Associations of Sexual Orientation-Related Minority and Military Stressors with Past-Year Cigarette Use among Lesbian, Gay, and Bisexual (LGB) Veterans.

INTRODUCTION: Lesbian, gay, and bisexual (LGB) individuals and Veterans are more likely to report current smoking than the general adult population in the United States. The Minority Stress Model may explain the high prevalence of cigarette smoking among LGB individuals, who experience unique interpersonal (e.g., discrimination) and intrapersonal (e.g., identity concealment) stressors related to their minoritized sexual orientation. This study assessed whether three types of stressors (interpersonal, intrapersonal, and LGB-specific military) were associated with past-year smoking among LGB Veterans. METHODS: Veterans were recruited online for a prospective cohort study. We conducted secondary data analysis of baseline surveys collected from 2019-2020. The study sample included cisgender, LGB Veterans (n=463). Adjusted nested multivariable logistic regression models were used to estimate the association of each stressor with past-year cigarette smoking. RESULTS: Participants were mostly male (54.0%), non-Hispanic White (82.1%), and at least a college graduate (58.5%). LGB Veterans who were younger, had lower levels of education, income, and healthcare coverage, higher general stressors, and post-traumatic stress disorder (PTSD) and depression symptoms were more likely to smoke in the past year (n=98, 21.2%). The adjusted odds of past-year smoking were higher among those who reported higher levels of harassment (aOR=1.13, 95%CI: 1.01-1.26), victimization (aOR=1.13, 95%CI: 1.02-1.43), and family rejection (aOR=1.13, 95%CI: 1.08-1.36). CONCLUSION: Multiple interpersonal stressors were associated with past-year smoking, highlighting the need to intervene on these stressors. Future interventions should aim to address policies that reduce prejudice against LGB Veterans, while helping those who smoke identify and develop positive coping skills that support cessation. IMPLICATIONS: Our findings contribute to the growing body of literature on tobacco use disparities among LGB individuals, particularly LGB Veterans. Results of this analysis provide some evidence for the Minority Stress Model as a conceptual model for understanding and intervening on disparities in smoking prevalence among LGB Veterans.

Intersectionality in Intervention Development: Insights From Formative Work on a Tailored Tobacco Cessation Program for LGBTQIA+ Young Adults.

Tailored tobacco cessation interventions focusing on minoritized communities are proliferating, but the extent to which these interventions address the needs of individuals with multiple minoritized social identities is unclear. We developed Empowered, Queer, Quitting, and Living (EQQUAL), an avatar-led digital smoking cessation intervention tailored for lesbian, gay, bisexual, transgender, queer or questioning, intersex, asexual, and more (LGBTQIA+) young adults based on acceptance and commitment therapy (ACT), via a multistage user-centered design process. The purpose was to evaluate feedback from EQQUAL development activities using an intersectional lens. Intersectionality is a paradigm created by Kimberlé Crenshaw illustrating the multiple social identities each person possesses along with the marginalization of these different social identities. We conducted a rapid deductive content analysis focused on intersectional design gaps using interviewer notes from user testing (n = 7), a diary study (n = 8), and treatment satisfaction responses from a single-arm trial of the EQQUAL intervention (n = 22). Feedback related to intersectional design fell under three broad themes: (a) inadequate representativeness of the avatar, (2) inadequate representativeness within the program broadly, and (3) non-inclusive ACT intervention content. Feedback on inclusiveness included reference to socioeconomic status, race/ethnicity, religious/cultural affiliation, and ability/disability. Although we previously found that EQQUAL was highly acceptable and showed promise in terms of efficacy in a single-arm pilot trial, we identified several gaps in intersectional design as the iterative intervention development proceeded. Because intersectional design is a critical part of developing interventions with a health equity focus, applying standardized procedures for intersectional design and analysis could improve intervention design and better address tobacco cessation treatment needs of individuals who may experience multiple forms of marginalization.

Worksite tobacco control - a qualitative study on perspectives from employers and employees at small worksites.

BACKGROUND: Evidence-based interventions (EBIs) for tobacco control can be implemented in worksite settings to reduce tobacco use. Small worksites are less likely to adopt tobacco control EBIs than large worksites. The purpose of this qualitative study was to 1) explore factors that impact small employers' decisions to offer tobacco control EBIs, and 2) understand employees' perceptions of tobacco control at small worksites. METHODS: Working with staff from small worksites (20-250 employees), we analyzed data from 12 semi-structured interviews with employers (via key informants) and four focus groups with employees. We recruited employers and employees through a purchased business list and market research company, respectively. Interview and focus group topics included perceptions of worksite tobacco control; internal and external forces shaping worksite tobacco control implementation; and perceived worksite support for cessation. We conducted thematic data analysis. RESULTS: Key themes from the employer interviews included: the local environment played an important role in implementation of tobacco control EBIs; tobacco control was perceived as important but not a priority; and tobacco control decisions were driven by worksite culture. Key themes from the employee focus groups included: perceived employer support for tobacco cessation was limited although there was interest from employees; employees who currently used tobacco were stigmatized for their behavior; and incentives and coaching were considered ideal tobacco control EBIs. CONCLUSIONS: Tobacco control has not been prioritized at small worksites, despite employees welcoming additional cessation support. This study contributes important information on contextual factors and employee preferences that could be targeted to improve tobacco control EBI implementation. Worksites should implement comprehensive tobacco-free policies, minimize stigma when promoting cessation, establish equitable break policies, and involve employees in decision-making related to tobacco control.

The Health of Undocumented Latinx Immigrants: What We Know and Future Directions.

Undocumented Latinx immigrants experience unique factors prior to migration, during migration, and after migration that shape their health. Our review summarizes the limited but growing literature highlighting how exposure to trauma, immigration enforcement, changes to social networks, and discrimination negatively affect the mental and physical health of undocumented Latinx immigrants. We also discuss how policies and social ties can promote their health. We focus on areas of particular concern, including health care, mental health, and HIV. Future research should use interdisciplinary approaches and intersectional frameworks to understand and address health inequities. Conducting research with undocumented Latinx immigrant communities requires community engagement, assurance of confidentiality, and creative recruitment and retention strategies. Recommendations for public health practice include investing in community health centers and organizations to ensure access to health and social services; presenting results with sufficient contextualization to interpret their generalizability; and advocating for federal-, state-, and local-level policy changes that reduce the negative health consequences associated with being undocumented.

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.

PURPOSE: To examine the benefits of a culturally targeted compared with a nontargeted smoking cessation intervention on smoking cessation outcomes among lesbian, gay, bisexual, and transgender (LGBT) smokers. METHODS: A prospective randomized design was used to evaluate the added benefits of an LGBT culturally targeted Courage to Quit (CTQ-CT) smoking cessation treatment (N = 172) compared with the standard intervention (CTQ; N = 173). The smoking cessation program consisted of six treatment sessions combined with 8 weeks of nicotine replacement therapy. The primary smoking cessation outcome was 7-day point prevalence quit rates. Secondary outcomes examined included changes in nicotine dependence, nicotine withdrawal, cigarettes per day, smoking urges, self-efficacy, and readiness to quit. RESULTS: Overall quit rates were 31.9% at 1 month, 21.1% at 3 months, 25.8% at 6 months, and 22.3% at 12 months. Quit rates did not differ between treatment groups [1 month OR = 0.81 (0.32, 2.09), 3 months OR = 0.65 (0.23, 1.78), 6 months OR = 0.45 (0.17, 1.21), 12 months OR = 0.70 (0.26, 1.91)]. Compared with baseline levels, all secondary smoking cessation outcomes measured were improved at 1 month and were maintained at 12-month follow-up. Compared with the CTQ, the CTQ-CT intervention was more highly rated on program effectiveness (d = 0.2, p = .011), intervention techniques (d = 0.2, p = .014), the treatment manual (d = 0.3, p < .001), and being targeted to the needs of LGBT smokers (d = 0.5, p < .0001). CONCLUSIONS: LGBT smokers receiving the CTQ intervention achieved smoking cessation outcomes in the range reported for other demographic groups. Cultural targeting improved the acceptability of the intervention but did not confer any additional benefit for smoking cessation outcomes. IMPLICATIONS: Study results have implications for understanding the benefits of culturally targeted compared with nontargeted smoking cessation interventions for improving smoking cessation outcomes among LGBT smokers. Shorter and longer term 7-day point prevalence quit rates associated with the targeted and nontargeted interventions were modest but comparable with other group-based interventions delivered in a community setting. Although cultural targeting improved the overall acceptability of the intervention, no added benefits were observed for the culturally targeted intervention on either the primary or secondary outcomes.

Cigarette Smoking Motives and Stages of Change in Smoking Cessation Among Veterans: Differences by Gender and Sexual Orientation.

PURPOSE: To examine differences across gender and sexual orientation in cigarette smoking motives and stages of change in smoking cessation among Veterans. DESIGN: Secondary data analysis of cross-sectional baseline surveys from a prospective cohort study. SETTING: United States, self-administered online survey. PARTICIPANTS: Cisgender Veterans who reported past-year smoking (N = 146); 66.4% identified as lesbian, gay, or bisexual and 52.1% were men. MEASURES: Smoking motives (i.e., social, self-confidence, boredom relief, and affect regulation), with higher scores indicating stronger motivation to smoke. Stages of change categories included precontemplation, contemplation/preparation, and action/maintenance. ANALYSIS: Analyses were stratified by gender and sexual orientation. Age-adjusted linear regression models estimated differences in smoking motives scores and multinomial logistic regression models estimated differences in stages of change categories relative to the precontemplation stage (reference category). RESULTS: In this Veteran sample, gay men reported higher social smoking motives vs heterosexual men (ß = 1.50 (95% CI: .04, 2.97), P-value = .045) and higher boredom relief smoking motives vs bisexual men (ß = 1.53 (95% CI: .06, 2.29), P-value = .041) in age-adjusted models. Lesbian women were more likely to be in the action/maintenance stage relative to the precontemplation stage when compared to both heterosexual women (aRRR = 4.88 (95% CI: 1.00, 23.79) P-value = .050) and bisexual women (aRRR = 16.46 (95% CI: 2.12, 127.57), P-value = .007) after adjusting for age. CONCLUSION: Smoking cessation interventions may benefit from enhancing peer support for gay men. Given bisexual and heterosexual women were in less advance stages of change, there may be a greater need for motivational interventions to encourage quitting and additional support to assist with cessation efforts. Overall, findings highlight the diversity of cigarette use within LGB communities.

A Scoping Review of Trends in the Size of Lesbian, Gay, and Bisexual Tobacco Use Disparities, 1996-2020, United States and Canada.

Purpose: Tobacco use is a major health disparity for lesbian, gay, bisexual, and transgender (LGBT) populations compared with heterosexual/cisgender populations. In this scoping review, we aimed to determine if LGBT tobacco use disparities are improving or worsening over time and if trends in disparities differed across subgroups. Methods: We included articles that longitudinally explored youth and adult LGB tobacco use in the United States and Canada after searching four databases and capturing records through July 2022. Two reviewers independently screened the title/abstract and full text of 2326 and 45 articles, respectively. Eleven articles from 18 larger assessments met inclusion criteria, spanning data collection from 1996 to 2020. Results: All studies consistently demonstrated tobacco disparities for LGB populations. No articles examined longitudinal transgender tobacco disparities. Most studies focused on smoking combustible cigarettes. Disparities in heavy or daily use for all LGB youth subgroups compared with heterosexual samples appear to be shrinking longitudinally. Results for early-onset, current, and lifetime smoking were less consistent. Adult evidence was relatively sparse; however, after 2010, studies show diminishing disparities over time, except for current smoking by bisexual women. Conclusions: Large tobacco use disparities persist for LGB populations, although the size of disparities may be decreasing for some groups. Initiatives for lesbian and bisexual women and girls should be prioritized, in addition to interventions addressing LGB smoking broadly. Surveillance instruments should uniformly and consistently assess LGBT identities and tobacco use behaviors.

Priority Populations Toolkits: Enhancing researcher readiness to work with priority populations.

The National Center for Advancing Translational Sciences has called for more comprehensive research with priority populations to reduce disparities and for the development of additional resources to assist researchers in implementing these recommendations. Here we report the development and initial evaluation of five Priority Populations Toolkits, which are resources developed by the University of Illinois Center for Clinical and Translational Science to meet these goals. Three aims guide the content: increasing knowledge, facilitating communication, and improving research design. Materials were curated from scientific literature reviews and Internet searches and revised iteratively. Analytics and user surveys provide information about usage. In 22 months, 387 unique users accessed the toolkits. The top reason for usage was to improve research recruitment. Comprehensive toolkits for working with priority populations show promising potential for increasing knowledge and readiness to work with underrepresented populations. Further toolkit development and evaluation of effectiveness are warranted.

White Paper from a CTSA Workshop Series on Special and Underserved Populations: Enhancing Investigator Readiness to Conduct Research Involving LGBT Populations.

Despite the significant health disparities experienced by lesbian, gay, bisexual and transgender (LGBT) populations, few investigators affiliated with NIH-funded Clinical and Translational Science Award (CTSA) programs are conducting research related to this underserved population. We provide recommendations shared during a half-day workshop aimed at increasing researcher readiness to conduct LGBT research. This workshop was presented as part of a series on conducting research with underserved populations offered by the Recruitment, Retention, and Community Engagement Program of the Center for Clinical and Translational Science at the University of Illinois at Chicago. Six LGBT health research experts provided focused presentations. The workshop presentations included a summary of significant health inequality issues, theoretical models relevant to research on LGBT health, best practices in measuring sexual orientation and gender identity, recommendations for recruitment and retention, a discussion of community engagement, and ethical considerations in conducting LGBT research. We provide a summary of recommendations to guide future research, training, and public policy related to LGBT health. The information can increase capacity among CTSA affiliated researchers in conducting research in this special population.