University of South Florida Scholar Commons Graduate Teses and Dissertations Graduate School 6-28-2016 Smoking Among Youth Living with HIV: Te Intersection of Behavioral Health and Chronic Disease Todd Wells University of South Florida, Smoking Among Youth Living with HIV: The Intersection of Behavioral Health and Chronic Disease by Todd Wells A dissertation submitted in partial fulfillment of the requirements for the degree of Doctor of Philosophy Community and Family Health College of Public Health University of South Florida Co-Major Professor: Oliver T. Massey, Ph.D. Co-Major Professor: Julie Baldwin, Ph.D. Patricia Emmanuel, M.D. Julianne Serovich, Ph.D. Dinorah Martinez Tyson, Ph.D. Date of Approval: July 8, 2016 Keywords: HIV/AIDS, youth, adolescents, young adults, tobacco, smoking, cessation, computers Copyright © 2016, Todd Wells Dedication I would like to dedicate this dissertation to my uncle A.G. He lost his life to complications related to HIV/AIDS during my formative years, which was a great loss for my family. Technological advances have provided the opportunity for persons with HIV to live longer lives; let us all strive to extend them even longer. Acknowledgements I thank the members of my doctoral supervisory committee, colleagues and friends who have provided me with their time, guidance and expertise through this, the final stage of my academic training. In addition, I would like to thank my wife Estela and our sons: Justin, Noah and Trevor for walking this long journey with me. Special thanks to: Dr. Tom Massey for guiding me through both my master’s and doctoral degrees, Dr. Julie Baldwin for her unwavering support and belief in me, Drs. Julianne Serovich & Judy Kimberly for helping to further develop my skills as a facilitator and investigator, Dr. Dinorah Martinez Tyson for her expertise in qualitative methodology and analysis and Dr. Patricia Emmanuel for her early insight and continued contributions to my development as a researcher and professional. Table of Contents List of Tables ..................................................................................................................... iii List of Figures .................................................................................................................... iv Abstract ................................................................................................................................v Chapter One: Introduction ...................................................................................................1 Smoking Among Youth ...........................................................................................2 Significance to Public Health ...................................................................................2 Purpose of Dissertation ............................................................................................4 Chapter Two: Background and Review of the Literature ....................................................7 Introduction ..............................................................................................................7 Developmental Aspects of Smoking ........................................................................9 Internal and Environmental Factors That Contribute to Smoking .........................11 Mental Health Correlates of Smoking ...................................................................12 Factors Associated with Smoking Cessation .........................................................14 Smoking Among Persons Living with HIV ...........................................................18 Biological Impact of Smoking on PLWH ..............................................................20 Smoking Cessation for PLWH who Smoke ...........................................................22 Current Policy Statements Regarding Smoking Amongst PLWH ........................24 Public Health Significance of Smoking Cessation Programs for YLWH .............26 Theoretical Orientation for Dissertation ................................................................29 Transactional Model of Stress and Coping in Practice ..............................33 Why is TMSC a Good Fit? ....................................................................................35 Chapter Three: Methods and Results from Component One .............................................39 Research Methodology ..........................................................................................39 Research Questions ....................................................................................39 Inclusion and Exclusion Criteria ................................................................40 Study Identification Procedures .............................................................................41 Process of Inclusion of Studies ..................................................................42 Results ....................................................................................................................42 Program Focus ...........................................................................................43 Theoretical Frameworks ............................................................................45 Association of Findings to Research Questions .........................................46 Summary of Component One ....................................................................48 Chapter Four: Methods and Findings from Component Two ............................................49 Introduction ............................................................................................................49 Research Methodology ..........................................................................................49 Overview of Participants and Eligibility ....................................................50 Recruitment Methods .................................................................................51 Procedures ..................................................................................................52 i Incorporation of Theoretical Orientation ...................................................52 Data Analysis .........................................................................................................56 Qualitative Analysis ...................................................................................59 Results from Component Two ...............................................................................59 Sample ........................................................................................................59 Perceived Susceptibility .............................................................................63 Perceived Severity .....................................................................................63 Coping Strategies .......................................................................................66 Stress and Coping ......................................................................................69 Disengaging Strategies ...............................................................................70 Engaging Strategies ...................................................................................72 Media/Peer Messages and Stress ...............................................................73 Interest in Cessation ...................................................................................74 Barriers to Cessation ..................................................................................74 Alternative Activities to Smoking .............................................................78 Who Can Help with Cessation? .................................................................80 Chapter Five: Discussion ...................................................................................................82 Introduction ............................................................................................................82 Summary of Study .................................................................................................82 Discussion of Findings ...........................................................................................83 Trajectory of Smoking ...............................................................................86 Perceived Susceptibility .............................................................................87 Role of Stress in Smoking .........................................................................89 Preferences in Cessation Programs ............................................................90 Barriers to Cessation Program ...................................................................90 Strategies Used ...........................................................................................90 Second-Hand Smoke ..................................................................................91 Implications for Public Health and Clinical Practice .............................................92 Directions for Future Research Studies .................................................................93 Implications for Development of a Smoking Cessation Program .........................94 Strengths and Limitations ......................................................................................94 References ..........................................................................................................................97 Appendices .......................................................................................................................126 Appendix A: IRB Approval Letter ......................................................................126 Appendix B: Search Strategy Overview ..............................................................129 Appendix C: Summary of Findings from Systematic Literature Review ............130 Appendix D: Pediatric Infectious Disease Letter of Support ..............................132 Appendix E: Interview Guide ..............................................................................133 Appendix F: Interview Guide (Former Smoker) .................................................137 Appendix G: Recruitment Flyer ...........................................................................141 Appendix H: Demographic Capture Sheet ..........................................................142 Appendix I: List of Codes Used to Identify Constructs During Analysis ...........144 Appendix J: Participant Interview Run Times .....................................................145 Appendix K: Resource List ..................................................................................146 Appendix L: Payment Log ...................................................................................149 ii List of Tables Table 1. Constructs of Transactional Model of Stress and Coping ...............................32 Table 2. Research Questions in Relation to Theoretical Orientation .............................54 Table 3. Constructs of Transactional Model of Stress and Coping ...............................55 Table 4. Study Demographics ........................................................................................60 Table 5. Interview and Participant Characteristics ........................................................61 Table 6. Participant Identification Key ..........................................................................61 iii List of Figures Figure 1. Primary Objectives & Research Questions ........................................................6 Figure 2. Process of Study Identification ........................................................................43 iv Abstract Smoking amongst youth living with HIV (YLWH) has major public health implications. When combined with the complications associated with smoking such as chronic obstructive pulmonary disorder (COPD) or heart disease, the impact of a HIV positive diagnosis increases morbidity exponentially (Nahvi & Cooperman, 2009). The purpose of this study was two-fold, to investigate the perceptions of smoking amongst YLWH aged 18-25 who received care at the CMS Clinic located at the University of South Florida and to determine factors related to cessation. A study design utilizing two components, a systematic literature review and primary qualitative data was used in this dissertation. The systematic literature review was used to identify and examine published research studies that compared smoking cessation interventions for youth and young adults. Twenty-five in depth interviews were conducted in order to determine themes related to smoking cessation and the factors associated with the experience of smoking. v Chapter One Introduction Modes of HIV transmission include perinatal and behavioral transmission. Perinatal transmission is the transmission of HIV from mother to child during vaginal birth. Behavioral transmission is transmission through high-risk behaviors such as intravenous drug use and unprotected sexual contact. HIV surveillance data indicate that less than 300 children a year are born with HIV, while the existing population of 8,500 perinatally acquired HIV children are under 19 and approaching adulthood (CDC, 2004). These data indicate that behaviorally acquired HIV positive youth represent the major share of adolescents and young adults that are infected with HIV. As behaviorally acquired HIV positive youth begin to age out of pediatric care, they face new psychosocial and behavioral challenges, including how to treat tobacco dependence. The etiology of smoking has its origins in multiple factors and continues to be a pervasive public health problem. While national rates of smoking continue to decline, the prevalence of smoking among several micro-populations, such as YLWH, continues to rise. Development of smoking cessation programs for YLWH has important implications including reducing morbidity and mortality among YLWH as well as reducing the long term costs associated with care for YLWH. The landscape of preventative medicine and evidenced based interventions designed to treat YLWH must adapt and consider solutions that are sensitive to their unique needs. Issues such as the biological impact of smoking and ability to tolerate pharmaceutical-based cessation 1