Tobacco use and cessation in the context of ART adherence: Insights from a qualitative study in HIV clinics in Uganda

Frances Thirlway, Kellen Namusisi Nyamurungi, Joseph K.B. Matovu, Andrew Kibuuka Miti, Noreen Dadirai Mdege

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Sub-Saharan Africa carries a disproportionate burden of human immunodeficiency virus (HIV). Tobacco use amongst people living with HIV is higher than in the general population even though it increases the risk of life-threatening opportunistic infections including tuberculosis (TB). Research on tobacco use and cessation amongst people living with HIV in Africa is sparse and it is not clear what interventions might achieve lasting cessation. We carried out qualitative interviews in Uganda in 2019 with 12 current and 13 former tobacco users (19 men and 6 women) receiving antiretroviral therapy (ART) in four contrasting locations. We also interviewed 13 HIV clinic staff. We found that tobacco use and cessation were tied into the wider moral framework of ART adherence, but that the therapeutic citizenship fashioned by ART regimes was experienced more as social control than empowerment. Patients were advised to stop using tobacco; those who did not concealed this from health workers, who associated both tobacco and alcohol use with ART adherence failure. Most of those who quit tobacco did so following the biographical disruption of serious TB rather than HIV diagnosis or ART treatment, but social support from family and friends was key to sustained cessation. We put forward a model of barriers and facilitators to smoking cessation and ART adherence based on engagement with either ‘reputation’ or ‘respectability’. Reputation involved pressure to enjoy tobacco with friends whereas family-oriented respectability demanded cessation, but those excluded by isolation or precarity escaped anxiety and depression by smoking and drinking with their peers.
Original languageEnglish
Number of pages8
JournalSocial Science & Medicine
Early online date17 Feb 2021
Publication statusPublished - Mar 2021

Bibliographical note

Copyright © 2021 The Author(s). Published by Elsevier Ltd. This is an open access article under the CCBY license (

This study was part-funded by the Wellcome Trust [ref: 204829] through the Centre for Future Health (CFH) at the University of York. NDM is grateful for salary support from the Tobacco Control Capacity Programme (grant MR/P027946/2) supported by UK Research and Innovation (UKRI) with funding from the Global Challenges Research Fund.


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