The Tobacco Use Reduction in People Living with HIV Project (TURP) was initiated in 2015 by the Michigan Department of Health & Human Services' Tobacco Section. The program was developed to encourage Ryan White HIV/AIDS Program (RWHAP) clients to abstain from or reduce their use of tobacco products to improve their health and well-being. Tobacco cessation services were integrated into the clinical care delivered at various AIDS Service Organizations (ASOs), and also offered outside of regularly scheduled medical appointments, such as during support groups and educational classes. The percentage of people with HIV who reported using tobacco products saw a statistically significant reduction from 2015 to 2017.
MI
A needs assessment of people with HIV in Michigan found that nearly 50% smoke cigarettes, compared to the overall state average of 18.9%.1 Among people receiving routine HIV care including antiretroviral therapy (ART), those with HIV who are also smokers lose more life-years to smoking-related illness than to HIV-related complications.2 Many tobacco users still try to quit “cold turkey,” which has a much lower success rate than quit attempts that use medications and/or counseling. TURP services were initiated in 2015 and will continue to operate through 2025 to address tobacco use and include tobacco cessation medications, client education, and support services.
Tobacco dependence treatment was incorporated into ASOs’ existing workflow with clients. Using the 5A’s intervention (i.e., Ask, Advise, Assess, Assist, Arrange) based on the clinical practice guidelines for tobacco dependence treatment, clients are screened for tobacco use status when they receive RWHAP medical and case management services, and referred to additional tobacco dependence treatment services if interested. Clients in the pre-contemplation stage (not yet considering quitting) can engage in these services later when they are ready. Through the Michigan AIDS Drug Assistance Program (ADAP), TURP offers all seven FDA-approved medications for treatment of tobacco dependence.
In addition to access to medications, ASOs offer support groups for clients either thinking about quitting tobacco or actively in the process of reducing their tobacco use. Groups are offered virtually and in-person depending on resources and demand. Some of these groups support members of the community who may feel underrepresented in traditional tobacco cessation support groups, such as a Black Women’s Tobacco Cessation Group for Women with HIV. ASOs also provide information and referrals to the Michigan Tobacco Quitlink, a free online coaching program that offers information and materials to assist in tobacco reduction and cessation efforts.
ASOs participating in TURP received funding to create their own marketing messages to advertise their tobacco treatment services and encourage RWHAP clients to use them. These promotional campaigns were informed by client focus groups conducted by TURP staff to better understand the types of messaging that would reach RWHAP clients. TURP also created two informational videos to motivate people to reduce tobacco use.
TURP began with staff education around the risks associated with tobacco use and how cessation efforts would benefit their clients’ overall health. Additionally, TURP worked to train staff at each ASO on tobacco dependence treatment and help them to obtain their Tobacco Treatment Specialist certification. TURP also encouraged the establishment of tobacco-free campus policies to create a supportive environment for clients and staff trying to quit or reduce their tobacco use. In the beginning of the program, only seven agencies had a tobacco free campus policy; by 2022, all 19 funded agencies had tobacco free campus policies.
An evaluation of TURP was conducted using client surveys during three time periods (2015 [baseline], 2017, and 2021) to examine clients’ use of tobacco, the number of quit attempts, and the types of tobacco cessation methods they used. The survey’s question on “smoking” status was updated to “tobacco use” in 2021 to reflect the growing trend of the use of e-cigarettes and other electronic nicotine delivery systems.
| Category | Information |
|---|---|
| Evaluation data | Client self-report surveys (2015, 2017, and 2021) |
| Measures |
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| Results |
* statistically significant |
Source: Shamo F, Macomber K, et al. The effect of a tobacco use reduction program on the prevalence of smoking and tobacco use and quitting behavior among people living with HIV/AIDS in Michigan. Prev Chronic Dis; 2024;21.
Small staff with tobacco/HIV experience. The TURP program was administered by a small team created out of the Michigan Department of Health & Human Services’ Tobacco Section. The team included at least one full-time consultant with previous experience providing tobacco treatment services for people with HIV, and at least one full-time evaluator/data analyst. There were additional staff for different parts of the evaluation period, at its peak employing three full-time consultants and one full-time evaluator/data analyst.
TURP staff and ASO staff training. All TURP and ASO tobacco dependence treatment staff were trained in the importance of tobacco cessation, as well as motivational interviewing, and the health effects of tobacco use on people with HIV. ASO staff were provided additional training on trauma-informed care, health equity, social justice, addressing implicit bias, and racial equity.
Regular client and outcomes monitoring. RWHAP clients’ use of tobacco treatment services were tracked via CAREWare, and funded agencies provided quarterly reports that reflected what services were provided and total units of service. Additionally, TURP conducted client surveys to track the percentage of clients accessing services, the types of services being utilized, and the percentage of clients who used tobacco.
Client engagement. TURP regularly engaged clients through client surveys, focus groups, and key informant interviews. Data collected was used to inform marketing messages, services offered, and evaluation methods.
TURP is currently supported by RWHAP Part B and the Michigan ADAP (2015 – 2025). Although TURP will no longer be funded after fiscal year 2025, all ASOs will continue to screen clients for tobacco use, engage clients about tobacco dependence treatment, and refer clients to coaching and counseling through the Michigan Tobacco Quitlink. Due to a lack of staff dedicated to tobacco dependence treatment, ASOs will transition from the 5As intervention approach (i.e., Ask, Advise, Assess, Assist, Arrange) to the Ask, Advise, Refer (AAR) method to assist clients in accessing services. Tobacco-free campus policies and tobacco screening policies will remain in place for all agencies.
- The project began with 16 participating ASOs but expanded to 19 ASOs by 2022. ASOs participating in TURP included health center and hospital clinics and community-based organizations, showcasing the adaptability of the intervention in a variety of settings, locations, and service populations.
- Based on client interviews and focus groups, many RWHAP clients who use tobacco indicated they also use other substances, such as alcohol, marijuana, and pain medications, to cope with daily stressors. Therefore, it was recommended providers ensure that they include referrals and treatment for other substances as well.
- Messages about the dangers of tobacco use may be less effective for individuals facing multiple chronic health conditions and challenging life circumstances who may see tobacco-related health consequences as the least of their concerns.
- Tracking all tobacco use (including e-cigarettes and other electronic nicotine delivery systems) instead of just cigarettes or leaf tobacco is essential in the ever-changing landscape of nicotine delivery systems.
- Data & Statistics About Tobacco in Michigan. Tobacco Use Reduction Program (TURP) for People Living with HIV Program Results and Evaluation Activities.
- Helleberg M, Afzal S, Kronborg G, Larsen C, Pedersen G, Pedersen C, Gerstoft J, Nordestgaard B, Obel N. Mortality attributable to smoking among HIV-1–Infected individuals: A nationwide, population-based cohort study. Clin Infect Dis 2013; 56: 5: 727–34. doi: 10.1093/cid/cis933
