The first goal of this study with Brazilian PLWH was to assess differences between smoking status within a context of demographic, behavioral and cognitive factors. Second, we sought to assess if SHS is pervasive in environments surrounding PLWH. Third, we assessed if sexual orientation was associated with either smoking or SHS environments.
In our sample, 39.0% of participants were current smokers and 28.8% were previous smokers. Of the men, 45.1% were current smokers; of the women, 31.5% were current smokers. This proportion is about twice the smoking rates seen in the general Brazilian population (8% - 20%). The U.S. experience with PLWH also reveals high smoking rates (37.9% - 59.0%) [3,23,38]. One study in Spain recorded PLWH smoking prevalence at a staggering 63.9% . Another study sampled PLWH from 33 countries and identified a smoking prevalence of 40.5% . High smoking rates with PLWH seem to be global phenomena and their smoking rates are double or triple compared to the smoking rates in the general population. The question that arises is, why would the HIV infected community tend to smoke tobacco at these higher rates?
According to one of our models (Table 5a), lower education level is the major factor that predicts ever-smoking, when controlling for age, ethnicity, work status, sex, and four cognitions. Current smokers had the least education, and those who had never smoked had higher education levels, proportionately. Low education attainment often correlates with low income, and is supported by research [3,16,19,38]. Though our results confirm other studies that implicated low education levels, it does not confirm studies citing lower income as a factor. Furthermore, even though lower education predicted ever-smoking, current smokers also had a high level of knowledge concerning the consequences of smoking tobacco. This suggests that they have been targeted before with anti-smoking campaigns or counseled to quit, and that they have paid attention. This raises optimism that even if one endures a poor quality educational experience (fixed factor), one still may retain an alert intellect (plastic factor).
According to our other model (Table 5b), attitude predicts current smoking status when controlling for sex, age, ethnicity, work status, education and three other cognitions. Interestingly, a health oriented attitude toward smoking leads to a higher likelihood of smoking. We found that female PLWH displayed significantly more positive attitudes than their male counterparts. This finding is similar to a Jordanian study that reveals that women discerned and expressed more proactive public health attitudes (both smokers and non smokers) than their male counterparts . However, this conclusion seems to contradict differences shown in Table 3, that is, non smokers and previous smokers showed better attitudes than current smokers (a finding supported by other research ). Nonetheless, the logistic regression analysis (Table 5b) is the standard for interpretation purposes because it controls for possible confounders. For instance, it is reasonable to expect that previous smokers have more positive health related attitudes than current smokers. Yet when age is taken into account (on average previous smokers are older) the attitude index shifts to favor current smokers. Coincidentally, we observed that current smokers are more knowledgeable about smoking hazards than previous smokers, and that knowledge significantly correlated with attitudes.
Is there anything in common between the two models? Interestingly, sex robustly stayed in both models after eight regression iterations. In both models, women were more likely to either show a history of smoking (Table 5a) or to be current smokers (Table 5b). Our analysis indicates that HIV infected women are 75% more likely to be current smokers than HIV infected men, though this was a marginally significant (.05 < p < .10) factor in predicting current smoking.
A new question arises, why would women impart a greater tendency for a poor health behavior more so than men? We offer two ideas and both ideas connect to one’s attitude, as if attitude mediates between smoking and another third factor. Recall from our study that female PLWH were more likely to be current smokers compared to male PLWH, despite having better attitudes toward smoking regulation. The first idea comes from the view that women are more likely to be the caregiver of the family, caring for both household individuals and the well-being of others [41,43]. This idea also advances the notion that women are more connected to the wider community. Weisberg et al. mentioned that women display more compassionate qualities, including investing emotionally and having traits of warmth and empathy, in comparison to their male counterparts. These researchers suggest that men have an independent self-construal quality, meaning that their sense of self is separate from others. While women can be described as interdependent. Women find a sense of self by including all others in their community . This could explain why women in our study displayed higher scores on the attitude scale- it shows that they are willing to protect others from harm.
The second idea comes from the notion that, in our data, positive attitudes significantly correlated with stress (Table 2). The stress index was constructed by one’s perception of social, household, and health related stressors. Therefore, a positive attitude may be a mediator between stress and smoking. We found a significant difference between men and women in stress scores; female PLWH expressed higher levels of stress compared to male PLWH. This could help explain why in our study stress influenced the likelihood of women to become smokers [44-45].
The field of HIV/AIDS stigma may further shed light on stress. Stigma explains why PLWH have worse morbidity and mortality outcomes due to avoidance of, or irregular access to, treatment. Stigma may explain why PLWH do not reveal their HIV status to partners, or why they are more likely to avoid social contact . Cardona-Garzón and colleagues found that about half (50.7%) of their sample of Colombian PLWH reported stigma. Furthermore, infected women were nearly 2½ times more likely to experience stigma than men. They revealed a trend whereby lower educated PLWH experienced more stigma, as well as those without work, but these latter findings were not significant . Therefore, the reason why HIV infected women are more likely to be current smokers may be because of the increasing impacts of stigma that they endure. In addition, in a Latin American country such as Brazil, this social pressure may be further exacerbated because of machismo . Indeed, HIV infected women in this study may experience stigma from multiple sources (disproportionate wage earnings, disproportionate domestic violence, etc.).
We speculate that women in our study may use smoking as a way to self-medicate or self-soothe in order to cope with the added stress and stigma of being female and HIV infected. Kaplan et al. used focus groups to understand the association among perceived stress and poorer health related variables in disadvantaged communities. They concluded that participants engaged in riskier behaviors like smoking, substance abuse, and over-eating as a way to self-medicate, despite knowing these behaviors can lead to poorer health outcomes. Smoking was a common theme; several of their participants expressed using smoking as a way to mellow out or calm down, or as a coping mechanism in moments of stress, stigma and distress . This may explain why female PLWH smokers are less likely to attempt to quit smoking. Mamary and colleagues found that HIV infected women were half as likely to have made attempts at smoking cessation than HIV infected men .
To conclude with Goal 1, we advance three possible reasons why PLWH in Brazil smoke at a high rate: lower education level, more positive health attitudes, and female sex.
Regarding SHS (Goal 2), we found a clear, significant connection between current smoking and being exposed to SHS, although we cannot claim that SHS exposure causes smoking, or vice versa. Another Brazilian study found that a high proportion (85%) of current or former smokers were exposed to SHS at home or work . In addition, Humfleet and colleagues found that, of PLWH who smoke, 43.2% of their social support was also made up of smokers . A harm reduction model of removing environmental risks to SHS, or launching SHS awareness campaigns, may help reduce the rates of tobacco smoking in PLWH.
Concerning Goal 3, we found no association between sexual orientation and smoking status, nor with sexual orientation and SHS. Some research cites that sexual orientation is a factor influencing tobacco consumption, with LGBT orientations presenting more risk [22,33]. We uncovered only one other Brazilian study which examined possible connections between sexual orientation and smoking. Contrary to our results, Torres et al. found that a significantly higher proportion of homosexual men with HIV were more likely to be current smokers, compared to men who reported being heterosexual . Our sexual orientation proportions were 80.0% heterosexual (69% male, 94% female), 15.6% homosexual, 3.9% bisexual, and .5% transsexual; this distribution is unusual for Latin American PLWH populations. For example, Cardona-Garzón et al. reported in their Colombian HIV/AIDS sample that 39.1% were heterosexual and 50.9% homosexual . Interestingly, these authors show no association between stigma and sexual orientation, or number of years infected , corroborating our results. Another study done in the same Brazilian state as ours reported a 70.3% heterosexual and 24.1% homosexual proportion in a sample of people with HIV/AIDS . Our sexual orientation data trended more toward reports of heterosexuality which did not allow us to pinpoint smoking differences by orientation. This can be explained partly by having nearly half of our participants composed of women- most of whom were heterosexual.
Strengths & Limitations
One limitation incurred by our research are consequences of convenience sampling (either over or underestimation of the true estimate). Another limitation is the possibility of recall bias. A third limitation is that our attitude index did not register a high Cronbach alpha measure. However, our strengths include a high response rate (99.5%) to counter non-response bias. Furthermore, our demographic results, including smoking prevalence, match other studies with PLWH, lending validity through generalizability [27,51]. Lastly, research about the risks of smoking often relies on applying only one of two analysis strategies. One strategy is finding differences between participants who consume tobacco, currently, versus non smoking participants. The other strategy is finding differences between those with a history of smoking versus those who never smoked. In this study, we use both methods in order to better examine factors leading to tobacco consumption.