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OWHN E-Bulletin
Tobacco Use in Lesbian, Bisexual
and Trans Women Communities
By Michèle Clarke, Health Promoter, LGBT Program, Sherbourne Health Centre1

CONTENTS

1. Tobacco as an LGBTTQ Health Disparity 3. The Rainbow Tobacco Intervention Project (RTIP) 4. Key Findings in RTIP’s “Toronto Rainbow Tobacco Survey” 5. Tobacco Use in LGBTTQ Female Youth 6. Resources

1. TOBACCO AS AN LGBTTQ HEALTH DISPARITY
Tobacco use has declined in Canada’s general population over the past few decades.
According to the latest results from the Canadian Tobacco Use Monitoring Survey (CTUMS) for data collected between February and December 2005, 19% of the population aged 15 years and older were current smokers, down from 25% in 1999. In Ontario, 16% of the population smokes with 22% of men and 11% of women reporting current smoking. Still, in 1998 22% of all deaths in Canada were attributable to smoking (Makomaski Illing & There is evidence that lesbian, gay and bisexual people are more likely to smoke than the general population (Greenwood, et al., 2005; Tang, et al., 2004). A review of the literature indicated a range of smoking rates from 38-59% for youth and 11-50% for adults (Ryan et. al, 2001). However, almost all of this research is from the United States. The smoking prevalence of lesbian, gay, bisexual, transsexual, transgender and queer (LGBTTQ) communities in Canada is not documented by CTUMS or other Canadian smoking researchers. A 2005 British Columbia survey showed that 36% of LGBTTQ adults smoke compared to 16% of the general population (www.proudtoquit.org) and a more recent study showed that 54.5% of young MSM smoke compared to 25.9% of the male BC population (Lampinen et. al, 2006). To address this shortage of Canadian data, in 2006 Toronto’s Rainbow Tobacco Intervention Project (RTIP) conducted a tobacco use survey of Toronto’s LGBTTQ communities. The majority of the research on LGBTTQ smoking prevalence has actually been conducted with gay men and lesbians, and few studies have included bisexual people. When bisexual people have been recruited as participants, the sample size is often very small and their results are combined with those of lesbians or gay men. No studies have been done on the prevalence of tobacco use by transsexual and transgender people. RTIP aimed to address these gaps in their survey. There are many factors that may contribute to the higher smoking rates in LGBTTQ communities. They may face more stress due to homophobia, biphobia and transphobia, as well as heterosexism. Smoking tends to be more prevalent among groups that experience high stress levels. Places where smoking is prevalent, such as bars, have historically been an important social focus for LGBTTQ communities, possibly because of a history of discrimination or exclusion in other social settings. Behaviour associated with smoking, such as drug and alcohol use has also been shown to be higher in LGBTTQ communities. Finally, evidence suggests that the tobacco industry has targeted the LGBTTQ market through direct advertising, sponsorship, and promotional events (Ryan et al, 2001). Research shows that lesbian, gay, and bisexual youth are more likely to be depressed or lonely, to attempt suicide, and to be physically and verbally victimized than heterosexual youth. These are all factors that may contribute to increased substance use. Smoking prevalence may be higher in LGBTTQ communities because of the unique role smoking may play during identity formation in queer adolescents (e.g. assumption of masculinity for males, assertion of power and independence for females), the stresses of coming out, the potential lack of support from parents, family members, and peers, feelings of isolation and loneliness, and anti-gay harassment (Ryan et al, 2001). 2. BARRIERS TO HEALTH CARE

An examination of any health issue that affects lesbian, gay, bisexual, transsexual,
transgender and queer (LGBTTQ) people must include a discussion of the broader health
care context that affects LGBTTQ health. Unfortunately, the barriers to accessing health care faced by LGBTTQ people are great. These barriers have a direct impact on access to health care and health-seeking behaviours for the LGBTTQ communities, which means that sexual orientation and gender identity serve as social determinants of health, even though they are not explicitly listed as such in the World Health Organisation’s definition of health.The barriers to care can include: Fear of real or perceived discrimination – LGBTTQ people are more likely to delay or decline seeking health care altogether to avoid having a negative experience. Homophobia, biphobia and transphobia – Health care providers may subject LGBTTQ people to derogatory comments, voyeurism, hostility toward themselves or their partners, undue roughness in physical examinations, etc. Heterosexual and gender identity assumptions – LGBTTQ patients can experience heterosexism in that health care providers may assume that they are heterosexual. Patients are rarely asked about sexual orientation during assessment or on medical history forms. This assumption of heterosexuality perpetuates LGBTTQ invisibility and marginalizes LGBTTQ health needs. Health care providers can be less likely to take the sexual and reproductive health of LGBTTQ women seriously if they do not have male partners. This prejudice can create barriers to basic things like pap smears or other • Lack of awareness of LGBTTQ health issues – Most health care educational programs do not include discussion of LGBTTQ health issues and thus most health providers are not sensitive to or knowledgeable about the particular health risks and needs. Due to these and other barriers, LGBTTQ people do not have the same access to health care that many Canadians take for granted. This reduces their interaction with the health care system and thus there is less intervention from health care providers with regards to negative health behaviours such as tobacco use. 3. THE RAINBOW TOBACCO INTERVENTION PROJECT (RTIP)

In the fall of 2004, a committee of community partners joined forces to begin exploring
options for smoking cessation and reduction for the LGBTTQ communities in Toronto, resulting in a coalition called the Rainbow Tobacco Intervention Project (RTIP). Members of RTIP include the Canadian Cancer Society, the Centre for Addiction and Mental Health (CAMH), The Council for a Tobacco Free Toronto, the Rainbow Health Network, Sherbourne Health Centre and Toronto Public Health. The goal of the Project is to reduce tobacco-related morbidity and mortality within the Lesbian, Gay, Bisexual, Transgender, Transsexual and Queer (LGBTTQ) communities in Toronto. 1. Lesbian, gay, bisexual, transsexual, transgender and queer (LGBTTQ) communities in 2. Service providers for the LGBTTQ communities in Toronto. 1. To develop effective smoking cessation/reduction programs tailored to meet the needs of the LGBTTQ communities in Toronto. 2. To educate mainstream tobacco cessation program providers and LGBTTQ service 3. To promote awareness of smoking issues in the LGBTTQ communities such as targeted tobacco industry marketing practices and to begin to change community norms that support tobacco use. The Council for a Tobacco-Free Toronto initiated a proposal and was able to secure a small amount of funding from the Ontario Tobacco-Free Network and Toronto Public Health to conduct a literature and program review. Further funding was secured from the Ministry of Health Promotion Smokefree Ontario and the Bent on Quitting program was developed. Bent on Quitting is an innovative 8-week program for LGBTTQ smokers wishing to quit or reduce the amount they are smoking. The program has been adapted from two successful programs: Queer Tips in San Francisco and Stop Dragging your Butt in Ottawa. It employs best practices and addresses the reasons for smoking, the benefits of quitting, how participants can ready themselves to quit and how they can stick to their plan once they have begun to cut down or quit. The first group was offered in the fall of 2005 and there are currently three groups per year and free individual self-help quit kits are also available. Next steps for RTIP include developing a Bent on Quitting group specifically for LGBTTQ youth smokers as well as further research into the smoking behaviour of LGBTTQ communities in Toronto.
4. KEY FINDINGS IN RTIP’S “TORONTO RAINBOW TOBACCO SURVEY”
The LGBTTQ population of Ontario is estimated to be between 5-10 % of the 12 million people who live in Ontario, and as far as we know, there is no research examining the smoking prevalence of these communities. There is actually little Canadian research that examines any health or wellness issue in LGBTTQ communities in Ontario or any other province. As such, the majority of Canadian LGBTTQ health and wellness programming is forced to rely on American data for evidence to inform their work. In the development of the Bent on Quitting program, RTIP also found itself having to rely on American data to design this program. In an attempt to inform their work with a local perspective and to contribute to Canadian LGBTTQ health and wellness research in general, RTIP decided to conduct their own survey to determine the prevalence of smoking in Toronto’s LGBTTQ communities. Additional objectives were to investigate tobacco use in a Canadian LGBTTQ population apart from BC – which had already been surveyed – and to address the lack of data on tobacco use among bisexual and trans populations.
Methods: The Toronto Rainbow Tobacco Survey (TRTS) gathered data from members of
Toronto’s LGBTTQ communities from April to July 2006. The self-administered survey collected information on the prevalence of smoking as well as very basic demographic information. Participants were recruited through outreach at a diverse range of LGBTTQ community events and group meetings including a health fair, a gay and lesbian film festival, a women’s soccer league and Pride Week events. Recruitment outreach was purposefully broad and strategic in an attempt to include as representative a sample as possible. The data collection also avoided relying on recruitment in bars because of the strong relationship between bar attendance and smoking. TRTS researchers described the survey and gave consenting participants a postcard survey to complete. The survey was also available online and advertising outreach was done through email networks and local LGBTTQ media. The web survey was implemented to attract a broader base of respondents beyond downtown Toronto and to encourage responses from LGBTTQ members who wished to remain anonymous. Eligible participants were self-identified LGBTTQ residents of Toronto.
Results: A total of 4080 LGBTTQ participants completed the questionnaire and 77% of
these were residents of Toronto for a final convenience sample of 3140. Postcard surveys
were completed by 2548 participants and 542 participants completed the survey online. The median age of the sample was 34 with an age range of 13 to 91 years and the majority of the participants identified as lesbian (30.3%) or gay (41.9%). Overall, 36% of LGBTTQ participants reported current smoking, 25% were past smokers and 39% had never smoked. This compares with Toronto Public Health reports of smoking prevalence in Toronto adults (18+) with 17% reporting current smoking, 22% reporting past smoking and 61% reporting never smoking (RRFSS 2005). The smoking prevalence rates ranged from 24% to 45% across the different sexual orientation and gender identity groups of the sample, with lesbians reporting a rate of 33%, trans women reporting a rate of 34%, queer women reporting a rate of 39%, and bisexual women reporting the highest
Figure 1: Smoking Prevalence by LGBTTQ Identity Group
rcen
e
20%

5. TOBACCO USE IN LGBTTQ FEMALE YOUTH
In the overall LGBTTQ sample, there were no gender differences in smoking prevalence
rates within the different sexual orientation and gender identity groups of the sample except
that the rates were higher for queer women (39%) compared to queer men (24%). However, recent studies in the U.S. have indicated that with younger LGBTTQ smokers, females smoke more than males. For example, in Austin et. al. (2004), 38.7% of adolescent lesbian/bisexual girls smoked at least weekly compared to 9.8% of gay/bisexual boys. In the current study, a similar gender difference was found for TRTS participants under the age of 25 (see Figure 2). In this age group, lesbians (53%) smoked more vs. gay men (43%), bisexual women (50%) smoked more vs. bisexual men (42%), queer women (55%) smoked more vs. queer men (30%) and FTM transpeople smoked (63%) more vs. MTF transpeople (40%). While young FTM transpeople are not women, at that age they would have had a significant amount of life experience living in female bodies which may explain the direction of the gender difference for this group. The gender difference seen in the overall LGBTTQ sample between queer women and queer men seems to be a product of the small sample size for queer men and this observed under-25 age/gender effect. The demographics show that 78% of the smokers in the queer men sample are under the age of 39, compared to 95% of the smokers in the queer women sample. Figure 2: Comparison of Smoking Prevalence by Gender by Age Group


Recommendations:

1. Toronto tobacco control efforts need to be targeted at the LGBTTQ population, including social marketing campaigns to raise awareness and educate LGBTTQ people about this significant health issue in their communities. 2. Treatment resources need to be expanded beyond the current Bent on Quitting program to address the most at-risk communities including youth, bisexual people and gender queer people. 3. The providers of tobacco cessation programs and services need to be educated about LGBTTQ smoking issues and their particular cessation concerns. 4. CTUMS and other Canadian smoking surveys need to include sexual orientation and gender identity demographic items on their questionnaires to produce more information on LGBTTQ smoking prevalence across Canada. 5. Further research needs to be conducted on the determinants of tobacco use among LGBTTQ communities as a better understanding is required to design effective
To view the complete survey report, please visit:
www.sherbourne.on.ca/PDFs/TRTS-Report.pdf

6. RESOURCES

‹ Bent On Quitting – Rainbow Tobacco Intervention Project
A quit smoking group for lesbian, gay, bisexual, transgender, and queer (LGTBQ) communities in Toronto. The support group runs during the evening hours for 8 weeks. Professionals trained in smoking cessation facilitate the group. Individuals interested in participating in the group, or who require additional information, may contact: ‹ Centre for Addiction & Mental Health
Nicotine Dependence Clinic: Services offered for persons whose primary concern is smoking,
as well as specialized services for persons who are dealing with mental health or substance use concerns and would like treatment for their smoking. Treatment is tailored to fit individual needs. Options include individual counseling, support groups and medical intervention. Clinic staff consists of therapists, nurses and physicians. An initial assessment interview is required to access treatment. All treatment is free with a valid Ontario Health Card. There may be an additional cost for medications. Subsidized nicotine replacement therapy (NRT) is available. Program is available tailored to the needs of pregnant women. Services are offered at the following sites, and assessment interviews can be booked directly by calling: ARF Site, 33 Russell Street, 416-535-8501 ext. 6662 Donwoods Site, 175 Brentcliffe Road, 416-535-8501 ext. 7057 Queen Street Site, 1001 Queen Street West, 416-535-8501 ext. 1155 www.camh.net ‹ Program Training and Consultation Centre (Ottawa)
Training and consultation supports to help build others’ capacity for effective tobacco control
program development and implementation. Consultation services on smoking cessation and
the GLBT community. Anne Meloche 613.482.7822 ext. 202 ameloche@ptcc-cfc.on.ca

‹ Stop Dragging Your Butt (Ottawa)
Development and delivery of smoking cessation program with components targeted to gay men, lesbians, bisexuals and members of the community living with HIV/AIDS. SELF-HELP
‹ Canadian Cancer Society of Ontario
Self-help booklets, "One Step at a Time". Online calculator of savings earned by quitting. Smokers' Helpline 1-877-513-5333. www.smokershelpline.ca ‹ Canadian Council for Tobacco Control
Self-help booklets, “Start Quit, Stay Quit” and “Preventing Smoking Relapse” available for pregnant women and their partners. For copies call 1-800-363-7822. www.cctc.ca ‹ Heart and Stroke Foundation of Ontario
Pamphlets with information about the harmful effects of tobacco use. Look under "Healthy Living" on the web site. 1-888-473-4636 or 416-489-7111 www.heartandstroke.ca ‹ How Not To Smoke
Video and self help book for women who want to quit smoking. Easy to read and easy to do in your own home. Available through the Toronto Public Library system. 416-393-7131 ‹ Ontario Lung Association
Self-help guide "Get on Track" and other helpful pamphlets free. 1-800-972-2636. ‹ Toronto Public Health
Various self-help materials such as pamphlets and booklets available. Free. ‹ ZybanPlus
Self-help Booklet "Make This Another Smoke-Free Day" is available for people taking Zyban. Call to register for additional support or information. 1-800-489-8424. www.zybannet.com
LGBTTQ ONLINE RESOURCES

Canadian Rainbow Health Coalition/Coalition santé arc-en-ciel Canada: A national
organization whose objective is to address the various health and wellness issues that
people who have sexual and emotional relationships with people of the same gender, or a gender identity that does not conform to the identity assigned to them at birth, encounter. www.rainbowhealth.ca

Gay American Smoke Out:
This is an opportunity for LGBT individuals to challenge
themselves to quit smoking and for LGBT organizations to provide resources for quitting and host fun events to raise awareness about tobacco use. www.gaysmokeout.net
Gay and Lesbian Medical Association: A North American organization that works to
ensure equality in health care for LGBT individuals and health care professionals. www.glma.org
National Association of Lesbian, Gay, Bisexual, and Transgender Community
Centers:
A U.S.-based association that supports LGBT community centers that are looking
to get involved with LGBT tobacco prevention and control or are already running a program. www.lgbtcenters.org/lgbttobaccoresearch.htm
National LGBT Tobacco Control Network:
A U.S.-based network that is working to
support the many local tobacco control advocates in helping to eliminate tobacco health disparities for all LGBTs. www.lgbttobacco.org 7. REFERENCES

Austin, S. B., Ziyadeh, N., Fisher, L. B., Kahn, J. A., Colditz, G. A., & Frazier, A. L.
(2004). Sexual orientation and tobacco use in a cohort study of US adolescent girls and
boys. Archives of Pediatric Adolescent Medicine, 158, 317-322. Canadian Tobacco Use Monitoring Survey (CTUMS), (2005). Greenwood, G. L., Paul, J. P., Pollack, L. M., Binson, D., Catania, J. A., Chang, J., et al. (2005). Tobacco use and cessation among a household-based sample of US urban men who have sex with men. American Journal of Public Health, 95(1), 145-151. Lampinen, T. M., Bonner, S. J., Rusch, M., & Hogg, R. S. (2006). High prevalence of smoking among urban-dwelling Canadian men who have sex with men. Journal of Urban Health, 83(6), 1143-1150. Makomaski Illing, E.M., & Kaiserman, M.J. (2004). Mortality attributable to tobacco use in Canada and its regions, 1998. Canadian Journal of Public Health, 95(1), 38-44. Rapid Risk Factor Surveillance System, Ontario, Canada, (2005). Ryan, H., Wortley, P. M., Easton, A., Pederson., & Greenwood, G. (2001). Smoking among lesbians, gays, and bisexuals. A review of the literature. American Journal of Preventative Medicine, 21(2), 142-149. Tang, H., Greenwood G. L., Cowling, D. W., Lloyd, J. C., Roeseler, A. G., & Bal, D.G. (2004). Cigarette smoking among lesbians, gays, and bisexuals: How serious a problem? Cancer Causes Control, 15(8), 797-803.

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