Jonathan Shuter, MD, professor in the division of infectious diseases, is an NIH-funded researcher who studies how to help HIV-positive patients stop smoking. In a recent study in Nairobi, Kenya, a combination of bupropion and a counseling program called Positively Smoke Free, one of the interventions he pioneered together with Alyson Moadel, PhD, helped 38.9 percent of patients quit smoking, as opposed to 6.6 percent in a control group. Here, he talks about how his work with HIV-positive patients has evolved over his career and his unconventional route to becoming a successful investigator.
![Jonathan Shuter, M.D.]()
Jonathan Shuter, M.D.
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“I saw my first HIV patient in Boston City Hospital in medical school in 1985. I came here in 1986 and New York was being overwhelmed. We had some amazing national leaders here at Montefiore Einstein including Gerald Friedland and Robert Klein. They were great role models, and this was a population that really needed help. So I was drawn to that.
At the beginning of the AIDS epidemic, things were completely bleak. All of our efforts were going toward palliating patients and making the transition to death as smooth as possible. All that changed at the end of 1995 when effective antiretroviral therapy first made its debut. The next five years were all about figuring out how to get patients to take their medicines. I was very involved in adherence research, and I started noticing that about 60 percent of my patients smoked.”
A shifting source of concern
“At that point, smoking was still condoned by the HIV care community. A patient's going to die of AIDS anyway, so why are we going to get on them about quitting smoking? By the early 2000s, that changed. We started seeing patients dying not from pneumonias and other HIV-associated infections, but lung cancer, heart attacks and strokes. That really struck me.
I had been collecting data regarding adherence to HIV medication regimens, and I started tracking whether patients were smokers or not. We found very tight correlations between cigarette smoking and medication non-adherence.
I didn't know anything about smoking cessation, but I connected with people here at Montefiore Einstein who are leaders in this area, including behavioral psychologist Alyson Moadel. We started small, got some funding, and developed Positively Smoke Free , which is really the heart of everything we do now. It’s an intensive behavioral smoking cessation intervention tailored for people with HIV. We did a lot of focus groups and spoke to a lot of HIV patients and many other experts to make sure it would resonate with this unique group.”
This is very personal to me. My goal is to get my patients to quit smoking, to save them from having heart attacks and strokes and getting lung cancer. If what we learn in the Bronx can get out there to the greater community and help people throughout the United States and the world, then that's fantastic.
Dr. Jonathan Shuter, professor of medicine, division of infectious diseases, and professor of epidemiology & population health
Know your audience
“The core of Positively Smoke-Free is eight sessions to help provide information, get people motivated to quit, give them strategies, anticipate high-risk situations likely to cause a relapse, and share long-term expectations about the benefits. And every single bit of it is saturated with HIV-specific material, which is one of the reasons behind its success.
We address the HIV population as a champion community as far as overcoming health-related challenges. You take your antiretrovirals to improve your health and this is one more important thing you can do. If you slip up once, all is not lost. That is like you missed one dose of your HIV medicine. But if you start smoking regularly again, that’s like you stopped your HIV medicines altogether. Those messages really hit home with patients.”
A local commitment yields global returns
“We’ve developed different iterations of Positively Smoke Free to help scale it. There is an online version, with or without a support community. It’s been offered in one-on-one settings. It's been offered in group therapy sessions. It's been offered by video, by Zoom chat. We have an app, and people in all 50 states can sign up for a study we’re doing in collaboration with the University of South Florida, in Tampa, and access Positively Smoke Free group therapy. In addition to the study in Nairobi, we also have studies in Chennai, India, and in Vietnam. We’ve had the intervention translated into Swahili, Telugu, Tamil, and Vietnamese.
Jonathan Shuter, MD, pictured second from right, and some of the team he works with in Nairobi, Kenya, on a study of the intervention he developed to help HIV-positive patients quit smoking.
I've had an atypical career for a researcher in that I’m mainly a clinician. But I had some background in research and biostatistics and data management. So I was always doing my own research and publishing, at first without funding or with small grants. It wound up being an advantage that I was immersed in the clinical world because with the time it takes to conduct and publish a study, what you read about HIV or any disease in the scientific literature always lags several years behind what you see in patients. I was able to keep my finger on the pulse of that literature and at the same time detect things in my day-to-day clinical practice that hadn't reached the attention of people who were primarily focused on writing grants and papers.
Now that I’ve been NIH funded since 2009, one of the secrets to my funding success is that I have never considered myself a success. I consider myself an abject failure. I still go to clinic, and my patients are still smoking. There’s rarely a time that I don’t have one of my own patients dying of lung cancer. This is very personal to me. My goal is to get my patients to quit smoking, to save them from having heart attacks and strokes and getting lung cancer. If what we learn in the Bronx can get out there to the greater community and help people throughout the United States and the world, then that's fantastic. It is crucial that research findings be disseminated and implemented. But on a day-to-day basis, I'm in a local battle here and that’s what really drives me.”
Posted on: Thursday, June 27, 2024