How to better address tobacco use and offer impactful treatment to members of the diverse LGBTQIA+ population
June is Pride Month, a nationwide celebration of the LGBTQIA+ population. This diverse group of individuals are heavily impacted by tobacco and nicotine use but often are less likely to get evidence-based cessation treatment or support.
I had the pleasure of speaking with Juliana Wilson (she/her), MSW, CTTS, the Gender and Sexual Minority (LGBTQIA+) Tobacco Treatment Coordinator for the North Carolina Department of Health and Human Services, Tobacco Prevention and Control Branch. She had some great insights on how Tobacco Treatment Specialists and other healthcare providers can better address tobacco use within this population and provide more effective care.
My first big takeaway from our conversation was the understanding that this is a diverse group of individuals with wildly different needs. This is why Juliana and her team are working on a health needs assessment for this population in North Carolina to better understand their tobacco use patterns and unique needs.
Rates of commercial tobacco product use among lesbian, gay, or bisexual adults were higher (25.1% vs 18.8%) compared to heterosexual/straight adults, according to a 2020 national survey.
Tell me a little bit more about the work you do at the NC Tobacco Control Branch.
The devastating impact of tobacco use is often unrecognized and deprioritized in this population. Most people are shocked to find out that tobacco use is the leading cause of death—most assume it is suicide. This creates a big challenge, so we are spending a lot of time on education. We are attending pride events throughout the state this summer, 35 in total. At our booth we play a Two Truths and a Lie game that helps people learn about the history of tobacco industry targeting of LGBTQIA+ folks. The tobacco industry has targeted this population with sophisticated targeted marketing campaigns beginning in the 1990s. Tobacco companies try to look gay-friendly by sponsoring events like prides and donating to queer causes. In the 1990s and early 2000s they gave out free tobacco products at our bars and clubs, which are our safe spaces. They also created specific products designed for the queer community—all of which contained menthol.
We know from the Tobacco Master Settlement documents that in 1995, Philip Morris created a marketing campaign targeting gay men and homeless people in San Francisco called “Sub-Culture Urban Marketing” or, to use their acronym, Project SCUM. Nowadays LGBTQIA+ identified folks see more ads and coupons for tobacco products and fewer ads for quitting on social media than the general population. All their advertising associates tobacco product use with experiencing pride, freedom, choice, and rebelliousness. Sharing this information can be very impactful with this group.
Transgender adults are over four times more likely to use e-cigarettes than cisgender individuals (31.3% transgender vs. 5.0% cisgender), according to a national 2017 study.
What unique challenges do individuals from the LGBTQIA+ population face in regards to tobacco use and treatment?
This population has experienced high levels of trauma. We have wildly higher rates of Adverse Childhood Experience (ACES). LGBTQIA+ youth experience higher levels of abuse and physical and sexual assault. Additionally, 28% of LGBTQIA+ youth experience homelessness or housing instability. So we are talking about people with a highly traumatized background, who are often using tobacco products to cope.
Lack of access to health insurance is another huge issue. As a population we have lower educational attainment and lower socioeconomic status, which limits access to healthcare in general. Our population has a higher percentage of individuals who don’t have a health care provider. This stems in part from stigma and a lack of cultural competency within healthcare. A lot of members of this population avoid accessing care because they have experienced or are afraid of experiencing mistreatment.
What can we do as Tobacco Treatment Specialists to provide better care to this population?
Become an ally. Always be respectful and treat LGBTQIA+ folks with kindness. Take courses on gender identity. Become familiar with terms. Get comfortable with these things. Have a personal experience and connection with the population—go to events, staff booths, volunteer with LGBTQIA+ groups. Look up how to be a good ally. When you’ve done this work yourself, then tell people about it by using a rainbow flag to signify that you are an ally.
Create a treatment environment that is safe and affirming. Make sure everyone in your organization has done trainings on cultural competency related to this population. Look at your intake forms. Do they only say male and female? Learn about gender. Here are some resources: The Trevor Project and Human Rights Campaign. Read about the range of options such as non-binary and other. Ask about pronouns and make sure all staff, including front desk staff, use them. For some people it can be very triggering when the wrong pronouns are used. It can feel like a punch in the stomach. Also, put a rainbow flag sticker on the door to your clinic. Perhaps find a Safe Zone training near you. Queer people are always looking for cues on whether they are safe or not.
Provide trauma informed care. Given the much higher rates of ACES and violence experienced by the LGBTQIA+ population, many individuals may be using tobacco products to cope. Being proficient in trauma informed care is important for providing successful tobacco treatment to this group.
Below is a list of additional resources for providing more tailored care to members of the LGBTQIA+ population:
QuitlineNC - https://quitlinenc.dph.ncdhhs.gov/tobacco-users/priority-populations/lesbian-gay-bi-sexual-transgender-lgbt.html
CDC - https://www.cdc.gov/tobacco/campaign/tips/groups/lgbt.html
National LGBT Cancer Network - https://cancer-network.org/outlast-tobacco/#
National LGBTQIA+ Health Education Center - https://www.lgbtqiahealtheducation.org/resources/
About the Author
Rachael Joyner, DNP, FNP-BC, APRN, is a family nurse practitioner with the Duke Smoking Cessation Program. She holds a National Certificate in Tobacco Treatment Practice and received her Doctorate in Nursing Practice from the University of Florida. She loves working collaboratively with patients to help them become tobacco free.
Visit www.dukeunctts.com to learn about our upcoming comprehensive tobacco treatment training and CE Short Course programs.
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