You may have noticed we’ve talked a lot here about smoking and HIV here lately. Perhaps a word of explanation is needed about the context for all this. Because while I’m personally an ex-smoker – and we all know how annoying non-smokers can be – I’m not a rabid anti-smoker. Really!
Some of my best friends are smokers . . .
No really, my live and let live attitude applies to all manner of foibles, least of all smoking. Hell, I even turn a blind eye to religion. But, to be serious, I'm a do-gooder at heart, so I do have a profound interest in the health and well being of people living with HIV – have done for years – so I'm drawn to try to persuade more HIVers who want to to give quitting another try. But, yes, I do get annoyed by the lack of interest, uo 'til now, by some ASOs in helping them do just that. Because if we believe the research – and why wouldn’t we – smoking is doing more harm to HIVer's prospects of a long and healthy life than any other factor.
Lately though there has been an upsurge of interest in the topic, at least in Ontario. More on that another time.
Today though we are turning to smoking in the LGBT community. Many HIVers, of course, also belong to the LGBT community, where smoking rates are also extremely high compared to the general population. So it’s instructive to look at WHY.
You’ll quickly find that the research is not particularly strong on WHY smoking levels are high in the LGBT community, although there is plenty of speculation. We’ll get to that in a minute. Let’s first look at how extensive smoking is in the LGBT community.
First Canada. According to a 2007 survey of tobacco use in the LGBT community (3,140 participants) by Toronto Public Health, 36% of LGBT participants were smokers, compared to 17% of Toronto adults.
Within the Toronto LGBT community there are significant variations in smoking prevalence between different factions, with, surprisingly, bisexual men and women leading the way with a 45% smoking prevalence rate. Overall, smoking prevalence declined with age, with participants in the under 15 age group (50% smoking rate) and the 15 to 19 age group (57%) more likely to be current smokers compared to participants in the 55 to 59 age group (22%) and the over 60 age group (28%).
The average number of cigarettes lit up per day by LGBT smokers was 10.8, but as high as 18.5 for smokers over the age of 60, That represents both a health hazard and an opportunity to save a LOT of money for those who quit. How much? About $1,580 per annum for the average LGBT smoker. Which, by the way, is just one of the reasons I quit about a decade ago.
There are fascinating comments on smoking demographics in this report too. Like “a gender difference was found in the average number of cigarettes a day within the different sexual orientation groups of the sample, as gay men smoked more daily cigarettes than lesbians (12.5 vs. 9.5)”.
Recommendations? If you have researched smoking in the LGBT community, you'll know they almost always follow a smilar path, calling for targetted tobacco control efforts at the LGBT population, expanding treatment resources to address the most at-risk communities and conducting further research on the determinants of tobacco use among LGBT communities.
Clear the Air, a group formed to tackle smoking in the Toronto LGBT community, tries to answer the question of why we LGBT people smoke. LGBT communities, of course, are subject to the same factors that result in smoking within the general population, but the additional factors they experience are higher levels of stress due to the impact of stigma, a culture of socializing in bars and clubs, lower health access and greater vulnerability of LGBT people to depression and alcohol use. At the same time, they acknowledge it’s complicated and there is a lack of evidence. However they comment on four key factors. I quote . .
"Stigma, Discrimination and Oppression
Stigma, discrimination and oppression create stress and can result in reduced social supports and social exclusion including bullying – two strong indicators of smoking behaviour. The process of coming out can be met with actual or perceived rejection from family and/or peers. Self-esteem and self-confidence can suffer. These factors may also have impacts on increased rates of school leaving and homelessness – additional risk factors for smoking. Social exclusion resulting from these factors can also mean that LGBT people have fewer opportunities to develop positive coping skills to be resilient to the risks of smoking.
LGBT Communities’ Social Norms
Social norms in LGBT communities have been found in some research to be more accepting of smoking. Modeling of smoking behaviour in (or, now, outside of) LGBT bars as a common site of initiation for people to LGBT culture has been identified as a possible contributing factor supporting smoking behaviour. Also, smoking may be perceived as a way to belong and as a way to initiate conversation as an icebreaker or a social bonding opportunity in these sites.
Tobacco Industry Targeted marketing (Editor’s note: see the images which accompany this article).
Targeted marketing by the tobacco industry is a also a contributing factor to higher smoking rates among LGBT populations. Tobacco companies aim to normalize smoking through advertising and promotion that appeal specifically to LGBT communities. The industry has targeted the LGBT communities for decades.
Access to and Adequacy of Health Services
LGBT people are less likely to access health services due to barriers in access, availability or acceptability, past negative experiences/discrimination, and/or a lack of culturally competent healthcare providers. Yet, support of health services and a family physician increases the likelihood of quitting smoking. Health service providers can inform smokers of the health risks of smoking and refer people to smoking cessation programs and supports.
That’s the Canadian research. Go further afield and there is quite a bit more, notably “Smoking out a Deadly Threat, Tobacco Use in the LGBT community” from the American Lung Association. Their 2009 report prefaces its findings with this . .
“Since the smoking rate within the LGBT community is roughly double that of the general population, more members of the LGBT community are at greatly increased risk of these deadly diseases, as well as other tobacco-related health threats such as heart attacks and strokes. Tobacco’s toll on this underserved community is far too great.”
On the question of why LGBT smoking is so prevalent, the American report offers similar answers to the Canadian one. For example, on the impact of stigma, the report says “the social environment in which LGBT individuals come out to themselves, their families and the community can have a significant impact on their health and well-being. Although social acceptance has been slowly improving, there is still a lot of stigma associated with being in a sexual minority. Actual or even perceived stigma causes stress, and research has shown that smoking rates, as well as other negative health behaviors and outcomes, are higher in groups that experience high levels of stress.
Also there is this . .
“I think tobacco products are heavily promoted in the bar/club scene. The same is true in the straight community but I think the difference is more people in the LGBT community rely on the bar/club scene to be social.” –Zeb, 27, Washington DC
On societal mores, the report says “Historically, bars were among the few safe spaces for LGBT people, and they have played an important social role in the LGBT community for many decades. Because there is a biological and behavioral link between drinking and smoking, it is likely that the bar culture would have contributed to elevated smoking rates in this population. There is also the social aspect of smoking together with peers, which seems to be an especially strong risk factor among young people.”
The report also mentions as contributing factors worse access to health care for LGBTesr and of course, targeting of our community by the tobacco industry.
Interesting – and mirroring the situation in the HIV community and its ASOs who express little interest in addressing the HIV smoking problem - the report quotes “acceptance of the status quo by LGBT advocacy organizations” as a contributing factor. The US report says this: “Despite the impact of tobacco use on the health and well-being of the LGBT community, many LGBT organizations do not seem to view tobacco control as a relevant issue. Researchers at the University of California, San Francisco interviewed the leaders of 74 LGBT organizations between 2002 and 2004. Only 24 percent of the leaders surveyed named tobacco use as a pressing LGBT community health concern.”
“The community and its allies need to advocate for funding to establish culturally-specific programs. Civil rights and health are both important in our community.”
The report concludes “LGBT people should be treated as a priority population for tobacco control, similar to those racial and ethnic groups disproportionately affected by smoking. Specific interventions targeted to LGBT people are needed in order to help reduce the impact of tobacco use in this population. Since there are multiple reasons for this disparity, several different strategies are required to address the problem.”
We'll look at smoking cessation strategies another time.
I hate to end on a sombre note – yet perhaps that's appropriate. Here's what I think. The cigarette industy's contempt for its consumers knows no bounds. On the issue of the tobacco company’s efforts to ingratiate their way in to the LGBT community, and promote smoking within our ranks, the evidence is pretty damning that there has been a concerted effort to do so. Watch the video below – please - and learn about Project SCUM - yes, they used that word internally in an advertzing campaign aimed at the LGBT community - as one example. It’s truly frightening.
I hope it will make you mad. Because, it strikes me, being mad at those who profit from tobacco at our community's expense is a good start.
There are many more LGBT/smoking related resources here.
This article originally appeared in PositiveLite.com in July 2012.