Smoking and accelerated lung function decline in HIV-positive individuals: A secondary analysis of the START pulmonary substudy

David M. MacDonald, Anne C. Melzer, Gary Collins, Anchalee Avihingsanon, Kristina Crothers, Nicholas E Ingraham, Matti Ristola, Jonathan Shuter, Ken M. Kunisaki

Research output: Contribution to journalArticlepeer-review

9 Scopus citations


Background:Chronic obstructive pulmonary disease (COPD) is a leading cause of death and disability globally. Both cigarette smoking and HIV have been identified as independent risk factors for COPD. We used data from the strategic timing of antiretroviral treatment (START) Pulmonary Substudy to quantify the impact of smoking on rate of lung function decline in HIV.Methods:We included START Pulmonary Substudy participants who contributed at least 2 good quality spirometry measures during the study. Slope of forced expiratory volume in 1 second (FEV1) was estimated using a repeated-measures model adjusted for the treatment group (immediate vs deferred treatment arm of START), age, sex, race, baseline COPD, and region.Results:Of 1026 START Pulmonary Substudy participants, 915 (89%) were included in this analysis. Median follow-up time was 3.9 years. Smokers and nonsmokers were similar in baseline age (median 36 years), but smokers were more likely to be white, male, and from Europe/Israel/Australia. Smokers had faster average FEV1 decline compared with nonsmokers [-38.3 mL/yr vs -25.1 mL/yr; difference of -13.2 mL/yr (95% confidence interval: -23.6 to -2.7); P = 0.013], were more likely to meet criteria for rapid FEV1 decline [7.2%-11.7% more likely (P = 0.09-P = 0.002), depending on the definition of rapid decline], and had borderline, but not statistically significant, higher incident COPD during follow-up (9.7% vs 5.8%, P = 0.06).Conclusions:Compared to nonsmokers, HIV-positive smokers experience faster decline in lung function. These results underscore the need for a better understanding of how to best support smoking cessation among HIV-positive populations.

Original languageEnglish (US)
Pages (from-to)E85-E92
JournalJournal of Acquired Immune Deficiency Syndromes
Issue number3
StatePublished - 2018

Bibliographical note

Funding Information:
Supported by the National Heart Lung and Blood Institute (R01 HL096453); the parent START trial was primarily supported by the National Institute of Allergy and Infectious Diseases Division of AIDS (UM1 AI068641 and UM AI120197) with additional support from the German Ministry of Education and Research, the European AIDS Treatment Network (NEAT), the Australian National Health and Medical Research Council, and the UK Medical Research Council and National Institute for Health Research. The Veterans Health Administration Office of Research and Development also provided protected research time in support of this study. The University of Minnesota served as sponsor of the study. None of the funders nor sponsors had any input regarding the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. Study Drugs: Antiretroviral drugs were donated to the central drug repository by AbbVie, Bristol-Myers Squibb, Gilead Sciences, GlaxoSmithKline/ViiV Healthcare, Janssen Scientific Affairs, and Merck. St. George’s Respiratory Questionnaire for COPD: Permission for use granted to investigators by Dr. Paul Jones (St. George’s, University of London, London, United Kingdom).

Funding Information:
G.C., A.A., H.M., M.R., J.S., and K.M.K. received grant support from the National Institutes of Health (R01 HL096453, UM1 AI068641, and UM AI120197) for conduct of this study. K.M.K. has received consultancy fees from GlaxoSmithKline. The remaining authors have no funding or conflicts of interest to disclose.

Publisher Copyright:
© 2018 Wolters Kluwer Health, Inc. All rights reserved.


  • HIV
  • chronic obstructive
  • pulmonary disease
  • smoking
  • spirometry
  • tobacco


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