Abstract

Introduction:

Little is known about preferences, intentions, and behaviors regarding evidence-based cessation treatment for smoking cessation among gay, lesbian, bisexual, and transgendered (GLBT) adults.

Methods:

We obtained and analyzed questionnaire responses from GLBT smokers (n= 1,633) surveyed in 129 GLBT-identified Colorado venues and online during 2007.

Results:

Most respondents (80.4%) smoked daily. Nearly one-third smoked 20 or more cigarettes/day. Fewer than half (47.2%) had attempted quitting in the previous year, and only 8.5% were preparing to quit in the next month. More than one-fourth (28.2%) of quit attempters had used nicotine replacement therapy (NRT), and a similar proportion said they intended to use NRT in their next quit attempt. Lesbians were significantly less likely than gay men to have used or intend to use NRT. One-fourth of respondents said they were uncomfortable talking to their doctor about quitting smoking. Four factors (daily smoking, ever having used NRT, a smoke-free home rule, and comfort asking one’s doctor for cessation advice) were associated with preparation to quit smoking.

Conclusions:

GLBT self-identification was not associated with lower than average acceptance of evidence-based smoking cessation strategies, especially NRT, but a large minority of GLBT smokers were unlikely to seek cessation assistance through clinical encounters. Public health campaigns should focus on supporting motivation to quit and providing nonclinical access to evidence-based treatments.

Introduction

Cigarette smoking is roughly twice as prevalent among gay, lesbian, bisexual, and transgendered (GLBT) adults as it is among heterosexual adults (Cochran et al., 2001; Dilley et al., 2005; Easton, Jackson, Mowery, Comeau, & Sell, 2008; Gruskin & Gordon 2006; Gruskin, Greenwood, Matevia, Pollack, & Bye, 2007; Hughes, Johnson, & Matthews, 2008; Lee, Griffin, & Melvin, 2009; McElroy, Everett, & Zaniletti, 2011; Pizacani et al., 2009; Ryan, Wortley, Easton, Pederson, & Greenwood, 2001; Tang et al., 2004). Proposed explanations include elevated social stress with higher risk of mental disorders due to stigma, prejudice, rejection, and homophobia (Meyer, 2003); more prevalent substance use and risky health behaviors, perhaps as a coping response to social stress (Garofalo, Wolf, Kessel, Palfrey, & DuRant, 1998; Lee et al., 2009; Sheahan & Garrity, 1992); and aggressive, targeted cigarette industry marketing campaigns, including community outreach and sponsorships (Dilley, Spigner, Boysun, Dent, & Pizacani, 2008; Offen, Smith, & Malone, 2008; Smith, Thomson, Offen, & Malone, 2008; Stevens, Carlson, & Hinman, 2004). Higher smoking prevalence may also reflect lower cessation rates, which typically result from lower rates of cessation attempts or successful outcomes. Since evidence-based smoking cessation treatments increase the likelihood of success, the question arises whether GLBT smokers are less likely than other smokers to use evidence-based treatment in quit attempts. However, few studies have reported on cessation methods used or preferred by GLBT smokers. A four-city study of urban men who have sex with men (MSM) found that 19% of MSM ex-smokers had used nicotine replacement therapy (NRT) as an aid to quitting (Greenwood et al., 2005). A small survey study found no evidence that GLBT-specific variables were associated with intention to quit smoking, a construct that predicts attempts to quit in both general populations and in subpopulations (Burkhalter, Warren, Shuk, Primavera, & Ostroff, 2009). Regarding preferred cessation counseling or coaching approaches, some but not all GLBT quit attempters prefer GLBT-targeted group support (Harding, Bensley, & Corrigan, 2004; Schwappach, 2008). Limited evidence suggests that cessation programs can be effective among gay/bisexual populations whether they are targeted specifically to GLBT smokers or designed without regard to GLBT identity (Covey, Weissman, LoDuca, & Duan, 2009; Harding et al., 2004).

The current study addressed the knowledge gap regarding preferences, intentions, and behaviors related to evidence-based smoking cessation treatment (NRT, counseling, prescription medicines) by surveying a large sample of GLBT smokers.

Methods

Sample

The GLBT Community Center of Colorado (Center) and other GLBT organizations across Colorado recruited respondents at 129 separate venues; 28% of surveys were completed at GLBT events, 19% at GLBT bars or nightclubs, 17% online, and the remainder in GLBT centers, homes, outdoor public spaces, or other settings. Recruiters were staff and volunteers from eight GLBT-identified community organizations. The recruiters approached prospective respondents face-to-face and explained that the survey was for GLBT current smokers, respondents would remain anonymous, and results would be used to help improve smoking cessation programs for GLBT individuals. Respondents completed the paper questionnaire or received a web address for online completion. Participating community organizations also posted the survey’s web address on their Web sites and in their centers. About half of respondents received appreciation tokens for completing the survey, including smoking cessation “Quit Kits,” tote-bags, t-shirts, gum, food, and other small items. Data were collected during January to July 2007 by the Center and seven partner agencies around the state.

Two-thousand sixty-two questionnaires were received, including 414 completed online. Questionnaires with extensive missing information (n = 129, 6.3%) were removed from the data file, and 166 questionnaires (8.1%) were deemed ineligible for exclusively heterosexual orientation and behavior or no current smoking. Age was collected categorically (18–24, 25–64 in 10-year increments, 65+). Although all ages were eligible to complete the survey, the analytic sample was reduced to ages 18–54 because younger (n = 74) and older (n = 60) subsamples were too small to support the intended analysis of smoking and quitting behaviors and intentions, which often differ between young, middle-aged, and older age groups (Al-Delaimy, Pierce, White, Trinidad, & Gilpin, 2007; Clark, Hogan, Kviz, & Prohaska, 1999; Kviz, Clark, Crittenden, Freels, & Warnecke, 1994, Kviz, Clark, Crittenden, Warnecke, & Freels, 1995; Maguire et al., 2000; Messer et al., 2007). The final sample included 1,633 respondents aged 18–54.

Although large, the sample was not randomly selected. To explore its generality, secondary data were obtained from the Colorado Tobacco Attitudes and Behaviors Survey (TABS). In brief, TABS is a repeated cross-sectional general population study that conducts anonymous random-digit–dialed telephone interviews among a stratified, multistage household-based sample of adults aged 18+ (n ∼ 13,000 per wave). Constructed weights in the data file support inferential estimation to represent the Colorado adult population in the year of the survey. Further details of TABS methods are available elsewhere (Levinson, Pérez-Stable, Espinoza, Flores, & Byers, 2004). Almost all TABS respondents (97%) reported sexual identity (heterosexual, gay/lesbian, bisexual, other). Respondents in 2005 and 2008 included a total of 125 self-identified GLBT smokers aged 18–54.

Study Measures

AHL, in consultation with the Center, developed a questionnaire about smoking cessation attitudes, beliefs, behaviors, preferences, and resource access. The draft questionnaire was pilot-tested among a small number of GLBT individuals to see if they understood and could answer the questions and then was revised and retested with different individuals; pilot-test respondents were GLBT smokers (n = 11) who were regular Center visitors. The final questionnaire was printed in English and Spanish and also made available online in English (SurveyMonkey, Portland, OR). Items included in the current study are listed in Table 1.

Table 1.

Measures for Current Study

Smoking behaviors • Lifetime smoking of 100 or more cigarettes
• Current smoking (every day or some days)
• Usual number of CPD 
Smoking environment • Significant other or household member who smokes
• Complete voluntary home smoking restriction 
Cessation history and intentions • Past-year quit attempt (24+ hr)
• Duration of most recent abstinence
• Intention to quit (never/not in next 6 months/in next 6 months/in next month) 
Cessation aid history and attitudes • Used in most recent quit attempt
• Intention to use in next quit attempt
• Beliefs about NRT safety/efficacy
• Preferred cessation aid if free
• Appeal of specific quitline or group-session features 
GLBT attitudes and behaviors • Participation in one GLBT events or activities in the past 12 months (e.g., read GLBT newspapers, attended events sponsored by GLBT organization)
• Internalized homophobia (four-item scale, e.g., I wish I were heterosexual; Bye, Gruskin, Greenwood, Albright, & Krotki, 2005)
• Agreement that smoking is a bigger health problem for GLBT people than for others. 
Health and health care • Perceived health status
• Number of days in past 30 with poor physical or mental health
• Health insurance
• Past-year doctor’s visit
• Usual health facility (excluding emergency department) 
Demographic characteristics • Sexual orientation (gay, lesbian, bisexual, other)
• Gender (male or female, with transgender categories coded as current gender, or intersex)
• Gender of sex partners (men only, women only, mostly men, mostly women, men and women about equally)
• Age group
• Ethnicity (White, Hispanic, Black, other)
• Highest grade or year of school completed
• Household income 
Smoking behaviors • Lifetime smoking of 100 or more cigarettes
• Current smoking (every day or some days)
• Usual number of CPD 
Smoking environment • Significant other or household member who smokes
• Complete voluntary home smoking restriction 
Cessation history and intentions • Past-year quit attempt (24+ hr)
• Duration of most recent abstinence
• Intention to quit (never/not in next 6 months/in next 6 months/in next month) 
Cessation aid history and attitudes • Used in most recent quit attempt
• Intention to use in next quit attempt
• Beliefs about NRT safety/efficacy
• Preferred cessation aid if free
• Appeal of specific quitline or group-session features 
GLBT attitudes and behaviors • Participation in one GLBT events or activities in the past 12 months (e.g., read GLBT newspapers, attended events sponsored by GLBT organization)
• Internalized homophobia (four-item scale, e.g., I wish I were heterosexual; Bye, Gruskin, Greenwood, Albright, & Krotki, 2005)
• Agreement that smoking is a bigger health problem for GLBT people than for others. 
Health and health care • Perceived health status
• Number of days in past 30 with poor physical or mental health
• Health insurance
• Past-year doctor’s visit
• Usual health facility (excluding emergency department) 
Demographic characteristics • Sexual orientation (gay, lesbian, bisexual, other)
• Gender (male or female, with transgender categories coded as current gender, or intersex)
• Gender of sex partners (men only, women only, mostly men, mostly women, men and women about equally)
• Age group
• Ethnicity (White, Hispanic, Black, other)
• Highest grade or year of school completed
• Household income 

Note. CPD = cigarettes/day; NRT = nicotine replacement therapy; GLBT = gay, lesbian, bisexual, and transgendered.

Analysis

Item-missing and inconsistent responses for age, sexual orientation, gender, or ethnicity were resolved if possible by inspection of the original questionnaire. Remaining missing values on these items were imputed using predicted values from best subsets regression (Stata “impute”; see Little & Rubin, 2002); 7.3% of cases were imputed on one or more of the four demographic items. Analyses were conducted during 2010–2011 using Stata 10.1 software (StataCorp, College Station, TX). Demographic and health-related estimates were examined in both samples (GLBT survey and secondary general-population data) to explore representativeness of the study sample. Differences were designated as potential sample limitations if confidence intervals did not overlap. Logistic regression was used to compare smoking and quitting behaviors by sexual orientation (gay, lesbian, bisexual male or female), adjusted for age group, ethnicity, and education. Logistic regression was also used to identify factors associated with preparation to quit smoking, defined as having a past-year quit attempt lasting 24 hr or longer and an intention to quit smoking in the next month (Velicer, Prochaska, Fava, Norman, & Redding, 1998). Model building followed purposeful selection, and final model fits were good (Hosmer & Lemeshow, 2000).

No author had a financial interest in the results of the study.

Results

Characteristics and Health Status

The sample comprised 45% gay men, 38% lesbians, 14% bisexual men and women, and 2% transgendered individuals (Table 2). Two-thirds were aged 18–35; 22% were Hispanic or Latino, 10% were Black or African American, 2% were American Indian, and 2% were Asian American. Nearly two-thirds (63.1%) had completed at least some college. Eleven percent described their general health status as fair or poor, and 40% had no health insurance. Half did not have a smoke-free home rule, and nearly half (48%) resided with another smoker. Compared with population-weighted GLBT smokers, the sample had similar demographic and health characteristics except sexual orientation (respondents were more likely to be gay or lesbian and less likely bisexual), ethnicity (less White and more Black/African American), income (lower household income), and perceived general health status (more reporting “excellent” and fewer reporting “poor” health). A comparison table is available from AHL upon request.

Table 2.

Demographic and Health-Related Characteristics of Survey-Respondent GLBT Smokers (n = 1,633), Colorado 2007

 95% CI 
Sex 
    Male 50.2 47.8, 52.6 
    Female 46.8 44.4, 49.2 
    Transgender 2.0 1.3, 2.6 
    Intersex 1.0 0.5, 1.5 
Self-identified sexual orientation 
    Gay 44.9 42.5, 47.3 
    Lesbian 38.2 35.9, 40.6 
    Bisexual (male) 5.3 4.2, 6.4 
    Bisexual (female) 8.6 7.2, 9.9 
    Other 3.0 2.2, 3.8 
Age (years) 
    18–24 36.6 34.3, 39.0 
    25–34 30.3 28.0, 32.5 
    35–44 20.6 18.7, 22.6 
    45–54 12.5 10.9, 14.1 
Ethnicity 
    Hispanic or Latino 22.0 20.0, 24.0 
    White or Caucasian 60.2 57.8, 62.6 
    Black or African American 9.9 8.4, 11.3 
    Asian or Asian American 1.9 1.2, 2.6 
    American Indian 2.0 1.3, 2.7 
    Other/multiracial 4.0 3.1, 5.0 
Education 
    0–8 years 1.3 0.7, 1.8 
    9–11 years 10.7 9.1, 12.2 
    High school graduate 24.9 22.7, 27.1 
    Some college 35.3 32.9, 37.7 
    College graduate or more 27.8 25.6, 30.1 
Annual household income 
    <$15,000 19.0 17.0, 21.0 
    $15,000 to <$25,000 23.1 21.0, 25.3 
    $25,000 to <$35,000 21.3 19.2, 23.3 
    $35,000 to <$50,000 17.9 16.0, 19.9 
    $50,000 or more 18.7 16.7, 20.6 
Perceived health status 
    Excellent 23.0 20.9, 25.2 
    Very good 35.7 33.3, 38.1 
    Good 30.4 28.1, 32.7 
    Fair 9.6 8.1, 11.1 
    Poor 1.3 0.7, 1.8 
Other health and environmental indicators 
    Days physical health not good 3.3 3.0, 3.6 
    Days mental health not good 5.8 5.3, 6.2 
    Have a regular health facility 54.0 51.5, 56.4 
    Visited MD in last 12 months 44.9 42.4, 47.4 
    Have health insurance 59.8 57.3, 62.3 
    Have smoke-free home policy 50.5 48.1, 52.9 
    Other household member smokes 47.8 45.4, 50.2 
 95% CI 
Sex 
    Male 50.2 47.8, 52.6 
    Female 46.8 44.4, 49.2 
    Transgender 2.0 1.3, 2.6 
    Intersex 1.0 0.5, 1.5 
Self-identified sexual orientation 
    Gay 44.9 42.5, 47.3 
    Lesbian 38.2 35.9, 40.6 
    Bisexual (male) 5.3 4.2, 6.4 
    Bisexual (female) 8.6 7.2, 9.9 
    Other 3.0 2.2, 3.8 
Age (years) 
    18–24 36.6 34.3, 39.0 
    25–34 30.3 28.0, 32.5 
    35–44 20.6 18.7, 22.6 
    45–54 12.5 10.9, 14.1 
Ethnicity 
    Hispanic or Latino 22.0 20.0, 24.0 
    White or Caucasian 60.2 57.8, 62.6 
    Black or African American 9.9 8.4, 11.3 
    Asian or Asian American 1.9 1.2, 2.6 
    American Indian 2.0 1.3, 2.7 
    Other/multiracial 4.0 3.1, 5.0 
Education 
    0–8 years 1.3 0.7, 1.8 
    9–11 years 10.7 9.1, 12.2 
    High school graduate 24.9 22.7, 27.1 
    Some college 35.3 32.9, 37.7 
    College graduate or more 27.8 25.6, 30.1 
Annual household income 
    <$15,000 19.0 17.0, 21.0 
    $15,000 to <$25,000 23.1 21.0, 25.3 
    $25,000 to <$35,000 21.3 19.2, 23.3 
    $35,000 to <$50,000 17.9 16.0, 19.9 
    $50,000 or more 18.7 16.7, 20.6 
Perceived health status 
    Excellent 23.0 20.9, 25.2 
    Very good 35.7 33.3, 38.1 
    Good 30.4 28.1, 32.7 
    Fair 9.6 8.1, 11.1 
    Poor 1.3 0.7, 1.8 
Other health and environmental indicators 
    Days physical health not good 3.3 3.0, 3.6 
    Days mental health not good 5.8 5.3, 6.2 
    Have a regular health facility 54.0 51.5, 56.4 
    Visited MD in last 12 months 44.9 42.4, 47.4 
    Have health insurance 59.8 57.3, 62.3 
    Have smoke-free home policy 50.5 48.1, 52.9 
    Other household member smokes 47.8 45.4, 50.2 

Note. GLBT = gay, lesbian, bisexual, and transgendered.

Smoking and Quitting Behaviors

More than four-fifths of respondents (80.4%) smoked daily; compared with gay men, lesbians and bisexuals of both sexes had significantly lower adjusted odds ratios (AORs, adjusted for age, ethnicity, and education) for daily smoking (Table 3). Among daily smokers, nearly one-third (31.0%) smoked heavily (≥20 cigarettes/day [CPD]) and a similar proportion (29.0%) were light smokers (<10 CPD).

Table 3.

Smoking and Cessation Behaviors and Intentions by Sexual Orientation: GLBT Smokers Aged 18–54, Colorado 2007

  95% CI AOR 95% CI n 
Smoking status and dependence 
    Smoke daily Gay 84.1 81.4, 86.8 1.00 – 724 
Lesbian 77.9 74.6, 81.2 0.69* 0.51, 0.94 615 
Bisexual (male) 74.7 65.5, 83.9 0.55* 0.32, 0.94 87 
Bisexual (female) 77.1 70.2, 84.1 0.58* 0.36, 0.92 140 
Other 75.5 63.3, 87.7 0.50 0.25, 1.01 49 
    Smoke 1–9 CPDa Gay 29.2 25.6, 32.8 1.00 – 609 
Lesbian 29.0 24.9, 33.1 0.89 0.66, 1.19 479 
Bisexual (male) 18.5 8.9, 28.0 0.47* 0.24, 0.93 65 
Bisexual (female) 33.3 24.4, 42.3 1.16 0.73, 1.85 108 
Other 29.7 14.8, 44.7 0.75 0.33, 1.69 37 
    Smoke 20+ CPDa Gay 35.0 31.2, 38.8 1.00 – 609 
Lesbian 27.3 23.3, 31.3 0.83 0.63, 1.10 479 
Bisexual (male) 29.2 18.1, 40.4 0.87 0.48, 1.56 65 
Bisexual (female) 24.1 16.0, 32.2 0.74 0.45, 1.20 108 
Other 37.8 22.0, 53.7 1.41 0.68, 2.93 37 
Cessation history 
    Quit attempt in past year Gay 44.5 40.8, 48.1 1.00 – 713 
Lesbian 47.5 43.6, 51.5 1.12 0.88, 1.41 608 
Bisexual (male) 51.2 40.4, 62.0 1.30 0.82, 2.07 84 
Bisexual (female) 54.7 46.4, 63.0 1.65* 1.12, 2.42 139 
Other 54.3 39.8, 68.9 1.53 0.82, 2.84 46 
    Abstinent > 6 months in last quit attemptb Gay 14.4 10.5, 18.3 1.00 – 313 
Lesbian 12.9 8.9, 16.8 0.99 0.60, 1.63 280 
Bisexual (male) 14.0 3.5, 24.5 0.93 0.36, 2.38 43 
Bisexual (female) 14.7 6.6, 22.7 1.32 0.62, 2.81 75 
Other 4.0 0.0, 11.9 0.26 0.03, 2.00 25 
    Used NRT in last quit attemptb Gay 33.7 28.4, 38.9 1.00 – 312 
Lesbian 23.7 18.7, 28.7 0.61* 0.42, 0.90 279 
Bisexual (male) 27.9 14.3, 41.5 0.85 0.41, 1.75 43 
Bisexual (female) 24.0 14.3, 33.7 0.63 0.35, 1.15 75 
Other 24.0 6.9, 41.1 0.70 0.26, 1.86 25 
    Used quitline in last quit attemptb Gay 7.7 4.7, 10.7 1.00 – 312 
Lesbian 7.2 4.1, 10.2 0.76 0.39, 1.49 279 
Bisexual (male) 9.3 0.5, 18.1 1.22 0.39, 3.84 43 
Bisexual (female) 4.0 0.0, 8.5 0.39 0.11, 1.38 75 
Other 12.0 0.0, 25.0 1.37 0.37, 5.08 25 
Intentions to quit 
    Preparation Gay 8.5 6.5, 10.6 1.00 – 727 
Lesbian 8.3 6.2, 10.5 0.93 0.61, 1.40 611 
Bisexual (male) 6.0 0.9, 11.0 0.66 0.26, 1.70 84 
Bisexual (female) 10.3 5.2, 15.4 1.40 0.74, 2.63 136 
Other 8.5 0.4, 16.6 1.18 0.40, 3.45 47 
    Contemplation Gay 21.0 18.1, 24.0 1.00 – 727 
Lesbian 22.3 19.0, 25.6 1.03 0.78, 1.37 611 
Bisexual (male) 21.4 12.6, 30.3 1.02 0.58, 1.79 84 
Bisexual (female) 25.7 18.4, 33.1 1.26 0.81, 1.95 136 
Other 17.0 6.2, 27.9 0.82 0.37, 1.82 47 
  95% CI AOR 95% CI n 
Smoking status and dependence 
    Smoke daily Gay 84.1 81.4, 86.8 1.00 – 724 
Lesbian 77.9 74.6, 81.2 0.69* 0.51, 0.94 615 
Bisexual (male) 74.7 65.5, 83.9 0.55* 0.32, 0.94 87 
Bisexual (female) 77.1 70.2, 84.1 0.58* 0.36, 0.92 140 
Other 75.5 63.3, 87.7 0.50 0.25, 1.01 49 
    Smoke 1–9 CPDa Gay 29.2 25.6, 32.8 1.00 – 609 
Lesbian 29.0 24.9, 33.1 0.89 0.66, 1.19 479 
Bisexual (male) 18.5 8.9, 28.0 0.47* 0.24, 0.93 65 
Bisexual (female) 33.3 24.4, 42.3 1.16 0.73, 1.85 108 
Other 29.7 14.8, 44.7 0.75 0.33, 1.69 37 
    Smoke 20+ CPDa Gay 35.0 31.2, 38.8 1.00 – 609 
Lesbian 27.3 23.3, 31.3 0.83 0.63, 1.10 479 
Bisexual (male) 29.2 18.1, 40.4 0.87 0.48, 1.56 65 
Bisexual (female) 24.1 16.0, 32.2 0.74 0.45, 1.20 108 
Other 37.8 22.0, 53.7 1.41 0.68, 2.93 37 
Cessation history 
    Quit attempt in past year Gay 44.5 40.8, 48.1 1.00 – 713 
Lesbian 47.5 43.6, 51.5 1.12 0.88, 1.41 608 
Bisexual (male) 51.2 40.4, 62.0 1.30 0.82, 2.07 84 
Bisexual (female) 54.7 46.4, 63.0 1.65* 1.12, 2.42 139 
Other 54.3 39.8, 68.9 1.53 0.82, 2.84 46 
    Abstinent > 6 months in last quit attemptb Gay 14.4 10.5, 18.3 1.00 – 313 
Lesbian 12.9 8.9, 16.8 0.99 0.60, 1.63 280 
Bisexual (male) 14.0 3.5, 24.5 0.93 0.36, 2.38 43 
Bisexual (female) 14.7 6.6, 22.7 1.32 0.62, 2.81 75 
Other 4.0 0.0, 11.9 0.26 0.03, 2.00 25 
    Used NRT in last quit attemptb Gay 33.7 28.4, 38.9 1.00 – 312 
Lesbian 23.7 18.7, 28.7 0.61* 0.42, 0.90 279 
Bisexual (male) 27.9 14.3, 41.5 0.85 0.41, 1.75 43 
Bisexual (female) 24.0 14.3, 33.7 0.63 0.35, 1.15 75 
Other 24.0 6.9, 41.1 0.70 0.26, 1.86 25 
    Used quitline in last quit attemptb Gay 7.7 4.7, 10.7 1.00 – 312 
Lesbian 7.2 4.1, 10.2 0.76 0.39, 1.49 279 
Bisexual (male) 9.3 0.5, 18.1 1.22 0.39, 3.84 43 
Bisexual (female) 4.0 0.0, 8.5 0.39 0.11, 1.38 75 
Other 12.0 0.0, 25.0 1.37 0.37, 5.08 25 
Intentions to quit 
    Preparation Gay 8.5 6.5, 10.6 1.00 – 727 
Lesbian 8.3 6.2, 10.5 0.93 0.61, 1.40 611 
Bisexual (male) 6.0 0.9, 11.0 0.66 0.26, 1.70 84 
Bisexual (female) 10.3 5.2, 15.4 1.40 0.74, 2.63 136 
Other 8.5 0.4, 16.6 1.18 0.40, 3.45 47 
    Contemplation Gay 21.0 18.1, 24.0 1.00 – 727 
Lesbian 22.3 19.0, 25.6 1.03 0.78, 1.37 611 
Bisexual (male) 21.4 12.6, 30.3 1.02 0.58, 1.79 84 
Bisexual (female) 25.7 18.4, 33.1 1.26 0.81, 1.95 136 
Other 17.0 6.2, 27.9 0.82 0.37, 1.82 47 

Notes. GLBT = gay, lesbian, bisexual, and transgendered; AOR = odds ratio adjusted for age, ethnicity, and education; CPD = cigarettes/day; NRT = nicotine replacement therapy.

a

Among daily smokers.

b

Among past-year quit attempters.

*p < .05.

Fewer than half of respondents (47.2%) had attempted quitting during the preceding 12 months; bisexual females were 65% more likely than gay men to have made a past-year quit attempt. Among those who did attempt to quit in the past year, 28.2% used NRT, including one-third of gay men; 7.4% used a telephone quitline, and less than 1% used a cessation prescription medicine. Lesbian smokers were significantly less likely than gay (male) smokers to have used NRT in past quit attempts.

Regarding intentions to quit, only 8.5% were preparing to quit, and more than two-thirds (67.6%) were not contemplating cessation (no intention to quit in the next 6 months).

Intentions and Attitudes Regarding Cessation Aids

More than one-fourth (28.0%) of respondents said they intended to use NRT in the next quit attempt; lesbians and bisexual females were significantly less likely than gay men to intend to use NRT (AOR = 0.75, CI = 0.58–0.96, and AOR = 0.57, CI = 0.36–0.90, respectively). About one in eight respondents (13.3%) said they intended to use quitline support in the next quit attempt, with lesbians significantly more likely than gay men to say so (AOR = 1.48, CI = 1.06–2.07). Fewer than 10% said they would use the Internet, a cessation class or program, or prescription cessation medicine in their next quit attempt, with no significant differences by sexual orientation.

Under a hypothetical scenario of cost-free availability, interest in using NRT or a prescription cessation medicine was more widespread overall and within each sexual orientation group than when interest was assessed without the cost-free scenario (data not shown). At the same time, inaccurate beliefs about NRT were widespread. More than half (53.0%) believed NRT is “as addictive as cigarettes,” 44.6% believed NRT “can cause heart attacks,” and 27.3% believed that NRT is “as carcinogenic as smoking”; all three beliefs are incorrect. Bisexual males were more than twice as likely as gay men to believe NRT can cause heart attacks (AOR = 2.32, CI = 1.43–3.76); bisexual males and respondents with “other” sexual orientations were twice as likely as gay men to believe NRT is as carcinogenic as smoking (AOR = 2.68, CI = 1.66–4.32, and AOR = 2.72, CI = 1.46–5.08, respectively).

Roughly two-thirds to three-fourths of respondents said four hypothetical features would increase the likelihood that they would use a smoking cessation quitline: proven effectiveness (74.9%), expert advice (70.8%), free NRT (68.5%), and confidentiality (63.0%). In contrast, 43% of respondents said they were less likely to use a quitline if they could not talk to the same coach each time they connected to the quitline. Almost one-third (30.5%) were less likely to use a quitline that does not offer GLBT-identified coaches, and one-fifth (21.3%) were less likely to use a quitline that does not address sexual orientation or gender identity in coaching.

Among those with a regular doctor, 25.2% were somewhat uncomfortable or very uncomfortable asking their doctor for help with smoking cessation. Compared with gay men, discomfort was significantly more prevalent among lesbians (AOR = 1.44, CI = 1.06–1.96), bisexual females (AOR = 2.12, CI = 1.36–3.32), and respondents with other sexual orientations (AOR = 2.26, CI = 1.07–4.78).

Factors Associated with Preparation to Quit Smoking

Six factors were bivariately associated with preparation to quit: smoking frequency (daily/nondaily smoking, CPD), NRT past use, a smoke-free home rule, a past-year doctor’s visit, comfort asking one’s doctor for cessation advice, and age (Table 4). In the full logistic regression model, four factors remained significantly associated with preparation to quit: daily smoking, ever having used NRT, a smoke-free home rule, and comfort asking one’s doctor for cessation advice. Gender, sexual orientation, ethnicity, education, general health status, health insurance status, and coresidence with a smoker were not associated with preparation to quit smoking.

Table 4.

Regression Models of Preparationa to Quit Smoking: GLBT Smokers Aged 18–54, Colorado 2007

 Bivariate OR  
Factor (95% CIAORb (95% CI
Smoking behavior 
  CPD 0.97* (0.95–0.99)  
  Daily smoker 0.28* (0.19–0.40) 0.28* (0.18–0.44) 
Cessation history 
  Ever used NRT 1.77* (1.23–2.54) 2.18* (1.43–3.33) 
Environmental influences 
  Household smoking ban 2.83* (1.91–4.19) 2.42* (1.54–3.80) 
  Other household smoker(s) 0.85 (0.60–1.22)  
GLBT-related attitudes and behaviors 
  Smoking is bigger problem for GLBT 1.39 (0.94–2.04)  
  Homophobic attitudes 1.15 (0.78–1.68)  
  Participated in GLBT-specific events 0.85 (0.60–1.22)  
Access to health care 
  Have health insurance 1.38 (0.94–2.04)  
  Been to doctor in past year 1.60* (1.11–2.30)  
  Have regular health facility 0.90 (0.63–1.28)  
  Comfortable asking doctor about quitting 1.80* (1.21–2.67) 1.83* (1.15–2.92) 
General health status 
  Excellent 1.00  
  Very good/good 1.26 (0.80–2.01)  
  Fair/poor 1.21 (0.61–2.40)  
Demographics 
  Age (years)   
    18–24 1.00  
    25–34 1.38 (0.87–2.18)  
    35–44 1.91* (1.19–3.06)  
    45–54 1.43 (0.80–2.57)  
Gender 
  Male 1.00  
  Female 1.08 (0.76–1.53)  
Sexual orientation 
  Gay 1.00  
  Lesbian 0.98 (0.66–1.44)  
  Bisexual (male) 0.68 (0.27–1.74)  
  Bisexual (female) 1.23 (0.67–2.27)  
  Other 1.00 (0.35–2.87)  
Ethnicity 
  Caucasian 1.00  
  Hispanic 1.16 (0.77–1.75)  
  African American 0.47 (0.21–1.03)  
  Other 0.52 (0.22–1.21)  
High school or less education 0.68 (0.45–1.01)  
 Bivariate OR  
Factor (95% CIAORb (95% CI
Smoking behavior 
  CPD 0.97* (0.95–0.99)  
  Daily smoker 0.28* (0.19–0.40) 0.28* (0.18–0.44) 
Cessation history 
  Ever used NRT 1.77* (1.23–2.54) 2.18* (1.43–3.33) 
Environmental influences 
  Household smoking ban 2.83* (1.91–4.19) 2.42* (1.54–3.80) 
  Other household smoker(s) 0.85 (0.60–1.22)  
GLBT-related attitudes and behaviors 
  Smoking is bigger problem for GLBT 1.39 (0.94–2.04)  
  Homophobic attitudes 1.15 (0.78–1.68)  
  Participated in GLBT-specific events 0.85 (0.60–1.22)  
Access to health care 
  Have health insurance 1.38 (0.94–2.04)  
  Been to doctor in past year 1.60* (1.11–2.30)  
  Have regular health facility 0.90 (0.63–1.28)  
  Comfortable asking doctor about quitting 1.80* (1.21–2.67) 1.83* (1.15–2.92) 
General health status 
  Excellent 1.00  
  Very good/good 1.26 (0.80–2.01)  
  Fair/poor 1.21 (0.61–2.40)  
Demographics 
  Age (years)   
    18–24 1.00  
    25–34 1.38 (0.87–2.18)  
    35–44 1.91* (1.19–3.06)  
    45–54 1.43 (0.80–2.57)  
Gender 
  Male 1.00  
  Female 1.08 (0.76–1.53)  
Sexual orientation 
  Gay 1.00  
  Lesbian 0.98 (0.66–1.44)  
  Bisexual (male) 0.68 (0.27–1.74)  
  Bisexual (female) 1.23 (0.67–2.27)  
  Other 1.00 (0.35–2.87)  
Ethnicity 
  Caucasian 1.00  
  Hispanic 1.16 (0.77–1.75)  
  African American 0.47 (0.21–1.03)  
  Other 0.52 (0.22–1.21)  
High school or less education 0.68 (0.45–1.01)  

Note. GLBT = gay, lesbian, bisexual, and transgendered; CPD = cigarettes/day; NRT = nicotine replacement therapy.

a

Attempted to quit in past year and planning to quit in next month.

b

Final adjusted model includes variables retaining significance (p < .05) after inclusion.

*p < .05.

Conclusions

Among a large sample of Colorado GLBT smokers, four factors were significantly associated with preparation to quit smoking: daily smoking, ever having used NRT, a smoke-free home rule, and comfort asking one’s doctor for cessation advice. The smokers who had previously attempted to quit used NRT or a quitline at rates similar to those among U.S. smokers in the general population (Cummins, Bailey, Campbell, Koon-Kirby, & Zhu, 2007; Shiffman, Brockwell, Pillitteri, & Gitchell, 2008). The use rates for these evidence-based treatments suggest that GLBT self-identity does not inhibit use, especially of NRT. At the same time, however, fears and misinformation about NRT were common among these smokers, as they are among smokers generally (Cummings et al., 2004). Effective education campaigns might reduce these barriers and increase the proportion of GLBT quit attempters who try NRT.

Preparation to quit smoking as well as contemplation of quitting (intending to quit in the next 6 months but not next month) were less prevalent in this study population than rates typically and consistently found in U.S. smoker populations (Fava, Velicer, & Prochaska, 1995; Laforge, Velicer, Richmond, & Owen, 1999; Velicer et al., 1995; Velicer, Redding, Sun, & Prochaska, 2007; Wewers, Stillman, Hartman, & Shopland, 2003). However, the cessation-preparation rate matched the rate (8.5%) among the general population random sample of Colorado GLBT smokers aged 18–54. We speculate that smoking may not yet be denormalized among Colorado sexual minority populations. Targeted social marketing campaigns may be an effective public health response.

Among several factors associated with intention to quit, smoke-free home policies present a potentially promising public health target. Such policies may appeal to smokers who are not ready to quit, especially those who live with a nonsmoker, and voluntary smoke-free home policies increase the likelihood of future cessation attempts (Mills et al., 2009). Intervention research should develop effective, GLBT-targeted communications strategies that individuals (e.g., nonsmoking partners) and community campaigns can use to encourage adoption of smoke-free home rules.

Regarding cessation assistance, a substantial minority said they were less likely to use smoking cessation telephone quitlines that lack GLBT-identified coaches or protocols that address sexual orientation. Other studies have found mixed attitudes: Some GLBT smokers prefer GLBT-explicit cessation programs, and GLBT-explicit cessation support groups can be effective (Harding, Bensley, & Corrigan 2004; Schwappach, 2008), while others have found little interest in tailored programs among GLBT smokers (Mills et al., 2009). We conclude that GLBT smokers, like other populations of smokers, have heterogenous cessation preferences and needs. Cessation programs should include both untargeted evidence-based cessation aids and GLBT-explicit coaching or counseling options.

Smoking cessation quitlines are a core U.S. public health strategy, and multisession coaching is standard because it is more effective than one-time contact (Fiore et al., 2008). Unlike face-to-face counseling, where a patient or client typically sees the same therapist across multiple visits, most quitlines manage staffing and cost by transferring callers to any available coach regardless of who previously served the caller. To our knowledge, caller acceptance of this practice has not previously been explored. In the current study, nearly half of GLBT smokers said the practice would make them less likely to call a quitline. The most relevant previous evidence on this topic is a finding that smokers are less likely to call a quitline if they are skeptical that quitline staff can “relate” to them (Solomon et al., 2009). Further research should determine whether large numbers of smokers in general are dissuaded from using quitlines by the unavailability of a consistent coach during the cessation process.

Physician advice to quit smoking is an evidence-based strategy for increasing quit attempts (Fiore et al., 2008). In the current study, about one-fourth of GLBT respondents were uncomfortable talking to their regular doctor about smoking cessation. In addition, prescription cessation medication use was rare, which may also reflect a lack of clinical cessation engagement. We are unaware of previous reports of highly prevalent discomfort with clinical cessation help-seeking among smokers generally or GLBT smokers specifically. In California, GLBT smokers were less likely to receive a health care provider’s advice to quit than were general population smokers (Mills et al., 2009). In a general population study, 8% of smokers reported keeping their smoking status a secret from a health care provider (Stuber & Galea, 2009). Together, these somewhat related findings suggest that GLBT smokers may experience communication barriers with health care providers, perhaps arising from fears of homophobic reactions or stigmatization, confidentiality concerns, or past negative experiences (Mayer et al., 2008). Avoidance of clinical engagement may be smoking-specific, or it may affect other risky behaviors, a possibility that should be investigated. In either case, use of evidence-based support for smoking cessation might be increased by making it available in GLBT-identified community venues, as Leibel, Lee, Goldstein, & Ranney (2011) have recommended.

Limitations

To our knowledge, this study is the first to investigate cessation preferences and intentions, and factors related to intentions to quit, in a large sample of GLBT smokers. Several limitations apply to the work. The study population was not randomly selected, a common limitation among studies of self-identified GLBT smokers because random sampling of any small dispersed population requires costly screening for study eligibility. Using randomly selected Colorado GLBT smokers as a reference population, the study population may underrepresent those who are bisexual, White, with higher income, and in poorer health. These characteristics were not influential in full regression models; the study and general populations shared many other demographic, health, and quit-intention characteristics, which somewhat lessens concern about generality of the findings. A similar limitation is that a majority of respondents completed the survey in publicly GLBT-identified venues, and the findings may underrepresent GLBT smokers who do not visit such venues.

In summary, evidence-based cessation aids appear well-accepted among GLBT smokers attempting to quit, but these smokers may be less likely than others to seek cessation assistance through clinical encounters. Public health campaigns among GLBT smokers should focus on increasing motivation to quit—perhaps in part by promoting smoke-free homes, GLBT venues, and events—and should evaluate reach and impact of providing community access to evidence-based treatments.

Funding

This study was supported in part by the Colorado Department of Public Health and Environment (#FLA07-00165).

Declaration of Interests

No author has any financial disclosures.

RM contributed to this report while at the University of Colorado Cancer Center. The authors deeply appreciate the survey fieldwork led by Jennifer Woodard and conducted by staff and volunteers of the GLBT Community Center, Lambda Community Center, Western Equality, Boulder Pride, El Futuro, Brothas4Ever, Kaleidoscope, and the Pride Center, all in Colorado. We also thank two anonymous reviewers whose feedback was instrumental in improving the manuscript.

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