Similar to the experience in Western countries 10 years ago, with the advent of effective and accessible ART in Kenya, ⁷ cigarette smoking in Kenyan PLWH is poised to emerge as a leading killer in this group. Developing effective smoking cessation interventions for PLWH has been a challenge, ³¹ and it is reasonable to expect that getting established PLWH smokers to quit in Kenya will be difficult as well. In order to create a culturally appropriate cessation strategy in a new target population, one must begin by understanding the social and behavioral milieus of their tobacco use and how they may differ from those of other smoking populations. Accomplishing this task often relies upon the examination of aggregate statistics, for example, national reports, and the performance of thoughtfully constructed structured interviews and focus groups in subsets of the target population. In the process of developing a cessation intervention for PLWH smokers in Kenya, we have done both. Herein we report the results of a structured interview on cigarette smoking behaviors and beliefs conducted in a group of 50 PLWH smokers in Kenya.

Our participant sample had a mean age of 38.5 and was predominantly male, similar to the gender pattern of smoking in the nation as a whole.^2,9,10 The mean daily cigarette consumption of 14.9 is higher than the national average of 8 cigarettes per day. ² It is notable that all of our participants purchased their cigarettes as single sticks and not as packs. This may be a strategy to lessen the financial burden of smoking (a pack of cigarettes costs approximately 140 KES/1.20 USD, and the cost of a single stick ranges from 5-25 KES/0.05-.23 USD), and it may reduce the impact of package-based tobacco warnings. It is likely that the heavy representation of persons in methadone maintenance contributed to the relatively high cigarette consumption rate and the cigarette purchasing behaviors of our sample. Both nicotine dependence levels and motivation to quit were high in our sample. Similar to the national surveys, dual tobacco use was uncommon, and there was little use of medications to assist quit attempts.^2,9,10 Our participants had relatively low educational attainment and high levels of past or present alcohol and drug use. They reported low levels of smoking-related comorbidities, although 36% of them had had tuberculosis.

The locus of control measure assessed our participants’ perception of factors contributing to their involvement with smoking. The scale permits the separate evaluation of intrapersonal (control resides within the participant), interpersonal (control resides with other individuals), and fate (smoking and quitting are outside of human control). Higher intrapersonal locus of control beliefs predicts better health-related behavior outcomes. ³² Our observation that locus of control scores were equivalent across the intrapersonal, interpersonal, and fate domains suggests that a counseling intervention should try to strengthen the belief that a smoker is the ultimate decisor of his/her tobacco use, and not others or fate. Intrinsic and extrinsic motivations to quit are important predictors of successful cessation, and higher levels of intrinsic vs extrinsic motivation are predictive of better cessation outcomes. ²¹ Our participants’ significant tilt toward intrinsic motivation suggests that they may be more amenable to cessation interventions. Their significant self-conceptual identification with the abstainer persona over the smoker persona is also a favorable predictor of successful quitting. ²²

Anxiety and depression both play important roles in cigarette smoking. ³³ The rates of anxiety and depression that we observed were much lower than the 61.7% and 73.3% rates reported in a US sample of PLWH smokers. ³⁴ The interactions of psychiatric illness with HIV, tobacco use, other substance use, and poverty are complex and multilayered, and assumptions about anxiety and depression derived from data in the US are not necessarily applicable to sub-Saharan Africa ³⁵ or other areas of the world. The relationship of anxiety and depression to tobacco use in Kenya is beyond the scope of this project, but it is a worthy topic for future research. Although coping with chronic pain is an important driver of tobacco use in certain populations, ³⁶ only about a quarter of our sample reported severe pain in the past 7 days.

In accordance with the national sample surveyed by the International Tobacco Control (ITC) Project, ² we observed near universal recognition of the health harms of cigarette smoking and significant concern over the damage that smoking could do to themselves and to those around them. In contrast to the ITC report, a large majority of our participants were concerned with the financial costs of their smoking. The leading causes of stress identified by our participants were financial and job-related. In comparison to other groups that we have studied in the United States, ³⁷ our participants did not minimize their risk of suffering serious health consequences of smoking, including death, when they compared themselves to other patients in their clinics.

Slightly more than half of participants reported that their primary health care providers had discussed smoking cessation with them, but few offered them any sort of cessation assistance. The government of Kenya has been a leader in promoting tobacco control throughout the nation. Further measures may be indicated to better recruit health care professionals into this effort and to put more cessation resources at their disposal.

Finally, we found high levels of spiritual well-being in our participants. Despite the enormous socioeconomic and health challenges that they faced, they scored high on self-assessments of meaning, peace, and faith. For those who are counseling such individuals to quit, this may provide a source of strength and resolve to smokers trying to overcome their addiction to cigarettes.

Our study had several weaknesses that require mention. The sample size was small and inferences from a group of this size should be interpreted with caution. Participants were recruited from several care centers, but all within Nairobi. They may not be representative of Kenyan PLWH from other locales or from non-urban areas. The majority of our sample was in methadone maintenance. This likely contributed to the larger proportion of women in the group than would be expected from national cigarette smoking statistics. Although substance use is common in cigarette smokers and vice versa, our findings may not be fully generalizable to a non-substance-using PLWH population. Finally, the data collection methodology, that is, direct questioning by study staff, introduces concern for social desirability bias and likely accounts, in part, for the extremely high interest in quitting reported by our participants.