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Smoking and life expectancy among HIV-infected individuals on antiretroviral therapy in Europe and North America

Helleberg, Mariea,b; May, Margaret T.c; Ingle, Suzanne M.c; Dabis, Francoisd; Reiss, Petere; Fätkenheuer, Gerdf; Costagliola, Dominiqueg,h; d’Arminio, Antonellai; Cavassini, Matthiasj; Smith, Colettek; Justice, Amy C.l,m; Gill, Johnn; Sterne, Jonathan A.C.c; Obel, Nielsa,b

doi: 10.1097/QAD.0000000000000540
Epidemiology and Social

Background: Cardiovascular disease and non-AIDS malignancies have become major causes of death among HIV-infected individuals. The relative impact of lifestyle and HIV-related factors are debated.

Methods: We estimated associations of smoking with mortality more than 1 year after antiretroviral therapy (ART) initiation among HIV-infected individuals enrolled in European and North American cohorts. IDUs were excluded. Causes of death were assigned using standardized procedures. We used abridged life tables to estimate life expectancies. Life-years lost to HIV were estimated by comparison with the French background population.

Results: Among 17 995 HIV-infected individuals followed for 79 760 person-years, the proportion of smokers was 60%. The mortality rate ratio (MRR) comparing smokers with nonsmokers was 1.94 [95% confidence interval (95% CI) 1.56–2.41]. The MRRs comparing current and previous smokers with never smokers were 1.70 (95% CI 1.23–2.34) and 0.92 (95% CI 0.64–1.34), respectively. Smokers had substantially higher mortality from cardiovascular disease, non-AIDS malignancies than nonsmokers [MRR 6.28 (95% CI 2.19–18.0) and 2.67 (95% CI 1.60–4.46), respectively]. Among 35-year-old HIV-infected men, the loss of life-years associated with smoking and HIV was 7.9 (95% CI 7.1–8.7) and 5.9 (95% CI 4.9–6.9), respectively. The life expectancy of virally suppressed, never-smokers was 43.5 years (95% CI 41.7–45.3), compared with 44.4 years among 35-year-old men in the background population. Excess MRRs/1000 person-years associated with smoking increased from 0.6 (95% CI –1.3 to 2.6) at age 35 to 43.6 (95% CI 37.9–49.3) at age at least 65 years.

Conclusion: Well treated HIV-infected individuals may lose more life years through smoking than through HIV. Excess mortality associated with smoking increases markedly with age. Therefore, increases in smoking-related mortality can be expected as the treated HIV-infected population ages. Interventions for smoking cessation should be prioritized.

aDepartment of Infectious Diseases, Copenhagen University Hospital, Rigshospitalet

bFaculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark

cSchool of Social and Community Medicine, University of Bristol, Bristol, UK

dUniversité Bordeaux, ISPED, Centre INSERM U897-Epidémiologie-Biostatistique, Bordeaux, France

eDepartment of Global Health, Academisch Medisch Centrum bij de Universiteit van Amsterdam, and Stichting HIV Monitoring, Amsterdam, The Netherlands

fDepartment of Internal Medicine, University of Cologne and German Centre for Infection Research (DZIF), Cologne, Germany

gSorbonne Universités, UPMC Univ Paris 06

hINSERM, UMR_S 1136, Institut Pierre Louis d’Epidémiologie et de Santé Publique, Paris, France

iClinic of Infectious Diseases & Tropical Medicine, San Paolo Hospital, University of Milan, Milan, Italy

jService des maladies infectieuses, CHUV, Lausanne, Switzerland

kResearch Department of Infection and Population Health, University College London, London, UK

lYale University, New Haven

mVA Connecticut Healthcare System, West Haven, Connecticut, USA

nDivision of Infectious Diseases, University of Calgary, Calgary, Alberta, Canada.

Correspondence to Marie Helleberg, Department of Infectious Diseases, Copenhagen University Hospital, Rigshospitalet. Blegdamsvej 9, 2100 Copenhagen Ö, Denmark. E-mail:

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This is an open access article distributed under the Creative Commons Attribution License 4.0, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Received August 4, 2014

Received in revised form October 17, 2014

Accepted November 3, 2014

© 2015 Lippincott Williams & Wilkins, Inc.