LGBTQ people smoke cigarettes at higher rates, and they face barriers to quitting

Garfield leads the UNIQUE (Uniting in Inter-professional learning to serve the QUeer community through Education) Project: an initiative designed to help Temple Health internal medicine residents and clinicians improve their communication skills, build empathy and learn about the experiences of trans and non-binary patients through simulated standardized patient interactions. Garfield is also the director of the LGBTQ curriculum for the Internal Medicine Residency Program at Temple's Lewis Katz School of Medicine. 

Garfield and colleagues have identified commercial tobacco as one of the "greatest LGBTQ+ health" issues "of all time."

Big Tobacco targets LGBTQ+ communities

"There's good evidence that minorities in sexual orientation and gender identity report a higher exposure to tobacco marketing," Garfield said. "There's data that people in this community see more tobacco ads than people cisgendered and heterosexual people, and that higher exposure to tobacco marketing is associated with higher rates of tobacco use."

When tobacco companies began running ads featuring gay and lesbian people in the 1990s, it was "... exciting for LGBTQ people, because they saw themselves represented for the first time, as sort of a community who does everyday things with their partners and their loved ones," Garfield said. "But it was very intentional, of course, to create a market."

Philip Morris made large donations to AIDS-related causes in 1991 in response to gay men boycotting Marlboro cigarettes because of the company's support of Sen. Jesse Helms, who opposed gay rights.

In 1995, R.J. Reynolds Tobacco Co. launched a cigarette marketing campaign called "Project SCUM," an acronym for "Subculture Urban Marketing," targeting gay men and people experiencing homelessness in San Francisco.

Tobacco companies have continued to directly market to LGBTQ+ populations through targeted advertising in LGBTQ press, nightlife marketing, donations, sponsorships and other tactics.

Higher rates of tobacco use in the LGBTQ+ community 

About 1 in 6 of gay, lesbian or bisexual adults smoke compared to about 1 in 9 of heterosexual adults, according to CDC statistics.

Lesbian, gay or bisexual high school students use tobacco products at nearly 1.5 times the rate of heterosexual students, according to research from 2022. Similarly, 20.5% of transgender high school students use tobacco products compared to 14.8% of their cisgender peers.

Transgender and gender-expansive adults are twice as likely to smoke cigarettes than cisgender individuals, findings from a 2021 study show. Transgender youth use cigarettes at rates four times higher than cisgender youth and e-cigarettes at rates three times higher than cisgender youth, a 2019 study found.

A 2023 report from the Federal Trade Commission found that 36% of LGBT smokers use menthol cigarettes compared to 29% of straight smokers. Research shows that menthol cigarettes are more addictive and harder to quit than unflavored cigarettes, but a push to ban menthol cigarettes from the Food and Drug Administration, health advocates and lawmakers has stalled.

Barriers to cessation

Proven treatments to help people quit smoking include counseling and medicines approved by the FDA. But people in LGBTQ+ communities are less likely to seek or receive smoking cessation help than heterosexual or cisgender people, Garfield said.

"It's more difficult for them to quit because they're less likely to use counseling services and quit lines and pharmacotherapy, and that has to do with quit lines and counseling services not being really directed to their community," Garfield said. "They don't feel understood or supported."

Public Health Solutions, an organization that works to reduce health inequities in New York, determined in a 2018 report that lesbian, gay and bisexual people are five times less likely to call a smoking cessation quit line due to discrimination, poverty, rejection by family members and friends, and other factors. The same report indicated that gay, bisexual and transgender men are 20% less aware of smoking quit lines than straight men and that only 28% of LGBT people use nicotine replacement therapy — even when covered by insurance.

In a study of smoking adults in Colorado, lesbian, gay and bisexual adults who were aware of the state's quit line were less likely to report an intention to call the quit line than their heterosexual counterparts.

One in four transgender people reported that they did not see a doctor when they needed to in the last 12 months due to fear of mistreatment, according to the 2022 U.S. Trans Survey.

"People within the queer community, especially the transgender and gender diverse community, are fearful of coming to health care practices in many ways because of discrimination, and so health care providers who are knowledgeable or understanding of these disparities need to make themselves visible," Garfield said. "If we don't bring more awareness and help more people within the community feel supported and help them with cessation, we know that there will be an increased incidence of all tobacco-related diseases."

A need for change

To reduce barriers to cessation and prevent tobacco-related illnesses among the LGBTQ+ community, Garfield said the following actions are needed:

• More clinicians becoming gender-affirming by wearing pronoun pins, using inclusive and patient-first language, and understanding the disparities and unique needs of this population

• Including LGBTQ people in leadership positions within medical institutions

• Creating culturally-competent education and training for people who work in health care settings and enlisting people from the LGBTQ+ community to help

• Including gender and sexual minorities in all local, state and national surveys of smoking behaviors

• Making collection of data and research about tobacco use-related subjects inclusive of demographic data in the LGBTQ+ community

• Including specific messaging for gender and sexual minorities in all media campaigns aimed at increasing education and outreach regarding tobacco