INTRODUCTION

Tobacco use remains the leading cause of preventable death and disease in the United States (US) despite the significant decline in commercial use over the past five decades¹. People with HIV (PWH) are disproportionately affected by cigarette use, with an estimated 40–60% prevalence rate^2-4, which is quadruple the 11.5% rate in the general population¹. Advances in antiretroviral therapy (ART), along with engagement in HIV clinical care services, allow PWH to achieve an increased or near-normal lifespan⁵. However, the detrimental health effects of smoking lead to premature death from lung cancer and other smoking-related diseases. PWH who smoke have a higher incidence of comorbidities, including heart disease, cancer, and pulmonary disease, and lung cancer is now the leading cause of death among PWH, with tobacco use being the most significant risk factor for lung cancer incidence and mortality^2,6-10. Indeed, prior research has determined that PWH lose more years of life due to smoking than to HIV-related morbidity^11,12.

According to an evaluation of the beliefs and clinical practices of healthcare providers affiliated with the HIV Medical Association, clinicians agree that tobacco use is a critical issue in PWH¹³. Clinical tobacco treatment guidelines indicate that evidence-based behavioral and pharmacological interventions are still recommended for all people who smoke, including PWH¹⁴. However, previous smoking cessation intervention trials consistently report poor outcomes and lower success rates with traditional tobacco treatment, including poor adherence to therapy, despite PWH reporting great interest in tobacco treatment^13,15-22. Considering their high levels of nicotine dependence and low quit rates, PWH who smoke may require additional support for quitting compared with the general population of smokers, as they may not only have more smokers in their social network but also may smoke to cope with social isolation related to living with HIV^23,24.

Peer Navigators (PNs) have been utilized in the HIV care continuum for many years to support HIV prevention, testing, entry and retention in care, and adherence to ART^25-28. Peers can use their personal experiences to establish meaningful connections with patients. They can then leverage these connections to inform, support, and retain patients in care²⁵. Linking PWH who smoke with PNs (PWH who have quit smoking and remained smoke-free) could potentially increase motivation to quit, improve access to and utilization of available resources, and provide an example of mastery. This novel and sustainable approach can encourage smoking cessation and provide the additional social support necessary for successfully quitting and maintaining abstinence. The purpose of this qualitative study was to explore the experiences of PWH who received a PN-based intervention to provide social support for smoking cessation in a recent randomized clinical trial.

METHODS

The parent study (n=64), was a pilot randomized controlled trial that examined the feasibility, acceptability, and preliminary efficacy of a peer navigation social support for smoking cessation intervention tailored for PWH who smoke cigarettes^29,30. Participants were primarily recruited from an HIV care clinic in Providence, RI, and the local community. Eligible participants for the parent study were aged ≥18 years, diagnosed with HIV, smoked ≥5 cigarettes a day for more than a year, and tested positive for cotinine in their saliva at baseline. Participants were ineligible if they were already using smoking cessation pharmacotherapy, had an unstable medical or psychiatric condition (past 30-day medical or psychiatric hospitalization prior to enrollment), were experiencing psychotic symptoms, had past-month suicidal ideation or past-year suicide attempt, or were pregnant. Additionally, it is worth noting that participants did not have to endorse readiness to quit to be eligible.

Participants were enrolled June 2020–2021 and living in Providence, RI, USA. After their baseline visit, all participants were randomized upon completing a 30–45-minute smoking cessation counseling session with a study nurse. They then participated in follow-up interviews at 4, 12, and 24 weeks. The study methods and results of the RCT have been previously published^29,30. All sessions were conducted via a HIPAA-compliant version of Zoom due to the COVID-19 pandemic. Briefly, the PN group received 12 weekly phone calls, lasting approximately 10–20 minutes each, from a PN following the initial session with the study nurse. These calls were manual-guided but not prescriptive – the PN was instructed to let the participant guide the conversation. One female PN who previously smoked daily for many years and had quit 1–2 years prior was hired for the study. She also had previous healthcare experience working as a nursing assistant. Abstinence was biochemically verified by an exhaled carbon monoxide (CO) level of ≤5 ppm at the time of hire. She received approximately 8 hours of didactic training (two 4-hour sessions conducted by PAC and MP), including role play. A manual was developed as a guide for the PN to deliver weekly phone sessions; including standard cessation counseling, local cessation resources, encourage readiness to quit, and social support for quitting. A more detailed overview of the PNs’ training, qualifications, and role, including details on participant phone call structure, is published elsewhere²⁹.

The PN intervention concluded at the week 12 assessment. At week 12, 60-minute semi-structured, in-depth interviews were conducted via Zoom to examine the acceptability of the PN by active condition study participants. Twenty-seven out of thirty participants randomized to the PN condition attended the week 12 follow-up visit and were invited to complete the interview. Of those, 23 completed the interview. Descriptive statistics (means and measures of central tendency) were generated for select demographic, clinical, and smoking history variables collected via self-report in the parent study³⁰. Data from the control group were not analyzed as those participants did not interact with the PN, and this report focuses solely on the experimental arms experience with the intervention.

The trained interviewers (research assistants on the project) queried participants’ perceptions of the PN, including perceived helpfulness. Interviews were audio-recorded, transcribed verbatim, and de-identified. Data management and analysis were conducted using NVivo version 11. Data were analyzed using an applied abductive thematic analysis approach (Supplementary file)³¹. A preliminary coding structure was created based on the semi-structured agenda and was refined as the coding process progressed to incorporate emerging themes. Codes were summarized, and five key themes were identified – illustrative quotes were chosen to represent each theme. The coding was conducted independently by the PI (PAC) and a medical student research assistant (BC), both of whom were not involved in the delivery of the intervention or assessing outcomes to ensure objectivity in the qualitative analysis. Coding discrepancies in codes were resolved through consensus.

Participants were asked: ‘Tell me what you liked and/or disliked about your peer navigator’; ‘Can you give one example of helpfulness or one thing they said that was helpful? One great piece of advice?’; ‘Can you tell me, in more detail, one thing the PN addressed with you?’; and ‘Would you have preferred a male or female PN? Why or why not? How might that have made a difference? How important was it that the PN be the same gender as you?’.

RESULTS

Twenty-three participants (76.7%) in the PN arm who attended the week 12 follow-up completed an interview. The four participants who did not participate did not provide a reason for declining. Table 1 summarizes the sample demographic and smoking characteristics. On average, participants were aged 57 years (SD=7.4), White (52.2%), and female (60.9%). Participants actively engaged with the PN, with a mean number of 9.5 (SD=2.4) weekly calls completed (out of 12 possible calls). One quarter (n=7; 23.3%) of participants completed all 12 weekly calls with the PN, while 50% completed 10 calls. The initial efficacy of the PN intervention showed promising results for increased social support for quitting. By week 24, 16 participants (53.3%) in the PN group reported making a quit attempt, and five self-reported (CO-biochemically verified) as having successfully quit. Interestingly, the quit rates did not differ between the study conditions. However, as anticipated, participants in the active condition experienced a significant increase in positive social support from baseline to week 12. This included enhanced self-efficacy for quitting, which also improved over time, although not significantly when compared to the control group.

The five themes that were generated from the interview data describe several key aspects of the PN and participant interaction, including: 1) social support through peer navigation; 2) storytelling for success; 3) perceived salient traits of PN; 4) accountability; and 5) enhanced self-efficacy.

DISCUSSION

The findings from this study support that participants found substantial value in receiving support for smoking cessation from a PN. In particular, they spoke to how the PN provided social support for quitting and increased their self-efficacy. According to social cognitive theory, these two outcomes may facilitate smoking cessation since both can influence the ability to take on a new challenge (such as smoking cessation) and persevere in time of difficulty (such as cravings)³². The PN, as a person living with HIV themselves and who formerly smoked, also may have provided an example of mastery – someone who has faced similar challenges and has maintained smoking abstinence, which some participants explicitly noted. Further, the theory of triadic influence also emphasizes that streams of influence, such as those found in social networks, influence the individual’s attitudes and behavioral choices³³. This is particularly relevant for PWH, as they often report that their social networks, including friends and family, include many smokers, which can hinder their self-efficacy to quit³⁴.

A key point that is especially relevant and was emphasized in the interviews was described by one participant as ‘talking theory’. This highlights the belief that the PN was a more credible source of information due to their lived experience as a former person who smoked. While healthcare providers often recommend smoking cessation to their patients with HIV, many providers lack the personal experience that the PN brings, which can make their advice feel less impactful. They may struggle to connect as deeply with patients who smoke. In contrast, participants held the PN in high regard for their honesty, authenticity, and credibility as someone who has quit smoking. Their sincerity fostered a deeper connection with the participants that healthcare staff might be unable to achieve. The bond that developed over time between the participant and the PN fostered a ‘feeling’ of community the participants appreciated, highlighting the importance of encouragement and rallying support that PWH may need to start the process of reducing cigarette smoking, staying abstinent, or combatting cravings.

The importance of social support and self-efficacy in promoting medication adherence (e.g. ART) among PWH is well-established³⁵. The PN in our trial provided salient social support and education related to cessation efforts and access to treatment resources (e.g. quitline, and nicotine replacement therapy [NRT]), emphasizing the positive influence of perceived support through shared lived experiences surrounding access and use of available treatment options. Our findings that real-time social support may promote continuous abstinence align with a wealth of previous work³⁵, and are consistent with recent findings of Shuter et al.³⁶.

We trained one peer navigator who identified as female and had previous experience working in healthcare as a nursing assistant; thus, she may have had more well-developed communication skills. To our knowledge, this is the first study to qualitatively examine the acceptability of cross-training HIV clinic peer navigators to provide smoking cessation counseling and social support for quitting.

CONCLUSIONS

The findings of this study are promising as this qualitative data demonstrates that cross-training and utilizing PNs in smoking cessation programs for PWH who smoke appears to be highly acceptable by clinic patients who express interest in smoking cessation. The data suggest that the PN provided social support and education that was salient. Consistent with the underlying theory, the guidance, advice, and support from the PN were perceived as authentic and impactful, increasing self-efficacy for quitting. Training peer navigators in HIV care clinics to offer social support for smoking cessation could be a cost-effective way to leverage an underutilized clinical resource and enhance smoking cessation outcomes for this population. However, a future clinical trial would be needed to test whether social support and accountability do, in fact, act as mechanisms of action for PN and whether sex- or gender-identity-matching does not, in fact, affect responses to PN.