Tobacco use has emerged as a major problem in the PLWH population, and efforts to confront it have met with significant challenges. Understandably, the literature and research in this area have focused on PLWH who actively smoke cigarettes. Building a profile of PLWH ex-smokers, especially long-term ex-smokers, has importance because a primary goal of tobacco control measures targeting PLWH is to convert as many current smokers as possible into long-term ex-smokers. We established a very rigorous definition of “long-term ex-smokers” in this study since in the general population there is a significant relapse rate in the early years, especially between the second and third year, that drops gradually over time. ¹⁵ Although we required at least 5 years smoke-free to enroll, our ex-smoker sample had quit a mean of 16.4 years prior to the study and, thus, had most likely quit for life. A clearer understanding of what a successful PLWH ex-smoker “looks like” may help to guide intervention development and better assist PLWH trying to change their smoking behaviors.

There is a marked disparity in the proportion of never smokers in the PLWH community as compared to the US adult population as a whole. The vast majority of PLWH smokers began smoking cigarettes prior to their HIV diagnoses. There is little doubt that multiple factors act individually or in concert to promote smoking initiation as well as HIV acquisition. However, many individuals subjected to these influences manage to completely avoid tobacco use. A better understanding of the factors that induce young adults at risk for HIV infection to avoid tobacco use could prove useful in promoting smoke-free living at the young ages during which smoking prevention is so critical.

A startling finding of our study was the significant rate of non-cigarette tobacco use in both never-(cigarette) smokers and long-term ex-(cigarette) smokers. These individuals would likely be classified as non-tobacco users on cursory screening in clinic, but 7.8% reported the current use of cigars, cigarillos, pipes, hookahs, blunts, and/or chewing tobacco. We repeated all analyses excluding participants who admitted to other tobacco product use, and there were no appreciable changes to the findings that we observed. These statistics highlight the need for comprehensive screening for non-cigarette tobacco and nicotine product use in all PLWH.

Given the reality that every study participant was either a never smoker or a long-term ex-smoker, it is not surprising that almost all of them expressed high levels of confidence in their ability to resist smoking temptations in a variety of situations. It is interesting that within both categories of non-smokers, the setting that was most tempting was in a bar while having a drink.

We are not aware of prior research investigating family and household smoking histories in PLWH. As noted in Table 2, never smokers were significantly less likely than ex-smokers to grow up with nuclear family members who smoked cigarettes. These differences were significant for mothers, both parents in the aggregate, and siblings. Our finding of transgenerational smoking patterns is consistent with observations made in the general population. ²³ At the time of the study interview, never smokers were significantly more likely than ex-smokers to live in non-smoking households. Half of ex-smokers were living with another smoker at the time that they quit for good, and 36.1% of them were living with a smoker at the time of the study interview. These findings suggest that never smokers may preferentially assort with non-smokers as domestic/housing partners.

In addition to contributing to the corpus of knowledge relating to tobacco use behaviors in PLWH, our findings may have practical value to those caring for PLWH non-smokers and smokers. It is clear that screening for tobacco use should not be limited to questions about cigarettes since a surprisingly large minority of PLWH non-smokers use other tobacco products. We are not aware of any prior research delineating the multigenerational nature of tobacco use in PLWH and their families. This should be acknowledged in behavioral interventions and is worthy of future scientific inquiry. The temptation of long-term ex-smokers and even never smokers to smoke in social situations involving alcohol is interesting and suggests that abstinence counseling should advise PLWH to anticipate and perhaps avoid such high-risk situations. Finally, the frequency that long-term ex-smokers and never smokers share living space with current smokers is important for several reasons: (1) these “low-risk” individuals may still incur the significant health risks associated with second-hand smoke, (2) counseling should provide practical advice about maintaining abstinence in a home where cigarette smoking occurs, and (3) the myth that “it is impossible to quit” if there are other smokers in the home needs to be dispelled.

Our study had limitations that require mention. All participants were recruited from a single center in the Bronx, and they may not be representative of PLWH in other geographic areas. Although a number of prior studies have characterized PLWH smokers, our sample does not include a contemporaneous group of current smokers for comparison, and this may limit the ability to contextualize some of the findings. Our sample size was small, creating the possibility that some important associations were undetected and precluding us from completing more sophisticated, multivariate analyses. We employed an ECO definition for non-smoker (<10 ppm) that accorded with expert guidance at the time that the study was conceived, ²⁴ but this cut point has been lowered in the most recent guidelines. ²⁵ However, the authors of those guidelines do note that non-smokers commonly have ECO values up to 8 ppm in industrialized urban centers, and 94% of our sample had ECO levels below this lower cut point.

This study is the first to carefully characterize the clinical, sociodemographic, and behavioral profiles of PLWH who do not smoke cigarettes. As tobacco use continues to be the leading killer of PLWH in the US, and as effective measures to control the rampant tobacco use in this population remain elusive, ²⁶ a more thorough understanding of the factors that drive tobacco use and non-use in the PLWH community may be helpful in guiding practice and policy in the future.