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Background <p>Smoking is an important driver of morbidity and mortality among people living with HIV (PLWH), with nicotine dependence complicating cessation efforts and worsening HIV-related outcomes. Although early smoking initiation is a known predictor of dependence in the general population, its specific influence on PLWH in sub-Saharan Africa remains unclear.</p> Methods <p>We conducted a cross-sectional study involving 393 PLWH receiving care at HIV clinics in Lagos, Nigeria. Participants provided sociodemographic, behavioral, and clinical information, including age at smoking initiation, use of marijuana, alcohol, waterpipe, and e-cigarettes, and HIV viral suppression status. Nicotine dependence was measured using the Fagerström Test for Nicotine Dependence (FTND). Associations were evaluated using bivariate analyses and regression with sensitivity analyses exploring dose–response patterns, product-specific effects, and potential effect modifications.</p> Results <p>Early initiators (&lt; 18&#xa0;years) were younger, more frequently female, less socioeconomically advantaged, and more likely to use marijuana, whereas late initiators (≥ 18&#xa0;years) were predominantly male and more socioeconomically stable. In unadjusted analyses, each additional year of delayed initiation was associated with a 1.25-point lower FTND score (β = –1.25; 95% CI –2.26 to –0.24; <i>p</i> = 0.016), and this association persisted after adjustment for sociodemographic factors (β = –1.18; 95% CI –2.20 to –0.16; <i>p</i> = 0.023). After full adjustment for behavioral and clinical covariates, the association was attenuated and was no longer statistically significant (β = –0.51; 95% CI –1.43 to 0.41; <i>p</i> = 0.271). Independent predictors of higher FTND scores included male sex, lack of viral suppression, and current cigarette use intensity. Sensitivity analyses supported a linear relationship between initiation age and FTND score among cigarette-only and dual users of cigarettes and waterpipes, but not among waterpipe-only users.</p> Conclusions <p>Early smoking initiation was associated with higher nicotine dependence and marked sociodemographic and behavioral vulnerabilities. However, dependence was more strongly shaped by sex, viral suppression, and education than by initiation age alone. These findings underscore the importance of adolescent-focused prevention and comprehensive cessation strategies integrated into HIV care, particularly for PLWH with lower education and suboptimal viral control.</p> <p><b>What is already known</b></p> <p>• PLWH exhibit consistently higher rates of cigarette smoking and nicotine dependence than the general population, contributing to poorer HIV treatment outcomes and elevated morbidity and mortality rates.</p> <p>• Early smoking initiation is a robust predictor of nicotine dependence in the general population; however, its relevance in African HIV-affected populations has been understudied.</p> <p>• Structural vulnerabilities, including lower education and socioeconomic disadvantage, shape both smoking behavior and HIV outcomes in sub-Saharan Africa.</p> <p><b>What this study adds</b></p> <p>• Early initiators (&lt; 18&#xa0;years) demonstrated distinct vulnerability profiles, including higher proportions of females,and lower educational attainment, whereas late initiators were predominantly male and exhibited higher socioeconomic stability and greater waterpipe use.</p> <p>• Although early initiation predicted higher nicotine dependence in the unadjusted and partially adjusted models, male sex, lack of viral suppression, and smoking intensity were the dominant independent predictors in the fully adjusted analysis.</p> <p>• As the first large-scale study among African PLWH to evaluate this research question, the findings indicate that mitigating nicotine dependence requires adolescent-focused prevention and tailored cessation interventions embedded within HIV care, rather than strategies focused solely on delaying smoking initiation.</p>

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Association between Age at Smoking Initiation and Nicotine Dependence among People Living with HIV in Nigeria

  • 期刊论文

  • 发表日期：

    2026年3月16日

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  • Afolabi Oyapero,
  • Ziyad Ben Taleb,
  • Olatokunbo Osibogun,
  • Olufemi Erinoso,
  • Moyosoore Osoba,
  • Anyachebelu Ebuka,
  • Olatunbosun Olasunkanmi,
  • Olabode Ekerin,
  • Idowu Afeez Adedoyin,
  • Ebbie Kalan

摘要

Background

Smoking is an important driver of morbidity and mortality among people living with HIV (PLWH), with nicotine dependence complicating cessation efforts and worsening HIV-related outcomes. Although early smoking initiation is a known predictor of dependence in the general population, its specific influence on PLWH in sub-Saharan Africa remains unclear.

Methods

We conducted a cross-sectional study involving 393 PLWH receiving care at HIV clinics in Lagos, Nigeria. Participants provided sociodemographic, behavioral, and clinical information, including age at smoking initiation, use of marijuana, alcohol, waterpipe, and e-cigarettes, and HIV viral suppression status. Nicotine dependence was measured using the Fagerström Test for Nicotine Dependence (FTND). Associations were evaluated using bivariate analyses and regression with sensitivity analyses exploring dose–response patterns, product-specific effects, and potential effect modifications.

Results

Early initiators (< 18 years) were younger, more frequently female, less socioeconomically advantaged, and more likely to use marijuana, whereas late initiators (≥ 18 years) were predominantly male and more socioeconomically stable. In unadjusted analyses, each additional year of delayed initiation was associated with a 1.25-point lower FTND score (β = –1.25; 95% CI –2.26 to –0.24; p = 0.016), and this association persisted after adjustment for sociodemographic factors (β = –1.18; 95% CI –2.20 to –0.16; p = 0.023). After full adjustment for behavioral and clinical covariates, the association was attenuated and was no longer statistically significant (β = –0.51; 95% CI –1.43 to 0.41; p = 0.271). Independent predictors of higher FTND scores included male sex, lack of viral suppression, and current cigarette use intensity. Sensitivity analyses supported a linear relationship between initiation age and FTND score among cigarette-only and dual users of cigarettes and waterpipes, but not among waterpipe-only users.

Conclusions

Early smoking initiation was associated with higher nicotine dependence and marked sociodemographic and behavioral vulnerabilities. However, dependence was more strongly shaped by sex, viral suppression, and education than by initiation age alone. These findings underscore the importance of adolescent-focused prevention and comprehensive cessation strategies integrated into HIV care, particularly for PLWH with lower education and suboptimal viral control.

What is already known

• PLWH exhibit consistently higher rates of cigarette smoking and nicotine dependence than the general population, contributing to poorer HIV treatment outcomes and elevated morbidity and mortality rates.

• Early smoking initiation is a robust predictor of nicotine dependence in the general population; however, its relevance in African HIV-affected populations has been understudied.

• Structural vulnerabilities, including lower education and socioeconomic disadvantage, shape both smoking behavior and HIV outcomes in sub-Saharan Africa.

What this study adds

• Early initiators (< 18 years) demonstrated distinct vulnerability profiles, including higher proportions of females,and lower educational attainment, whereas late initiators were predominantly male and exhibited higher socioeconomic stability and greater waterpipe use.

• Although early initiation predicted higher nicotine dependence in the unadjusted and partially adjusted models, male sex, lack of viral suppression, and smoking intensity were the dominant independent predictors in the fully adjusted analysis.

• As the first large-scale study among African PLWH to evaluate this research question, the findings indicate that mitigating nicotine dependence requires adolescent-focused prevention and tailored cessation interventions embedded within HIV care, rather than strategies focused solely on delaying smoking initiation.