Integrating smoking cessation into HIV care settings: A systematic review and meta-analysis of effectiveness and the evidence gap in cost-effectiveness.

Clinical Snapshot

Key Findings

• P Value: Not explicitly reported in abstract; both CIs exclude the null (p <0.05 inferred for both)

• Effect Size: Pharmacological interventions: RR 1.86; Tailored intensive behavioural support: RR 1.34 (both vs. standard care)

• Primary Outcome: Smoking abstinence among PLWH following smoking cessation interventions integrated into HIV care settings

• Nnt Or Sensitivity: NNT not calculable from abstract data alone (baseline abstinence rate not reported); relative risk increase of 86% for pharmacotherapy and 34% for intensive behavioural support over standard care. No economic evaluations identified; cost-effectiveness data entirely absent from the literature.

• Confidence Interval: Pharmacological: 95% CI 1.42–2.45; Behavioural: 95% CI 1.05–1.71

Clinical Application

Pharmacological interventions (varenicline, NRT, bupropion) are feasible in HIV clinic settings with existing prescribing infrastructure. Tailored intensive behavioural support requires trained counsellors and sustained patient engagement, which may be resource-intensive. Integration into routine HIV care visits offers a pragmatic delivery model. Feasibility in LMICs is constrained by medication availability, cost, and healthcare workforce capacity. In Australia, PLWH represent a priority population for smoking cessation given their elevated cardiovascular and respiratory disease burden. Varenicline (Champix) was previously PBS-listed but was withdrawn from the Australian market in 2021 due to nitrosamine contamination concerns; its return to market should be monitored via TGA updates. NRT (patches, gum, lozenges) and bupropion remain PBS-subsidised (Section 85) for eligible patients. The RACGP's 'Supporting Smoking Cessation: A Guide for Health Professionals' (2021) supports opportunistic cessation counselling in primary care, which aligns with the review's findings on tailored behavioural support. Australian HIV clinics, often co-located with sexual health services, represent ideal integration points. The Quitline (13 7848) and digital cessation tools (QuitCoach) are accessible adjuncts. The TGA-approved cytisinicline (Cytisine) may offer a cost-effective pharmacological option warranting evaluation in PLWH. ASHM (Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine) guidelines do not currently include specific smoking cessation protocols for PLWH, representing a practice gap this evidence could help address. Adults living with HIV who are current smokers, particularly those engaged in HIV care in clinic or community settings. Evidence is strongest for HIC populations; emerging but limited evidence supports applicability in sub-Saharan African and Southeast Asian LMIC contexts.

Abstract

The prevalence of smoking among people living with HIV (PLWH) is higher than in the general population, and PLWH who smoke are at increased risk of both smoking- and HIV-related comorbidities. As most PLWH reside in low- and middle-income countries (LMICs), there is a need for effective and cost-effective smoking cessation interventions in resource-constrained settings. We systematically reviewed and meta-analyzed the effectiveness of smoking cessation interventions for PLWH and looked for economic evaluations. Four databases (PubMed, Cochrane, Scopus, Web of Science) were searched up to March 23rd, 2026. Interventional and quasi-experimental studies evaluating smoking cessation interventions for PLWH were included. Risk of bias was assessed using Cochrane's risk-of-bias tool for randomized studies and the Effective Public Healthcare Panacea Project tool for non-randomized studies. Thirty-two articles met the inclusion criteria. Most evidence originated from high-income countries, with three randomized controlled trials conducted in LMICs (Kenya, South Africa and Vietnam). No economic evaluations were identified. Smoking cessation interventions varied in type, duration, intensity, and mode of delivery. Overall, studies had low to moderate risk of bias. GRADE assessments indicated moderate-certainty evidence that pharmacological interventions (RR 1.86, 95% CI 1.42-2.45) and tailored, intensive behavioral support (RR 1.34, 95% CI 1.05-1.71) increase smoking abstinence compared with standard care. This review indicates that pharmacological and tailored, intensive behavioral support interventions can support smoking cessation among PLWH, including emerging evidence from LMICs, but the absence of economic evaluations limits guidance for resource-constrained settings. Future research should prioritise implementation strategies and economic evaluations to support scalable integration into routine HIV care. (PROSPERO Registration no: CRD42022313630).

References

1. 1.Nguyen, V. M., Hoang, T., Tozan, Y., Svensson, M., Van Hoang, M., & Ng, N. (2026). Integrating smoking cessation into HIV care settings: A systematic review and meta-analysis of effectiveness and the evidence gap in cost-effectiveness. PLOS ONE. https://doi.org/10.1371/journal.pone.0350040