1 - (OP4) "it's the One Thing That I Have Just for Me to Keep Going.": Gender Minority Stress, Mental Health, and Smoking Cessation Among Transgender and Gender Expansive Adults

Introduction: Disparities in tobacco use persist among transgender and gender expansive (TGE) individuals despite decreasing use in the general population. Smoking causes vascular injury that interacts with gender-affirming hormone therapy, increasing risk for negative cardiac events. Additionally, smoking impairs wound healing, which compromises recovery from gender-affirming surgeries. Because TGE individuals are vulnerable to these negative health consequences, this study explored a) how gender minority and general stressors impact smoking cessation and b) identified components in an existing cognitive behavioral smoking cessation intervention that should be tailored to the unique needs of TGE individuals.

Methods: Semi-structured interviews were conducted with TGE-identified participants (N = 26) recruited in Boston, MA. All participants were >18 years old, self-reported a difference between sex assigned at birth and gender identity, reported current or recent combustible cigarette use, and were proficient in English. Interviews were audio-recorded, transcribed, and analyzed using rapid qualitative analysis to extract and summarize key themes.

Results: Participants ranged in age from 20 to 63, with a median of 32; 38.5% identified as transgender women, 23.1% as transgender men, and 30.8% as nonbinary or gender nonconforming. Participants described smoking as a habitual part of daily life and a primary coping strategy for managing mental health concerns. Specifically, cigarettes were used to cope with gender minority stressors, including discrimination, misgendering, and heightened vigilance related to personal safety. Key barriers to cessation included withdrawal symptoms, limited alternative coping strategies for emotional distress, and disruption to established everyday routines. In response to these barriers, participants articulate the need for smoking cessation intervention for TGE individuals to include explicit attention to gender minority stress (e.g., alternative coping strategies for discrimination and misgendering), education about the impact of smoking on access to and outcomes of gender-affirming care, and opportunities for peer support within LGBTQ+ affirming communities. Additionally, participants emphasized the importance of the intervention being empowering and affirming, and delivered within a safe, LGBTQ+ affirming space.

Conclusion: Participants in this sample described smoking as an important emotion regulation strategy, shaped by chronic exposure to gender minority stress and structural vulnerability. Although health concerns and complications with gender affirming care motivated quit attempts, cessation was undermined by psychological and behavioral barriers, primarily using smoking to manage anxiety, dysphoria, and depression symptoms. Standard smoking cessation approaches may insufficiently address the functions that tobacco serves in this population. Thus, adapting existing smoking cessation interventions to promote empowerment, target minority stress-linked affective drivers of smoking, and cultivate identity-affirming coping strategies may be essential to improving their effectiveness among TGE individuals.