9A.6 Lesbian, gay, bisexual, trans, queer and intersex (LGBTQI+) people

Smoking has been identified as an issue that contributes to disadvantage for many people in the LGBTQI+ population.

9A.6.1 Trends in the prevalence of smoking

Smoking prevalence is significantly higher among lesbian, gay and bisexual (LGB) people in Australia compared with the overall population.^1,2 In the 2019 National Drug Strategy household survey, 22.9% of people who nominated themselves in the survey to be “homosexual (gay or lesbian)” or “bisexual” reported being a current smoker, compared with 13.5% of people who described themselves as heterosexual or straight. Daily smoking rates were also much higher: 16.0% compared with 10.7%. While both daily and current smoking prevalence significantly decreased between 2016 and 2019 among heterosexual people, no such change was seen among gay or bisexual people—see Figure 9A.6.1.³

Australian and international studies have observed higher smoking prevalence within the LGBQ population among individuals identifying as bisexual and/or queer and among LGBQ women.^4-7

There is a lack of robust research on smoking rates among transgender and intersex people in Australia. Until very recently, surveys in Australia have tended to ask respondents about their sexual orientation and their gender but not about their gender identity. Research in the US, however, indicates that people who are gender diverse (persons whose gender identity, including their gender expression, is at odds with what is perceived as being the gender norm in a particular context at a particular point in time, including those who do not place themselves in the male/female binary and those who are transgender (people whose gender identity is different from the gender they were thought to be at birth)^{8, 9} are more likely to smoke than cisgender people (people whose sense of personal identity and gender corresponds with their birth sex)^10,11 US research also indicates that adolescents and adults who experience changes in their gender identity over time (i.e. gender-varying) are more likely to use tobacco than individuals with stable gender identity (i.e. transgender-stable or cisgender-stable).¹²

9A.6.2 Contribution of smoking to health outcomes and social inequality

Data are limited, however there is likely a higher risk of smoking-related diseases among LGBTQI+ people given the higher prevalence of smoking in this population. LGBTQI participants in the Australian Private Lives 3 survey had poorer self-rated health compared to the overall population in the 2017–2018 National Health Survey.¹³ Australian and international research indicates that LGBTI+ people under-utilise health and crisis services due to actual or anticipated bias and discrimination from service providers.^14,15 Gay men, bisexual men (GBM) and other men who have sex with men also experience a higher prevalence of Human Immunodeficiency Virus (HIV).¹⁶ Research indicates that smoking can increase the risk of HIV complications, such as liver cancer and COPD,¹⁷ which is particularly concerning as GBM living with HIV have a high likelihood of tobacco use.¹⁶ See Section 3.9.6 for a more detailed explanation of the link between smoking and HIV. US research has also found that sexual minority cancer survivors had twice the odds of current smoking as their heterosexual counterparts,¹⁸ which can increase the risk of complications and the development of secondary cancers.¹⁹

The LGBTQI+ population experiences several forms of social disadvantage, which further widen the disparities between the LGBTQI+ and the general population. LGBTI people in Australia still experience discrimination, harassment and hostility in public, employment, education, accessing public services and other areas of everyday life.^{20, 21} LBGTQ people in Australia also experience a high risk of homelessness, mental illness, illicit drug use and excessive alcohol consumption.^{21, 22} Surveys conducted in Australia found that 83% of LGBTQ+ adolescents aged 16–17 and 57% of LGBTQ+ adults reported high and very high psychological distress.^{13, 21}

9A.6.3 Explanations for higher smoking prevalence

A number of the social and psychological risk factors associated with smoking have been prevalent in the LGBTQI community which may contribute to the higher smoking prevalence in this population.  

Lower educational attainment, unemployment, low-mid range income, older age and risky alcohol consumption were associated with continued smoking in an Australian sample of lesbian, gay and bisexual women.⁴ Another Australian study looking at gay/lesbian and bisexual women separately, found that employment and income were significantly associated with smoking for lesbian/gay women but not for bisexual women.² Research in the US found that educational attainment was less of a protective factor for smoking among LGB adults compared to heterosexual people and that highly educated LGB people where still at a high risk of smoking.²³

Australian and international research indicates that psychological distress is associated with smoking in LGBTQ people. A US study found that psychological distress was higher among LGBT people who smoked than those who didn’t smoke.²⁴ Similarly, a large US survey of transgender people found psychological distress was associated with cigarette and e-cigarette use.²⁵ An Australian study of lesbian and bisexual women also found that psychological distress was a significant factor associated with smoking.² Lower mental wellbeing was also identified as a key mediator of smoking behaviour among LGB people in England.²⁶ The potential explanations as to why people with mental health problems are more likely to smoke include: the higher prevalence of other smoking risk factors among people with mental illness (i.e. unemployment, lower income and less education), a shared genetic predisposition to smoking and mental illness, the perception of smoking as relieving mental illness symptoms and use of smoking to ‘self-medicate’.²⁸ See Section 9A.3 for a detailed explanation of why those with mental illness are more likely to smoke.

There is evidence that the discrimination and minority stress experienced by LGBTQI+ also contributes to the higher smoking prevalence among this population. US and Canadian studies have found evidence that discrimination in housing, employment, healthcare and legal settings was associated with increased tobacco use, lifetime smoking and current smoking among transgender people.²⁷ Sexuality-specific traumatic experiences were also associated with increased odds of smoking among gay and bisexual men in the US. ²⁸ For transgender adolescents, there is evidence that experiencing bullying may increase the likelihood of smoking.²⁹ Adverse childhood experiences, sexual and gender identity-related family rejection and violence are also associated greater likelihood of tobacco use among LGBTQI+ adolescents and young adults.^{30, 31} The roles of gender non-conformity, masculine self-consciousness and sexual orientation stress also appear to be important influences on smoking behaviour in young gay men.³²

It has been suggested that the higher prevalence among gay, lesbian and bisexual women within the LGBTQI+ community could be the result of stress from ‘double discrimination’ based on sex and sexual identity.⁵ Similarly, it has been suggested that the higher smoking prevalence among bisexual people may also be related to the double discrimination experienced by bisexual individuals from both heterosexual and gay/lesbian communities. ^33,7

Qualitative research with LGBTQ leaders from New York identified three main motivations for tobacco uptake among their communities—image building, socialisation and stress. Smoking was used as a tool for building an image of oneself or to attain a certain persona. Smoking was also used as a coping mechanism for stresses caused by the intersectionality of race, ethnicity and sexuality. Lastly, smoking was also perceived to aid socialisation with some fearing loss of friends if they were to quit. Gay bars and pubs, which traditionally have been one of few safe spaces for LGBTQI+ people to gather,³⁴ have a culture of smoking.³⁵ Attending LGB-specific clubs and bars, is associated with greater likelihood of smoking. Research with young gay, bisexual and other men who have sex with men has also indicated that affinity with the gay community was associated with smoking.³⁶ LGB young adults also appear to be more accepting of cigarette-related norms compared to heterosexual peers.³⁷

The prevalence of smoking in LGBTQI+ culture is not coincidental: from the 1990s the tobacco industry specifically targeted marketing of tobacco products to the LGBTQI+ community. Tobacco products were advertised in gay press publications depicting tobacco use as a normal part of LGBT life, and tobacco products were promoted at LGBTQI+ bars and pride events.³⁸

9A.6.4 Interventions for reducing smoking

The evidence to date does not indicate that quitting attitudes and behaviours differ between LGBTQI+ people and the general population. An analysis of UK-representative survey found no difference between LGBQ and heterosexual smokers in motivation to quit or number of quit attempts.⁶ A US study also found no significant differences in quit rates or use of cessation pharmacotherapies between LGBQ and heterosexual smokers. The quit rates were also not significantly different between bisexual and gay/lesbian smokers.³⁹ A US study concluded that LGBT smokers appear as likely to quit or abstain as heterosexual cisgender smokers in extended, non-tailored interventions; however, the authors note that the findings may not generalise to geographic areas where access to treatment is limited or a higher stigma of sexual orientation exists.⁴⁰ An Australian study of LGB and non-LGB smokers in alcohol and other drug treatment settings found the two groups shared similar preferences for quit support— free or low-cost nicotine replacement therapy (NRT), provision of support and encouragement and to be asked if they would like help to quit smoking.⁴¹

A 2016 systematic review of smoking cessation programs for LGBTI people concluded that quit rates were high across studies; however, none included control groups. Most studies included cultural modifications, such as meeting in LGBTI spaces, discussing social justice, and discussing LGBTI-specific triggers. Common behaviour change techniques included providing normative information, boosting motivation/self-efficacy, relapse prevention, social support, action planning, and discussing consequences. Individual populations were not proportionately represented in the studies, with findings most often relevant to gay men.⁴² More recent evidence also suggests that LGBTQ+ people prefer cessation and prevention interventions to be tailored to them. Focus groups with LGBTQ+ youth and young adults expressed preferences for smoking cessation and prevention interventions to: be LGBTQ+ specific; accessible; inclusive, relatable, and highlight diversity; incorporate LGBTQ+ peer support and counselling services; integrate other activities beyond smoking; be positive, motivational, uplifting, and empowering; provide concrete coping mechanisms; and integrate rewards and incentives.⁴³ In addition, interviews with LGBT-friendly US healthcare providers indicated that community outreach and holistic cessation treatment services for LGBT people are needed to address specific barriers faced by LGBT people.⁴⁴ The evidence for tailored interventions is mixed. In Switzerland, a modified version of a British smoking intervention program tailored to gay men improved short-term and sustained abstinence rates, as well as participants’ mental health.⁴⁴ A trial of a culturally tailored Facebook smoking intervention for LGBTQI  smokers did increase abstinence compared to a non-tailored intervention.⁴⁵ Another clinical trial comparing culturally targeted cessation treatment and standard cessation treatment for LGBT smokers found no significant difference in cessation outcomes, however the culturally targeted treatment was perceived as more effective and was more accepted.⁴⁶

A 2014 review of cessation promotion for LGBT people found evidence that tailored group programs are feasible and effective. Community interventions, although feasible, lack rigorous outcome evaluations. Findings from focus groups suggested that care is needed in selecting the messaging used in LGBT-targeted media campaigns.⁴⁷ An analysis of national US survey data found that LGBT individuals have similar exposure to tobacco cessation advertising, as well as similar awareness of and use of evidence-based cessation methods as compared to heterosexual peers. This highlights the need for LGBT-specific efforts to reduce smoking disparities, such as increasing awareness, access, and acceptability of existing interventions, developing tailored interventions, and denormalising smoking.⁴⁸ A US study identified that personal and family concerns were important motivators to quit for both heterosexual and LGBQ adults. Physical fitness was also a primary motivator for LGBQ women only.⁴⁹ For transgender people undergoing or wishing to undergo gender affirmation surgery, quitting to prevent complications that can occur in surgery could be a potential motivator.⁵⁰

Relevant news and research

For recent news items and research on this topic, click  here. ( Last updated January 2023)

References 

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