9A.6.1 Trends in the prevalence of smoking
The prevalence of smoking appears to be higher among lesbian, gay, bisexual, transgender, queer, and intersex (LGBTQI+) people compared with the overall population.1-5 In the 2022–23 National Drug Strategy Household Survey, 5.1% of Australians aged 14 years and over described themselves as lesbian, gay, or bisexual. Within this group, 16.1% reported that they smoked every day. In comparison, 8.1% of people who described themselves as heterosexual or straight reported that they smoked every day. While daily smoking prevalence significantly decreased between 2019 and 2022–23 among heterosexual people, no such change was seen among lesbian, gay, or bisexual people – see Table 9A.6.1 and Figure 9A.6.1.6
The 2022–23 iteration of the National Drug Strategy Household Survey was the first to ask respondents about their gender identity, of which 0.9% described themselves as trans or gender diverse (a person whose gender is different to the gender that they were assigned at birth).7 Within this group, 9.1% reported that they smoked everyday compared to 8.3% among people who identify as cisgender (a person whose gender is the same as the gender they were assigned at birth)7 – see Table 9A.6.1.6
There is emerging research from the US indicating that adolescents and adults who experience changes in their gender identity over time (i.e. gender-varying) are more likely to use tobacco than people with stable gender identity (i.e. transgender-stable or cisgender-stable).8-10
9A.6.2 Contribution of smoking to health outcomes and social inequality
It is likely that the risk of smoking-related diseases is higher 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 2017–18 National Health Survey.11 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.12,13
Gay men, bisexual men (GBM) and other men who have sex with men experience a higher prevalence of human immunodeficiency virus (HIV).14 Research indicates that smoking can increase the risk of HIV complications, such as liver cancer and chronic obstructive pulmonary disease,15 which is particularly concerning as GBM living with HIV have a high likelihood of tobacco use.14 See Section 3.9.6 for a more detailed explanation of the link between smoking and HIV. Research conducted in the US also found that sexual minority cancer survivors had twice the odds of current smoking as their heterosexual counterparts,16 which can increase the risk of complications and the development of secondary cancers.17
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 their everyday lives, including in public, employment, and educational settings.18-20 LBGTQ people in Australia also experience a high risk of homelessness, mental illness, illicit drug use and excessive alcohol consumption.19-21 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.11,19
9A.6.3 Explanations for higher smoking prevalence
People who identify as LGBTQI+ experience a number of social and psychological risk factors that may increase their likelihood of smoking in comparison to the overall 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.5 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 were still at a high risk of smoking.22
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 did not smoke.23 Similarly, a large US survey of transgender people found that psychological distress was associated with cigarette and e-cigarette use.24 An Australian study of lesbian and bisexual women also found that psychological distress was a significant factor associated with smoking.5 Lower mental wellbeing was also identified as a key mediator of smoking behaviour among LGB people in England.25 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+ people also contributes to the higher smoking prevalence among this population. A 2024 systematic review found that LGBTQ people who experienced minority stress (i.e. internalised queerphobia, perceived stigma, and prejudice events) were more likely to smoke in 42 of the 44 included studies.26 Australian qualitative research found that among lesbian, bisexual and queer women, smoking was commonly used as a coping strategy for the minority stress or stigma that they experience.27 Moreover, US and Canadian studies have found that discrimination in housing, employment, healthcare and legal settings was associated with increased tobacco use, lifetime smoking and current smoking among transgender people.28 Sexuality-specific traumatic experiences were also associated with increased odds of smoking among gay and bisexual men in the US.29 For transgender adolescents, there is evidence that experiencing bullying may increase the likelihood of smoking.30 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.31,32 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.33
It has been suggested that the higher prevalence of smoking among gay, lesbian and bisexual women within the LGBTQI+ community could also be the result of stress from ‘double discrimination’ based on sex and sexual identity.2 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.34
There are several socio-cultural factors that may also drive the higher smoking prevalence among LGBTQI+ people. Australian research has demonstrated that for some lesbian, bisexual, and queer women, smoking creates an opportunity for gender expression, affirmation, and rebellion. Smoking allowed participants to experience ‘marginalised connectivity’ which is a form of social solidarity created between people experiencing minority stress.27 Similarly, 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,35 have a culture of smoking.36 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.37 LGB young adults also appear to be more accepting of cigarette-related norms compared to heterosexual peers.1,38
Targeted marketing of tobacco products may also contribute to the higher smoking prevalence among LGBTQI+ people. Since the 1990s, the tobacco industry has advertised tobacco products in LGBTQI+ magazines and publications, sponsored LGBTQI+ and pride events, promoted tobacco products at LGBTQI+ spaces, and advertised pride-themed tobacco products and accessories.39-41
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 overall population. An analysis of a UK-representative survey found no difference between LGBQ and heterosexual people who smoke in motivation to quit or number of quit attempts.3 Research conducted in the US found that LGBT people who smoke were just as likely to quit or abstain from smoking compared to heterosexual cisgender people in extended, non-tailored interventions; however, the authors note that such findings may not be applicable to geographic areas where access to treatment is limited, or a higher stigma of sexual orientation exists.42 One study found no significant differences in quit rates or the use of cessation pharmacotherapies between LGB and heterosexual people who smoke who completed a web-based cessation intervention.43 Another study found that LGBTQ people were just as likely to utilise, engage and benefit from Quitline services compared to heterosexual people.44 An Australian study of LGB and non-LGB people who smoke 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.45
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 to quit for LGBQ women.46 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.47
Evidence 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.48 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.49
Several reviews have explored the ways in which smoking cessation interventions are being tailored to LGBTQI+ people.50-52 A 2024 systematic review found that cessation interventions are commonly tailored through the addition of sexual and gender minority psychoeducation, intra-community and peer support, and culturally impactful resources.50 Similarly, 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. It should be noted that individual populations were not proportionately represented in the studies, with findings most often relevant to gay men.52
To address the higher smoking prevalence among LGBTQI+ people in Australia, Quit launched a tailored campaign in 2024 titled “Quit with Pride”. The campaign encourages members of the LGBTQI+ community to quit smoking and seek support from culturally sensitive services such as the Quitline. Using personal stories from LGBTQI+ community members, the campaign highlights how each person’s quitting journey is unique.53
In studies that have assessed the acceptability of tailored cessation interventions, sexual and gender minorities have found that the interventions are acceptable and that the content is useful. However, it is important to note that acceptability results may be biased in favour of participants who have completed the intervention, as participants who do not complete the intervention are unlikely to provide accessibility data.50
In terms of the efficacy of tailored interventions, most studies have reported positive cessation outcomes, however there is some variation. In Switzerland, a modified version of a British cessation 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 intervention for LGBTQI people who smoke increased abstinence compared to a non-tailored intervention.54 Another trial found culturally tailored anti-smoking ads (i.e. anti-smoking ads containing LGBTQ+ branding and colours) increased intentions to quit and decreased intentions to purchase cigarettes among sexual minority women who smoked. However, when compared to participants who were exposed to control ads (i.e. anti-smoking ads not containing LGBTQ+ branding and colours) there were no significant differences in these measured outcomes.55 Moreover, a clinical trial comparing culturally targeted cessation treatment and standard cessation treatment for LGBT people who smoke found no significant difference in cessation outcomes, however the culturally targeted treatment was perceived as more effective and was more accepted.56
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References
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52. Berger I and Mooney-Somers J. Smoking Cessation Programs for Lesbian, Gay, Bisexual, Transgender, and Intersex People: A Content-Based Systematic Review. Nicotine & Tobacco Research, 2017; 19(12):1408-17. Available from: https://www.ncbi.nlm.nih.gov/pubmed/27613909
53. Quit. New Quit campaign unveiled to support the queer community. 2024. Available from: https://newsroom.quit.org.au/news/new-quit-campaign-unveiled-to-support-the-queer-community.
54. Vogel EA, Ramo DE, Meacham MC, Prochaska JJ, Delucchi KL, et al. The Put It Out Project (POP) Facebook Intervention for Young Sexual and Gender Minority Smokers: Outcomes of a Pilot, Randomized, Controlled Trial. Nicotine & Tobacco Research, 2020; 22(9):1614-21. Available from: https://www.ncbi.nlm.nih.gov/pubmed/31562765
55. Tan AS, Chen JT, Keen R, Scout N, Gordon B, et al. Culturally tailored anti-smoking messages: A randomized trial with U.S. sexual minority young women. American Journal of Preventive Medicine, 2023. Available from: https://www.ncbi.nlm.nih.gov/pubmed/38065403
56. Matthews AK, Steffen AD, Kuhns LM, Ruiz RA, Ross NA, et al. Evaluation of a Randomized Clinical Trial Comparing the Effectiveness of a Culturally Targeted and Nontargeted Smoking Cessation Intervention for Lesbian, Gay, Bisexual, and Transgender Smokers. Nicotine & Tobacco Research, 2019; 21(11):1506-16. Available from: https://www.ncbi.nlm.nih.gov/pubmed/30169797