Pride month is upon us, and the rainbow flag is flying high. At levels that would have been unimaginable a few decades ago, corporate sponsors acknowledge and celebrate the right of LGBTQ+ individuals to live free of violence, discrimination, and oppression.
Whether their actions reflect changing societal norms, the assertion of an equity mission, or engagement in “performative activism,” corporations as diverse as Google, MasterCard, and Legos are changing corporate logos to include the rainbow colors synonymous with the gay pride movement.
These visible signs of corporate support are vitally important and have contributed to the growing acceptance of LGBTQ+ individuals in sports, education, business, and entertainment. But, unfortunately, these more affirming corporate supporters arrived late to the “Pride Parade.”
Thirty years ago, in pursuit of new customers, the tobacco industry set its sights upon an untapped market characterized as “alternative lifestyles.”
In 1995, the R.J. Reynolds Tobacco Company established Project SCUM, an outreach strategy to sell cigarettes to gay men and people experiencing homelessness in the Castro and Tenderloin districts of San Francisco. The acronym “SCUM” officially stood for subculture urban marketing and reflected most corporate stances toward the LGBTQ+ communities.
During that same period, several other tobacco companies began active outreach to LGBTQ+ communities with targeted advertisements, event sponsorship, including pride festivals, and financial support for non-profit organizations struggling to provide services at the height of the AIDS epidemic. This early corporate attention garnered appreciation and even loyalty to those companies that frequented gay bars with free products and were ever-present at fund-raising galas and pride parades.
Perversely, this early “investment” in the LGBTQ+ communities by the tobacco industry has paid off. Although cigarette use among adults in the U.S. is at a 50-year low, tobacco use among LGBTQ+ youths and adults remains elevated. Indeed, many studies suggest that smoking rates among LGB adults are approximately 50% higher than heterosexual individuals.
Additionally, data indicate that LGB individuals are at elevated risk for lung health inequalities due to earlier age of initiation, use of highly addictive mentholated cigarettes, and a longer duration of high-frequency smoking. Data on tobacco use among transgender populations is more limited compared to sexual minorities.
However, over the past five years, several nationally representative studies have documented rates of tobacco use as more prevalent among transgender adults. With few exceptions, transgender male respondents had the highest use patterns across all the products (cigars, cigarettes, e-cigarettes) compared to cisgender males and females and transgender female respondents.
The current data on smoking underscore the need for attention and investment in the LGBTQ+ communities by tobacco prevention and control organizations. Effective tobacco prevention and control efforts consist of multi-pronged strategies, including outreach and awareness campaigns, targeted resources for minority populations, access to smoking cessation interventions, and public health policies.
Despite consistent tobacco-use disparities, gender and sexual minorities are not systematically included in most tobacco prevention and control efforts, and funded research to promote smoking cessation research among LGBTQ+ populations is limited. Specifically, there is scant information on evidence-based interventions for LGBTQ+ smokers.
The available research suggests that evidence-based treatments (e.g., individual counseling, pharmacotherapy) recommended in the U.S. Public Health Service’s Clinical Practice Guideline: 2008 Update (Fiore et al., 2008) are as effective for sexual minorities—if they are used. However, intervention research for transgender smokers is limited, and awareness and uptake of evidence-based treatments remain low among LGBTQ+ smokers.
Further, the LGBTQ+ community has been highly underserved by the medical community, including recommendations and assistance with smoking cessation. The barriers to accessing appropriate health care services are linked to bias among providers and system-level factors (e.g., inability to indicate gender identity, preferred name, and pronouns in the EHR) that create a hostile environment for sexual and gender minority patients.
The elimination of smoking inequalities among sexual and gender minority populations will require an investment in systematic and rigorous research. Many of the existing frameworks for understanding individual-level predictors of health risk behaviors among adult smokers can also be applied to research on LGBT populations (i.e., Transtheoretical Model of Behavioral Change).
In addition to individual-level factors, social factors including education, racial segregation, and poverty account for over a third of the total deaths in the U.S. each year. In response, health disparity researchers are moving beyond the exclusive focus on individual-level predictors of risk to evaluate the influence of social determinants on health inequalities.
Similarly, recent calls for the systematic study of the effect of social determinants (economic stability, neighborhood and physical environment, education, community, and social context, and the health care system) on LGBTQ+ health inequalities. LGBTQ+ individuals have been the target of systemic violence, oppression, and social exclusion. These factors influence life opportunities and influence health outcomes via the social determinants of health and should be examined and ultimately eliminated.
Finally, research is needed to understand the health implications of smoking among LGBTQ+ populations. A higher prevalence of smoking across the lifespan exposes LGBTQ+ people to elevated risk for lung cancer and other smoking-related morbidities. However, research on lung cancer risk among LGBTQ+ individuals is limited except for research among HIV-positive individuals.
A significant barrier for evaluating rates of smoking-related diseases in LGBTQ+ patients is that cancer registries do not collect information on sexual orientation or gender identity; thus, limiting examination of the influence of smoking on cancer-related incidence and mortality.
Two recent studies reported on the eligibility of LGB older adults for low-dose computed tomography (LDCT) lung cancer screening (a proxy for chronic high-frequency smoking and an indicator of elevated risk for lung cancer).
In the first study, my colleagues and I, using population-based data sets, examined the overall prevalence of eligibility for low-dose computed tomography (LDCT) lung cancer screening among older adults based on sexual orientation. Overall, 11.2% of older U.S. adults met eligibility criteria for LDCT lung cancer screening. Eligibility for LDCT lung screening was associated with sexual orientation; the highest eligibility rates were observed among bisexual women and men (26.9 and 24.5%, respectively).
A separate study using data from the Behavioral Risk Factors Survey Study (BRFSS) found that LGB respondents were more likely to meet guidelines for screening than heterosexuals but less likely to have received a screening test for lung cancer.
Together, these two studies demonstrate the need to increase awareness and develop lung cancer screening interventions for LGBTQ+ smokers. Appropriate interventions should be developed in collaboration with community partners and housed within LGBTQ+ serving health care facilities around the country.
As we continue to celebrate the tremendous strides achieved in the movements toward LGBTQ+ liberation, we cannot lose sight of the work that remains for LGBTQ+ health equity. During Pride month and throughout the rest of the year, freedom from oppression also includes freedom from smoking.
To achieve equity in lung health risk factors and outcomes, the tobacco prevention and control communities will need to take a page out of the corporate playbook and fly that pride flag high.
