drug abuse. The lowest rate of
smoking was present in patients with HIV-infection ac-
quired by blood transfusion. However, a no significant
differences to other groups were found due to the low
rate of patients of this way of infection.
As presented in Figure 1, the prediction value for
coronary events in the next 10 years was significantly
higher in smoking HIV-infected patients compared with
non-smoking HIV-infected patients (7.2% vs. 4.9%; p <
0.001), respectively. Especially, male HIV-infected pa-
tients exhibited an elevated probability of coronary
events compared with female HIV-infected patients in
the smoker group (9.8% vs. 2.3%; p < 0.001), respec-
tively. The calculated effect on the probability of coro-
Table 3. Gender differences.
Mean SD < 5 5-10 11-20 21-40 > 40
Cigarettes per day:
- all 25.0 14.0 2.1% 15.5% 40.1% 35.3% 7.0%
- males 25.2 13.5 2.0% 14.3% 39.6% 37.0% 7.1%
- females 24.0 16.4 3.0% 21.2% 42.4% 27.3% 6.1%
p-value (males vs. females): 0.68
Pack years:
all 21.9 15.2 6.4% 20.3% 30.5% 36.4% 6.4%
males 22.6 14.8 5.9% 18.8% 29.2% 39.6% 6.5%
females 19.1 17.0 9.1% 27.3% 36.4% 21.2% 6.0%
p-value (males vs. females): 0.24
Table 4. Age differences.
N (%)
Mean SD < 5 5-10 11-20 21-40 > 40
Cigarettes per day:
- 18-30 22 (11.8%) 19.4 8.4 9.1% 13.6% 54.6% 22.7% 0.0%
- 31-40 81 (43.3%) 24.7 12.5 1.2% 14.8% 38.3% 38.3% 7.4%
- 41-50 50 (26.7%) 26.5 15.5 0.0% 18.0% 34.0% 42.0% 6.0%
- > 50 34 (18.2%) 26.9 17.3 2.9% 14.7% 44.1% 26.5% 11.8%
p-value between groups: 0.31
T. Neumann et al. / HEALTH 2 (2010) 913-918
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Table 5. Way of Infection.
All Group 1 Group 2 Group 3 Group 4
Smoking, % 63.6% 66.4% 53.0% 85.7% 40.0%
package-years 21.4 1.0 22.5 1.4 25.2 2.5 24.7 2.6 38.8 14.6
cigarettes per day 24.8 1.0 24.9 1.4 20.1 2.3 20.2 2.1 44.2 16.0
Group 1: HIV-infection acquired by man having sex with man; Group 2: HIV-infection acquired by heterosexual contact; Group 3: HIV-infection
acquired by intravenous drug abuse; Group 4: HIV-infection acquired by blood transfusion.
Figure 1. The 10-year probability of coronary events deter-
mined by the Framingham prediction algorithm in distinct
groups of HIV-infected individuals, due to the quality of
smoking. The 10-year probability of coronary heart disease in
the next 10-years was significantly higher in smokers than in
non-smokers. Data are expressed as median plus lower quartile
and upper quartile.
nary events by smoking is superior compared with all
other classic cardiovascular risk factors.
The present study demonstrates that smoking is a com-
mon cardiovascular risk factor in HIV-infected patients.
Furthermore, smoking seems to have a remarkable and
superior impact for the occurrence of cardiovascular
events in this patient population compared with other
classic cardiovascular risk factors including hyperlipi-
Recent clinical trials describe an increased rate of car-
diovascular events in HIV-infected patients [9,10]. In
addition, the rate of atherosclerosis in autopsies of
HIV-infected patients has increased [12]. Consequently,
there is an increased concern that these changes may
lead to an epidemic increase of cardiovascular diseases
in the HIV-positive population.
The development of new antiretroviral drugs includ-
ing protease inhibitors has reduced the mortality and
morbidity of HIV-infected patients [13]. The increased
lifespan in combination with the metabolic side effects
of the highly active antiretroviral therapy (HAART),
such as hyperlipidaemia and insulin resistance, has been
expected to contribute to the increased rate of athero-
sclerosis in HIV-infected patients. However, other risk
factors than hyperlipidaemia and insulin resistance, may
also have an effect on the development of premature
atherosclerosis in HIV-infected patients [14-16].
The results of the present study emphasise, that smo-
king is an important risk factors, which has a remarkable
impact on the incidence of cardiovascular events in HIV-
infected patients. Our data further reveal a high percent-
age of smokers among the study population of individu-
als living with HIV. The rate of smokers in our sample
was far above the prevalence estimated for the general
adult population in the same area (63.6% vs. 23.5%, p <
0.001) [17]. In addition to the increased rate of smoking,
the cigarette consume per day of HIV-infected smokers
was elevated compared with HIV-negative smokers in
the general adult population (25.0 vs. 16.4 cigarettes per
day). One reason for the higher frequency of smokers
might be the portion of people with intravenous drug
abuse and men who have sex with men in the population
of HIV-infected patients. Both groups have an increased
smoking rate [18,19].
Among individuals living with HIV, previous studies
have found that smokers are at greater risk for develop-
ing bacterial pneumonia, oral lesions, and the acquired
immune deficiency syndrome. However, our study re-
sults reveal that smokers with HIV-infection also have
an elevated risk of cardiovascular events than non-
smokers with HIV-infection. The risk of cardiovascular
events was especially elevated in male smokers with
HIV-infection. However, the probability of cardiovascu-
lar events of female smokers with HIV-infection was
comparable or even lower than the risk of non-smoking
HIV-infected individuals.
Compared with HIV-infected non-smokers, the in-
creased probability of cardiovascular events in HIV-
infected smokers was not associated to differences in
other coronary risk factors, such as hypertension, hyper-
lipidaemia or hyperglycaemia. Furthermore, there were
no differences in antiretroviral therapy between the
smoker group and the non-smoker group.
T. Neumann et al. / HEALTH 2 (2010) 913-918
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Openly accessible at
As a limitation of the present study, the probability of
cardiovascular events for the next ten years was deter-
mined by an algorithm. This Framingham algorithm had
been used previously to determine the risk of cardiovas-
cular events in HIV-infected patients and the algorithm
considered the traditional cardiovascular risk factor such
as age, gender, lipid values, blood pressure, smoking,
and hyperglycaemia [11,20]. Nevertheless, this type of
calculation has limitations. In particular, it is only an
estimation of cardiovascular events and does not present
the de facto event rate. However, it is the only way to
receive an opinion about the impact of cardiovascular
risk factors in this patient population. Hence, it is a rele-
vant tool to compare the impact of different risk factors
in a specific patient population.
The results of the present study give insides in smok-
ing behaviour. These information about smoking behav-
ior are essential to evaluate the risk of cardiovascular
events and to implicate prevention strategies for HIV-
infected subjects. The reduction of cardiovascular risk
factors should become a routine prevention in the care of
HIV-infected patients, which now have an increased
lifespan due to highly active antiretroviral therapy.
This work was supported by the Competence Network of Heart Failure
(Kompetenznetz Herzinsuffizienz) funded by the Federal Ministery of
Education and Research (BMBF), FKZ 01GI0205. Our work was not
supported by any form of sponsorship or has any affiliations that might
lead to bias or conflict of interest.
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