Nicotine & Tobacco Research Advance Access published April 7, 2015 Nicotine & Tobacco Research, 2015, 1–8 doi:10.1093/ntr/ntv066 Original investigation

Original investigation

Minority Stress, Smoking Patterns, and Cessation Attempts: Findings From a Community-Sample of Transgender Women in the San Francisco Bay Area Downloaded from http://ntr.oxfordjournals.org/ at University of Manitoba on November 13, 2015

Kristi E. Gamarel PhD1, Ethan H. Mereish PhD2,3, David Manning MPH3, Mariko Iwamoto MA4, Don Operario PhD1,2,3, Tooru Nemoto PhD4 1 Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, RI; 2Center for Alcohol and Addiction Studies, Brown University, Providence, RI; 3Department of Behavioral and Social Sciences, School of Public Health, Brown University, Providence, RI; 4Public Health Institute, Oakland, CA

Corresponding Author: Kristi E. Gamarel, PhD, Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, 121 South Main Street, Providence, RI 02912, USA. Telephone: 401-863-6631; Fax: 401-863-6647; E-mail: [email protected]

Abstract Introduction: Research has demonstrated associations between reports of minority stressors and smoking behaviors among lesbian, gay, and bisexual populations; however, little is known about how minority stressors are related to smoking behaviors and cessation attempts among transgender women. The purpose of this study was twofold: (1) to examine the associations between transgender-based discrimination and smoking patterns among a sample of transgender women; and (2) to identify barriers to smoking cessation in a sample of transgender women with a history of smoking. Methods: A community sample of 241 transgender women completed a one-time survey. Binary and multinomial logistic regression models examined associations between minority stressors and (1) smoking behaviors and (2) cessation attempts. Both models adjusted for income, education, race/ethnicity, recent sex work, HIV status, depression, alcohol use, and current hormone use. Results: Overall, 83% of participants indicated that they had smoked a cigarette in the last month. Of these women, 62.3% reported daily smoking and 51.7% reported an unsuccessful quit attempt. Discrimination was positively associated with currently smoking (adjusted odds ratio [AOR] = 1.04, 95% confidence interval [CI]: 1.01, 1.08). Discrimination was positively associated with unsuccessful cessation (AOR = 1.03, 95% CI: 1.01, 1.18) and never attempting (AOR = 1.04, 95% CI: 1.01, 1.11) compared to successful cessation. Discrimination was also positively associated with never attempting compared to unsuccessful cessation (AOR = 1.01, 95% CI: 1.00, 1.03). Conclusions: Smoking cessation may be driven by unique transgender-related minority stressors, such as discrimination. Future research is warranted to address unique stigmatizing contexts when understanding and providing tailored intervention addressing smoking among transgender women.

Introduction Despite advances in treating nicotine dependence, smoking is one of the most preventable causes of early mortality in the United States.1 The health burden of smoking affects sexual minorities (ie, lesbian, gay, and bisexual individuals) disproportionately more than

heterosexual individuals. Results from national samples consistently demonstrate high prevalence smoking among sexual minorities with roughly twice those of their heterosexual counterparts2–5; however, there is a dearth of research on smoking among gender minorities (ie, individuals who identify as transgender).6 Transgender

© Published by Oxford University Press on behalf of the Society for Research on Nicotine and Tobacco 2015. This work is written by (a) US Government employee(s) and is in the public domain in the US.

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Methods A total of 241 transgender women completed a cross-sectional questionnaire between August 2004 and July 2006. The overarching purpose of the parent project was to examine correlates of HIV risk among transgender women with a history of sex work.

More detailed information about the methodology of this study have been published elsewhere.30 Participants were recruited from the San Francisco Bay Area in California using purposive sampling methods that identified a range of community spaces and venues where transgender women congregate (eg, community-based organizations, bars, and nightclubs) and posting flyers. Participants who called the study were initially screened, with eligible participants scheduled for an in-person interview either at the research center or a conveniently located confidential space at a community-based organization. The sample design for the original study consisted of recruiting white transgender women who resided in San Francisco and Black/African American women who resided in Oakland, CA; other race/ethnic groups are not represented in this analysis. Additional inclusion criteria were as follows: (1) self-reported gender identity as a transgender or transsexual woman (pre- or postoperative); (2) at least 18 years of age; (3) able to provide informed consent.

Procedures Surveys were administered to participants using audio computerassisted self-interview technology. Surveys took approximately 1 hour to complete and participants received $50 in reimbursement, safe-sex kits, and a brochure with a list of local community organizations addressing transgender issues. Procedures were approved by the Institutional Review Boards at the Public Health Institute, Oakland and University of California San Francisco. Sociodemographics and Covariates Participants self-reported their age, race and ethnicity, HIV serostatus (positive, negative, or unknown), any engagement in sex work in the past 6 months, level of education, and income level. Participants who reported any lifetime smoking were also asked to report age of smoking initiation (in years). Key covariates of smoking behaviors and cessation attempts are alcohol use and depression.31,32 Thus, a binary variable was included for alcohol use in the past 30  days: 1 = use versus 0 = no use. Depression was assessed with the Center for Epidemiological Studies Depression Scale (α = 0.95).33 Transgender-Based Discrimination The discrimination scale34,35 consisting of 11 items measured the frequency of harmful or detrimental experiences related to being transgender or transitioning to become a woman as an adult. Participants were asked to answer the scale’s questions (eg, How often were you made fun of or called names for being transgender or effeminate) using a 5-point Likert scale ranging from never to almost daily (α  =  0.82). Transgender-related discrimination scores ranged from 11 to 45 (M = 26.63, SD = 7.83) with higher scores indicating greater endorsement of discrimination experiences. Smoking Participants were asked whether they had ever smoked cigarettes in their lifetime (yes/no). Participants who reported yes were then asked about the number of cigarettes that they smoke per day, responses included: a few times a week, 1–9 cigarettes per day, 10–19 cigarettes per day, 20 or more cigarette per day. These responses were collapsed into four categories: daily smoking (1 or more cigarettes per day), intermittent (a few times a week), not current smoker, and no smoking history.

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women—individuals assigned a male sex at birth who identify on the transfeminine spectrum as women, female, or male-to-female transgender—constitute a socially disadvantaged group who experience high rates of negative health outcomes, including depressive symptoms, substance use, and HIV risk.7–11 While research on smoking prevalence among transgender individuals is limited, smoking estimates have been shown to be high among transgender women.12–14 For example, one population-based study found that transgender people smoked at twice the rate of all Californians.15 Further, transgender individuals may be especially vulnerable to the consequences of tobacco use, particularly as cross-sex hormone use (ie, estrogens in male-bodied people and androgens in femalebodied people to induce or maintain the physical and psychological characteristics of the sex that matches an individual’s gender identity) among smokers increases the risk of heart disease,16 and smoking is shown to hinder recovery from surgery.17 In addition, among transgender persons there is a higher prevalence of risk factors (eg, heavy drinking) for diseases associated with or exacerbated by smoking, such as HIV infection.9,18 Many transgender people demonstrate resilience in the face of societal oppression19; however, studies have documented a greater prevalence of many other social, substance use, and mental health problems that may enhance smoking behaviors and serve as barriers to smoking cessation for transgender women.20,21 Minority stress frameworks22–25 have been applied to explain the elevated prevalence of mental health and substance use disorders among sexual minorities relative to their heterosexual counterparts. Recent adaptations of this framework to gender minorities has been conceptualized and empirically tested to explain the adverse effects of minority stressors on mental health and substance use outcomes among transgender individuals.26 Applying minority stress theory to transgender women, smoking can be conceptualized as a coping mechanism in response to pervasive experiences of transgender-related discrimination, such as violence, victimization, and being called prejudicial epithets. While studies have shown associations between transgender-based discrimination and health outcomes,7–11 there is a paucity of empirical work examining the effects of transgender-based discrimination on smoking among transgender women. Tobacco prevention and control have emerged as public health priorities for researchers, policy makers, and national organizations focused on sexual and gender minority populations.27 More recently, research studies have developed tailored interventions for sexual minority individuals.28,29 However, to our knowledge, studies have yet to examine the unique barriers to cessation among transgender women who may need specifically targeted interventions due to social oppression. To design effective smoking cessation interventions for transgender women, it is critical to examine the specific facilitators of smoking and barriers to smoking cessation. Thus, the purpose of this study was twofold: (1) to examine the associations between discrimination and smoking patterns among a sample of transgender women; and (2) to identify barriers to smoking cessation in a sample of transgender women with a history of smoking.

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Smoking Cessation Attempts Participants who had reported lifetime smoking were also asked: Have you ever attempted to quit smoking? (yes/no response). Based on their reported smoking behaviors, these responses were categorized into three outcomes: successful cessation (those who no longer smoked), unsuccessful cessation (those who continued to smoke and endorsed “yes” to attempting to quit), and never attempted (those who currently smoked and endorsed “no” to attempting to quit).

initiation. For each multivariate regression effect, we report the adjusted odds ratio, representing the change in odds of the outcome relative to the reference group per unit change in the independent variable, the 95% confidence interval for the odds ratio, and the P value testing the null hypothesis that the adjusted odds ratio = 1.00 (ie, the null hypothesis of no association).

Results Demographics

Statistical Analysis

As presented in Table 1, the sample ranged in age from 18 to 65 years (M = 36.52; SD = 10.5). Approximately half of the sample self-identified as Black/African American (n = 123, 51%) and the other half identified as white (n = 118, 49%). The sample was relatively diverse in regards to socioeconomic status, with 66.8% (n = 161) reporting less than a high school education and 63.9% (n  =  154) reporting an annual income of less than $1000 per month. Over half of the sample (n = 139, 57.7%) reported an HIV-positive serostatus as well as engagement in sex work in the past 6 months (n = 124, 51.9%). The majority of the sample reported current hormone use (n = 169, 70.1%). In regards to smoking behaviors, 72% (n = 174) reported that they had smoked cigarettes in their lifetime. Of the participants who reported smoking in their lifetime, 40% (n = 58) reported smoking a pack or more per day, 26% (n = 38) reported smoking 10–19 per day, 25% (n =36) reported smoking 1–9 per day, and 9% (n = 13) reported smoking a few a week. On average, participants had initiated smoking in the early teens (M = 14.77, SD = 5.16). A little over half of the 145 participants who indicated lifetime smoking had reported that they had previously attempted to quit (82.1%, n = 119).

Correlates of Smoking History and Cessation Attempts Associations between study variables and smoking history are presented in Table  1. White participants were significantly less likely

Table 1. Characteristics of Study Sample and by Smoking History (N = 241)

Race  White   Black/African American Less than high school degree Less than $1000, 30 days Alcohol use, 30 days Current hormone use HIV serostatus  HIV-positive  HIV-negative/unknown Sex work, past 6 months

Age Age at smoking initiation Depression Transgender-based discrimination

Total (N = 241)

Daily (N = 167)

Intermittent (N = 13)

Former (N = 29)

Never (N= 67)

N (%)

N (%)

N (%)

N (%)

N (%)

118 (49.0) 123 (51.0) 161 (66.8) 154 (63.9) 154 (63.9) 169 (70.1)

76 (57.6) 56 (42.4) 95 (72.0) 90 (68.2) 90 (68.2) 91 (68.9)

1 (0.8) 12 (92.3) 8 (61.5) 7 (53.8) 13 (100) 12 (92.3)

19 (65.5) 10 (34.5) 16 (55.2) 18 (62.1) 12 (41.4) 22 (75.9)

22 (67.2) 45 (32.8) 42 (62.7) 39 (58.2) 39 (58.2) 44 (65.7)

139 (57.7) 102 (42.3) 124 (51.9)

70 (53.0) 62 (47.0) 72 (54.5)

7 (53.8) 6 (46.2) 8 (61.5)

18 (62.1) 11 (37.9) 12 (41.4)

44 (65.7) 23 (34.3) 32 (49.2)

Test statistic X(3) = 22.93***

X(3) = 4.03 X(3) = 2.60 X(3) = 15.71** X(3) = 4.23 X(3) = 3.23

X(3) = 2.33

M (SD)

M (SD)

M (SD)

M (SD)

M (SD)

Test statistic

36.5 (10.5) 14.8 (5.2) 20.0 (13.1) 25.8 (8.2)

37.2 (10.2) 14.3 (5.3) 20.2 (13.0) 27.0 (7.5)a

32.3 (9.6) 17.6 (4.8) 16.2 (13.2) 23.0 (10.8)ab

39.8(11.1) 15.5 (4.3) 20.6 (15.3) 26.6 (7.5)ab

34.7(10.6) — 13.4 (12.3) 23.5 (8.8)b

F(3) = 2.57 F(2) = 2.28 F(3) = 1.54 F(3) = 3.37*

Numbers with different superscript letters differ significantly at P < .05 using Tukey’s honestly significant different post hoc tests. *P ≤ .05; **P ≤ .01; ***P ≤ .001.

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Descriptive statistics were obtained for all variables in the analysis, including the distribution of scale scores, with appropriate tests for normality. We then examined associations between study variables and smoking history and smoking cessation attempts. Next, we fit a logistic regression model to examine the association between discrimination and smoking status. Due to the small number of participants who reported intermittent smoking (n = 13), we collapsed daily and intermittent smokers into a current smoker category. Thus our smoking status outcome variable was: (0) nonsmoker versus (1) current smoker. The associations between discrimination and participants’ reports of smoking cessation were established using multinomial logistic regression. To better understand predictors of smoking cessation among transgender women who had a history of smoking, our primary outcome variable was operationalized to have three unordered smoking cessation categories: (0) unsuccessful, (1) successful, (2) never tried, which were regressed onto participants’ reports of discrimination. Participants who had never attempted to quit smoking served as the referent category. A  redundant model was calculated to determine the significance of parameters in differentiating between those who had successfully quit smoking compared with those who reported an unsuccessful cessation attempt. All multivariate models accounted for race/ethnicity, income, education, HIV status, sex work in the past 6 months, current hormone use, depression, alcohol use in the past 30 days, and age of smoking

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Predicting Current Smoking Behavior Table  3 presents results from the multivariate logistic regression model examining correlates of current smoking status. White participants who resided in San Francisco had nearly a fourfold increase in their odds of being a current smoker when compared with Black/ African American participants who resided in Oakland (adjusted odds ratio [AOR]  =  3.99, 95% confidence interval [CI]: 2.11, 7.55). HIV-positive participants were 49% less likely to be a current smoker when compared to participants who reported an HIVnegative or unknown serostatus (AOR = 0.51, 95% CI: 0.27, 0.94).

Higher levels of transgender-based discrimination were positively associated with an increase in the odds of being a current smoker (AOR = 1.04, 95% CI: 1.01, 1.08). No other variables were associated with current smoking behavior.

Predicting Cessation Attempts Among Participants With a Smoking History As shown in Table 4, a multivariate multinomial regression was conducted to explain smoking cessation status (ie, successful, unsuccessful, or never tried) from the independent variables listed previously, with successful attempt as the referent group. Participants’ reports Table 3. Logistical Regression Model Predicting Current Smoking (N = 241)

White (vs. Black identity) Less than high school (vs. higher) Less than $1000 (vs. more) Alcohol use (vs. no use) Hormone use (vs. no use) HIV-positive (vs. negative/unknown) Sex work, past 6 months (vs. none) Age Depression Transgender-based discrimination

AOR

95% CI

3.99*** 0.75 1.47 1.47 0.16 0.51* 1.02 1.05 1.27 1.04*

2.11, 7.55 0.40, 1.39 0.79, 2.73 0.79, 2.73 0.02, 1.41 0.27, 0.94 0.55, 1.87 0.97, 1.14 0.66, 2.42 1.01, 1.08

AOR = adjusted odds ratio; CI = confidence interval. Age of smoking initiation was not included in the models because it was only asked of participants who reported any smoking history. *P ≤ .05; **P ≤ .01; ***P ≤ .001.

Table 2. Characteristics of Participants Who Have a Smoking History and by Cessation Attempts (N = 174)

Race  White   Black/African American Less than high school degree Less than $1000, 30 days Alcohol use, 30 days Current hormone use HIV serostatus  HIV-positive  HIV-negative/unknown Sex work, past 6 months Current smoking status  None  Intermittent  Daily

Age Age at smoking initiation Depression Transgender-based discrimination

Total (N = 174)

Successful (N = 29)

Unsuccessful (N = 90)

Never tried (N = 55)

N (%)

N (%)

N (%)

N (%)

96 (55.2) 78 (44.8) 119 (68.4) 115 (66.1) 115 (66.1) 125 (71.8)

19 (65.5) 10 (34.5) 16 (55.2) 18 (62.1) 12 (41.4) 22 (75.9)

55 (61.1) 35 (38.9) 64 (71.1) 57 (63.3) 60 (66.7) 67 (74.4)

22 (40.0) 33 (60.0) 39 (70.9) 40 (72.7) 43 (78.2) 36 (65.5)

95 (54.6) 79 (45.4) 92 (52.9)

18 (62.1) 11 (37.9) 12 (41.4)

49 (54.4) 41 (45.6) 48 (53.3)

28 (50.9) 27 (49.1) 32 (58.2)

29 (16.7) 13 (7.5) 132 (75.9)

29 (100) 0 0

0 9 (10.0) 81 (90.0)

0 4 (7.3) 51 (92.7)

Test statistic X(2) = 7.66*

X(2) = 2.81 X(2) = 0.45 X(2) = 11.50** X(2) = 1.64 X(2) = 0.96

X(2) = 2.17

M (SD)

M (SD)

M (SD)

M (SD)

Test statistic

37.2 (10.4) 14.8 (5.2) 19.9 (13.3) 26.6 (7.8)

39.8 (11.1) 15.5 (4.3) 20.6 (15.3)a 26.6 (7.5)ab

37.8 (10.2) 14.1 (4.7) 22.7 (13.8)ab 29.1 (7.9)b

34.9 (10.1) 15.5 (6.2) 15.0 (9.8)b 22.6 (6.2)a

F(2, 173) = 2.39 F(2, 173) = 1.58 F(2, 173) = 6.10** F(2, 173) = 13.42***

Numbers with different superscript letters differ significantly at P < .05 using Tukey’s honestly significant different post hoc tests. *P ≤ .05; **P ≤ .01; ***P ≤ .001.

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to report never smoking compared with the Black participants. Participants who reported alcohol use were significantly more likely to report daily and intermittent smoking than participants who did not report alcohol use in the past 30 days. In addition, participants who reported daily smoking had significantly greater discrimination scores than participants who never smoked. Table  2 presents bivariate differences among participants by smoking cessation history. Black/African American participants were more likely to report never having tried to quit smoking, whereas white participants were significantly more likely to have both successful and unsuccessful quit attempts compared with Black participants. Participants who had successfully quit smoking were significantly less likely to report alcohol use in the past 30 days. Participants who had unsuccessfully attempted to quit smoking reported significantly higher rates of discrimination compared to both those who reported a successful cessation as well as those never having tried to quit smoking. In addition, participants who had unsuccessfully attempted to quit smoking had significantly higher depression scores compared to both those who successfully quit smoking and those who never tried.

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Table 4. Multinomial Logistic Regression Predicting Cessation Attempts Among Transgender Women With Smoking History (N = 174) Unsuccessful vs. successful (ref.)

White (vs. Black identity) Less than high school (vs. more) Less than $1000 (vs. higher) Alcohol use (vs. no use) Hormone use (vs. no use) HIV-positive (vs. negative/unknown) Sex work, past 6 months (vs. none) Age Age of initiation Depression Transgender-based discrimination

Never tried vs. successful (ref.)

Never tried vs. unsuccessful (ref.)

AOR

95% CI

AOR

95% CI

AOR

95% CI

1.00 3.59 0.65 0.33 1.62 1.31 0.64 0.98 0.98 0.66 1.03*

0.37, 2.66 0.90, 7.45 0.21, 1.97 0.11, 1.01 0.49, 5.37 0.46, 3.78 0.22, 1.81 0.93, 1.03 0.89, 1.08 0.21, 1.98 1.01, 1.18

1.88 1.80 1.08 0.37 0.85 1.54 0.85 0.99 0.97 0.49 1.04*

0.65, 5.14 0.71, 4.57 0.40, 2.92 0.14, 1.11 0.27, 2.64 0.58, 4.06 0.33, 2.20 0.94, 1.03 0.86, 1.05 0.18, 1.33 1.01, 1.11

1.05 1.31 0.56 2.74* 1.18 0.65 1.17 1.11 1.04 2.04 1.01*

0.38, 2.88 0.57, 3.03 0.22, 1.51 1.04, 7.18 0.38, 3.67 0.25, 1.72 0.45, 3.02 0.97, 1.06 0.95, 1.13 0.75, 5.52 1.00, 1.03

of transgender-related discrimination differentiated those who had unsuccessfully attempted to quit smoking from those who had successful quit. Specifically higher levels of transgender-based discrimination among participants were associated with an increased odds of reporting unsuccessful cessation when compared with those who reported successful cessation (AOR  =  1.03, 95% CI: 1.01, 1.18). Further, higher levels of transgender-related discrimination were associated with an increased odds of reporting never attempting to quit compared to those who reported successful cessation (AOR = 1.04, 95% CI: 1.01, 1.11). No other variables were associated with reporting unsuccessful or no smoking cessation attempts, compared to the successful cessation group. A redundant model was fit to compare participants who had never tried to quit smoking in contrast to those who reported an unsuccessful cessation attempt. Participants who reported never attempting to quit had an increased odds of transgender-based discrimination compared with those who reported unsuccessful cessation (AOR = 1.01, 95% CI: 1.00, 1.03). Further, those who reported never trying to quit smoking had an increased odds of reporting alcohol use compared to those who had an unsuccessful cessation attempt (AOR  =  2.74, 95% CI: 1.04, 7.18). There were no other variables associated with reporting never attempt to quit with unsuccessful cessation.

Discussion This study examined the role of minority stressors, specifically of transgender-based discrimination, on smoking patterns and cessation attempts among transgender women. First, we found that over 69% of the women in this sample reported being a current smoker. Those who reported currently smoking had significantly higher discrimination scores compared to transgender women who did not currently smoke. These findings are consistent with literature on sexual minority populations in the United States,36,37 documenting the importance of understanding discrimination in smoking research and intervention efforts. Over 60% of the current smokers in the study had attempted to quit in their lifetime; however, only 17% reported successful cessation, suggesting the need for tailored cessation interventions. Further, our findings indicated that higher transgender-based discrimination scores were reported by women who either reported unsuccessful

cessation attempts or reported never having tried to quit as compared to those who had successfully quit smoking. These findings identify an important target for smoking cessation interventions. The extant literature has documented that the stress associated with discrimination has been shown to hinder smoking cessation among sexual minority populations38; our findings extend the literature to suggest that transgender-based discrimination may be a barrier to cessation among transgender women. Existing smoking cessation interventions for lesbian, gay, bisexual, and transgender populations include only a small proportion of transgender individuals28,29; and don’t take into account transgender women’s unique facilitators and barriers to smoking cessation. Future research and relapse prevention treatment approaches are warranted to address how discrimination impacts the maintenance of quit rates over time among transgender populations. There were complex racial and geographic differences in smoking behaviors in this sample. Bivariate analyses indicated that white transgender women residing in San Francisco were more likely to be daily or former smokers compared with Black/African American transgender women; similarly, our multivariate analyses illustrated that white transgender women in San Francisco were significantly more likely to be current smokers compared with Black/African American transgender women residing in Oakland. Additionally, our bivariate results indicated that white transgender women residing in San Francisco were more likely to have smoking cessation attempts than Black/African American transgender women residing in Oakland. These racial differences are complex and could be related to the geographical regions these women reside and/or to their coping resources. Given that the white transgender women in the sample lived in San Francisco, a city with many smoking cessation programs and services, and the Black/African American transgender women in the sample lived in Oakland, the racial differences in smoking and smoking cessation could be indicative of differences in community norms and access to support services. Notably, 45.5% of Black/African American transgender women residing in Oakland were daily smokers; thus, it is important to also consider their unique risks for smoking. On average, we found that the transgender women in our sample were 14 years of age when they initiated smoking, which is approximately 2–4  years younger than national samples.39 However, these findings are accordance with research on sexual minority populations, which demonstrates that disparities in smoking among sexual minority populations begins at 14  years old.40

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AOR = adjusted odds ratio; CI = confidence interval. *P ≤ .05; **P ≤ .01; ***P ≤ .001.

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transgender women residing in Oakland and white transgender women in San Francisco who were recruited from high-risk venues where all of the participants enrolled in the study had a history of sex work (an artifact of the parent project), which limits the generalizability of these findings. Despite these limitations, our study adds to the literature by documenting the role of transgender-based discrimination in current smoking behaviors and smoking cessation attempts. Our findings suggest that more research is needed to examine smoking behaviors of transgender women, which is consistent with federal health priorities.6 The heterogeneity within gender minority communities alongside race/ethnicity, socioeconomic status, sexual identity, to name a few, are underexplored. Thus, more research is warranted to disentangle the complex ways in which discrimination influences smoking outcomes among diverse samples of transgender people to guide effective and culturally-appropriate smoking prevention and cessation interventions.

Limitations

References

Several limitations are important to consider in light of the current findings. First, the study population was not randomly selected and targeted a high-risk sample, a common limitation among studies with transgender populations, which is part because gender identity items have not been systematically included in representative, population surveys. Second, these data were collected in the San Francisco Bay Area, and thus may differ from other geographic locations where higher discrimination towards gender minorities persists. Third, data were collected over 10 years ago. In the fall of 2009, US federal legislation extended the definition of hate crimes to include violent crimes committed against people on the basis of their gender, gender identity, or sexual orientation,47 and there has been increasing positive representations of transgender people in the media.48 Thus, these data may overestimate associations between discrimination, smoking, and cessation. Fourth, this study relies on self-report data which may be subject to a social desirability bias. Fifth, causal or temporal claims cannot be drawn due to the cross-sectional study design. Sixth, we did not assess the dates or numbers of quit attempts, which limits our ability to examine differences between individual who attempted recently or had several quit attempts to those who attempted in the past. Seventh, alcohol use was assessed with a single-item measure, which did not account for frequency or quantity; therefore, limiting our ability to examine whether different levels of alcohol consumption were related to smoking and cessation. Finally, this study consists of a convenience sample of Black/African American

1. Centers for Disease Control and Prevention. Tobacco product use among adults—United States, 2012–2013. MMWR Morb Mortal Wkly Rep. 2014;63(25):542–547. www.cdc.gov/mmwr/preview/mmwrhtml/ mm6325a3.htm. Accessed September 13, 2014. 2. Lee JGL, Griffin GK, Melvin CL. Tobacco use among sexual minorities, USA, 1987–2007 (May): a systematic review. Tob Control. 2009;18(4):275–282. doi:10.1136/tobaccocontrol-2011–050181. 3. Gruskin EP, Greenwood GL, Matevia M, Pollack LM, Bye LL. Disparities in smoking between the lesbian, gay, and bisexual population and the general population in California. Am J Public Health. 2007;97(8):1496– 1502. doi:10.2105/AJPH.2006.090258. 4. Balsam KF, Beadnell B, Riggs KR. Understanding Sexual Orientation Health Disparities in Smoking: a population-based analysis. Am J Orthopsychiatry. 2012;82(4):482–493. doi:10.1111/j.1939-0025.2012.01186.x. 5. Cochran SD, Bandiera FC, Mays VM. Sexual orientation-related differences in tobacco use and secondhand smoke exposure among US adults aged 20 to 59  years: 2003–2010 National Health and Nutrition Examination Surveys. Am J Public Health. 2013;103(10):1837–1844. doi:10.2105/AJPH.2013.301423. 6. Institute of Medicine. The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding. Washington, DC: National Academic Press; 2011. 7. Barrientos J, Silva J, Catalan S, Gomez F, Longueira J. Discrimination and victimization: parade for lesbian, gay, bisexual, and transgender (LGBT) pride, in Chile. J Homosex. 2010;57(6):760–775. doi:10.1080/00918369. 2010.485880. 8. Hotton AL, Garofalo R, Kuhns LM, Johnson AK. Substance use as a mediator of the relationship between life stress and sexual risk among young

Funding This project was funded by grants R01 DA11589 and U24 AA022000 from the National Institute of Health (NIH), and NIH training grants T32MH078788 and T32DA016184.

Declaration of Interests None declared.

Acknowledgments We thank the collaborating community-based agencies, project staff, and study participants for their help in and implementing the study.

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We found no age differences in smoking patterns or cessation history; however, developmental considerations warrant future attention in smoking cessation research, including research with young transgender women. During the developmental period between early adolescence to young adulthood, many transgender women struggle with their identity and feel pressure to conform to familial, peer, and gender norms to avoid discrimination.41 Discriminatory experiences may be particularly harmful for young transgender women and result in severe consequences, such as homelessness, sex work, and incarceration.42,43 Research has shown that these experiences contribute to mental health and substance use problems.42–44 Thus, understanding the unique developmental factors associated with tobacco use may offer promising directions for appropriate and effective tobacco prevention interventions for young transgender women. Our findings illustrate that alcohol use may be an important deterrent to smoking cessation attempts among transgender women. In bivariate analyses, we found that daily and intermittent smokers were more likely to drink alcohol compared with former smokers and those who never smoked. Multivariate analyses revealed that drinking alcohol in the past 30 days was associated with an increased odds of never attempting to quit compared to unsuccessful cessation attempts. These findings are consistent with prior literature, which has shown that individuals who drink alcohol are more likely to smoke,31 and levels of tobacco use have been found to increase alongside levels of alcohol use.45 Further, discrimination has been associated with alcohol use among sexual minority populations,46 and alcohol use has been shown to be a barrier to both smoking cessation attempts and maintenance.31 As such, future research and intervention approaches are warranted to target both alcohol use and smoking among transgender women.

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28. Eliason MJ, Dibble SL, Gordon R, Soliz GB. The Last Drag: an evaluation of an LGBT-specific smoking intervention. J Homosex. 2012;59(6):864– 878. doi:10.1080/00918369.2012.694770. 29. Matthews AK, Balsam K, Hotton A, Kuhns L, Li C, Bowen DJ. Awareness of media-based antitobacco messages among a community sample of LGBT individuals. Health Promot Pract. 2014;15(6):857–866. doi:10.1177/152483991453334. 30. Nemoto T, Bödeker B, Iwamoto M. Social support, exposure to violence and transphobia, and correlates of depression among male-to-female transgender women with a history of sex work. Am J Public Health. 2011;101(10):1980–1988. doi:10.2105/AJPH.2010.197285. 31. Kahler CW, Strong DR, Papandonatos GD, et al. Cigarette smoking and the lifetime alcohol involvement continuum. Drug Alcohol Depend. 2008;93(1):111–120. doi:http://dx.doi.org/10.1016/j.drugalcdep.2007. 09.004. 32. Cargill BR, Emmons KM, Kahler CW, Brown RA. Relationship among alcohol use, depression, smoking behavior, and motivation to quit smoking with hospitalized smokers. Psychol Addict Behav. 2001;15(3):272– 275. doi:http://dx.doi.org/10.1037/0893-164X.15.3.272. 33. Radloff LS. The CES-D scale a self-report depression scale for research in the general population. Appl Psych Meas. 1977;1(3):385–401. doi:10.1177/014662167700100306. 34. Diaz RM, Ayala G, Bein E, Henne J, Marin BV. The impact of homophobia, poverty, and racism on the mental health of gay and bisexual Latino men: findings from 3 US cities. Am J Public Health. 2001;91(6):927–932. doi:10.2105/AJPH.91.6.927. 35. Sugano E, Nemoto T, Operario D. The impact of exposure to transphobia on HIV risk behavior in a sample of transgendered women of color in San Francisco. AIDS Behav. 2006;10(2):217–225. doi:10.1007/ s10461-005-9040-z. 36. Austin SB, Ziyadeh N, Fisher LB, Kahn JA, Colditz GA, Frazier AL. Sexual orientation and tobacco use in a cohort study of US adolescent girls and boys. Arch Pediatr Adolesc Med. 2004;158(4):317–322. doi:10.1001/ archpedi.158.4.317. 37. McCabe SE, Boyd C, Hughes TL, d’Arcy H. Sexual identity and substance use among undergraduate students. Subst Abus. 2003;24(2):77–91. doi:10 .1023/A:1023768215020. 38. Blosnich J, Horn K. Associations of discrimination and violence with smoking among emerging adults: differences by gender and sexual orientation. Nicotine Tob Res. 2011;13(12):1284–1295. doi:10.1093/ntr/ntr183. 39. Huxley RR, Yatsuya H, Lutsey PL, Woodward M, Alonso A, Folsom AR. Impact of age at smoking initiation, dosage, and time since quitting on cardiovascular disease in African Americans and Whites. The Atherosclerosis Risk in Communities Study. Am J Epidemiol. 2012;175(8):816–826. doi:10.1093/aje/kwr391. 40. Corliss HL, Rosario M, Birkett MA, Newcomb ME, Buchting FO, Matthews AK. Sexual orientation disparities in adolescent cigarette smoking: intersections with race/ethnicity, gender, and age. Am J Public Health. 2014;104(6):1137–1147. doi:10.2105/AJPH.2013.30181. 41. Stieglitz KA. Development, risk, and resilience of transgender youth. J Assoc Nurses AIDS Care. 2010;21(3):192–206. doi:10.1016/j. jana.2009.08.004. 42. Wilson EC, Garofalo R, Harris RD, et al. Transgender female youth and sex work: HIV risk and a comparison of life factors related to engagement in sex work. AIDS Behav. 2009;13(5):902–913. doi:10.1007/ s10461-008-9508-8. 43. Garofalo R, Deleon J, Osmer E, Doll M, Harper GW. Overlooked, misunderstood and at-risk: exploring the lives and HIV risk of ethnic minority male-to-female transgender youth. J Adolesc Health. 2006;38(3):230–236. doi:10.1016/j.jadohealth.2005.03.023. 44. Wilson EC, Garofalo R, Harris DR, Belzer M. Sexual risk taking among transgender male-to-female youths with different partner types. Am J Public Health. 2010;100(8):1500. doi:10.2105/AJPH.2009.160051. 45. Falk DE, Yi H, Hiller-Sturmhofel S. An epidemiologic analysis of co-occurring alcohol and tobacco use and disorders. Alcohol Res Health. 2006;29(3):162– 171. http://pubs.niaaa.nih.gov/publications/arh312/100–110.pdf. Accessed September 10, 2014.

Downloaded from http://ntr.oxfordjournals.org/ at University of Manitoba on November 13, 2015

transgender women. AIDS Educ Prev. 2013;25(1):62–71. doi:10.1521/ aeap.2013.25.1.62. 9. Nemoto T, Operario D, Keatley J, Han L, Soma T. HIV risk behaviors among male-to-female transgender persons of color in San Francisco. Am J Public Health. 2004;94(7):1193. www.ncbi.nlm.nih.gov/pmc/articles/ PMC1448420/. Accessed September 13, 2014. 10. Gamarel KE, Reisner SL, Laurenceau JP, Nemoto T, Operario D. Gender minority stress, mental health, and relationship quality: a dyadic investigation of transgender women and their cisgender male partners. J Fam Psych. 2014;28(4):437. doi:http://dx.doi.org/10.1037/a0037171. 11. Reisner SL, Gamarel KE, Nemoto T, Operario D. Dyadic effects of gender minority stressors in substance use behaviors among transgender women and their non-transgender male partners. Psychol Sex Orientat Gend Divers. 2014;1(1):63. doi:http://dx.doi.org/10.1037/0000013. 12. McElroy JA, Jordan J. Disparate perceptions of weight between sexual minority and heterosexual female college students. LGBT Health. 2014;1(2):122–130. doi:10.1089/lgbt.2013.0021. 13. Cabrera-Serrano A, Felici-Giovanini ME, Díaz-Toro EC, CasesRosario AL. Disproportionate tobacco use in the Puerto Rico lesbian, gay, bisexual, and transgender community of 18  years and over—a descriptive profile. LGBT Health. 2014;1(2):107–112. doi:10.1089/ lgbt.2013.0011. 14. Lee JGL. Keeping the community posted: lesbian, gay, bisexual, and transgender blogs and the tobacco epidemic. LGBT Health. 2014;1(2):113–121. doi:10.1089/lgbt.2013.0012. 15. Bye L, Gruskin E, Greenwood G, Albright V, Krotki K. California Lesbians, Gays, Bisexuals and Transgender (LGBT) Tobacco Use Survey—2004. Sacramento, CA: California Department of Health Services; 2005. 16. Mueck AO, Seeger H. Smoking, estradiol metabolism and hormone replacement therapy. Curr Med Chem Cardiovasc Hematol Agents. 2005;3(1):45–54. doi:http://dx.doi.org/10.2174/1568016052773270. 17. Silverstein P. Smoking and wound healing. Am J Med. 1992;93(1):S22– S24. doi:10.1016/0002-9343(92)90623-J. 18. Herbst JH, Jacobs ED, Finlayson TJ, McKleroy VS, Neumann MS, Crepaz N. Estimating HIV prevalence and risk behaviors of transgender persons in the United States: a systematic review. AIDS Behav. 2008;12(1):1–17. doi:10.1007/s10461-007-9299-3. 19. Levitt HM, Ippolito MR. Being transgender: navigating minority stressors and developing and authentic self-representation. Psych Women Quarterly. 2014;38(1):46–64. doi:10.1177/0361684313501644. 20. Grady ES, Humfleet GL, Delucchi KL, Reus VI, Muñoz RF, Hall SM. Smoking cessation outcomes among sexual and gender minority and nonminority smokers in extended smoking treatments. Nicotine Tob Res. 2014; 16(9):1207–1215. 21. Burkhalter JE, Warren B, Shuk E, Primavera L, Ostroff JS. Intention to quit smoking among lesbian, gay, bisexual, and transgender smokers. Nicotine Tob Res. 2009;11(11):1207–1215. doi:10.1093/ntr/ntu050. 22. Meyer IH. Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: conceptual issues and research evidence. Psychol Bull. 2003;129(5):674–697. doi:10.1037/0033-2909.129.5.674. 23. Herek G, Gillis J, Cogan J. Internalized stigma among sexual minority adults: insights from a social psychological perspective. J Couns Psychol. 2009;56(1):32–43. doi:http://dx.doi.org/10.1037/a0014672. 24. Hatzenbuehler M. How does sexual minority stigma “get under the skin”? A  psychological mediation framework. Psychol Bull. 2009;135(5):707– 730. doi:10.1037/a0016441. 25. Rosario M, Schrimshaw E, Hunter J, Gwadz M. Gay-related stress and emotional distress among gay, lesbian, and bisexual youths: a longitudinal examination. J Consult Clin Psychol. 2002;70(4):967–975. doi:http:// dx.doi.org/10.1037/0022-006X.70.4.967. 26. Hendricks M, Testa R. A conceptual framework for clinical work with transgender and gender nonconforming clients: an adaptation of the Minority Stress Model. Prof Psychol: Res Pr. 2012;43(5):460–467. doi:http://dx.doi.org/10.1037/a0029597. 27. American Lung Association. Smoking Out a Deadly Threat: Tobacco Use in the LGBT Community. Washington, DC: American Lung Association; 2010.

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8 46. Hatzenbuehler M, Corbin WR, Fromme K. Discrimination and alcohol-related problems among college students: a prospective examination of mediating effects. Drug Alcohol Depend. 2011;115(3):213–220. doi:10.1016/j.drugalcdep.2010.11.002.

Nicotine & Tobacco Research, 2015, Vol. 00, No. 00 47. Stout D. Senate approves broadened hate-crime measures. The New York Times. 2009. www.nytimes.com/2009/10/23/us/politics/23hate.html?_ r=0. Accessed December 17, 2014. 48. Stryker S. Transgender History. Berkeley, CA: Seal Press; 2008.

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Minority Stress, Smoking Patterns, and Cessation Attempts: Findings From a Community-Sample of Transgender Women in the San Francisco Bay Area.

Research has demonstrated associations between reports of minority stressors and smoking behaviors among lesbian, gay, and bisexual populations; howev...
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