Adapting and testing a smoking cessation intervention for transgender and gender-diverse individuals

Despite the substantial decrease in the prevalence of smoking over the past 50-years, there are persistent and significant disparities in tobacco use among transgender and gender diverse (TGD) individuals. The prevalence of cigarette use in TGD individuals is 45.7 - 62.3%, compared to 39.8% in cisgender individuals.1

There are also disparities in e-cigarette use among TGD people relative to cisgender adults (26.5% vs. 5.5% in transgender and cisgender men, respectively).2 Transgender individuals may be particularly vulnerable to the consequences of tobacco use, as hormone therapy among those who smoke increases heart disease risk,3 and

smoking may hinder recovery from gender-affirming surgeries.4 Stigma, discrimination, gender dysphoria, and other gender minority stressors contribute to tobacco use disparities. Enacted stigma and discrimination toward TGD individuals are common (reported by over 75% of participants in some samples5), and experiencing stigma or discrimination increases the odds of current cigarette

smoking, e-cigarette use/vaping, and dual use among TGD people.6 Gender dysphoria and gender minority stress may also lead to and/or exacerbate disparities in anxiety and depression,7 which are major impediments to smoking cessation8 that are more prevalent among TGD than cisgender individuals.9 Anxiety symptoms co-

occur with smoking at high rates and significantly impair cessation success.10,11 Similarly, depressed mood and major depressive disorder, both more common among individuals who smoke than among those who do not,12– 14 are associated with reduced odds of cessation.15 Therefore, gender minority stress and high prevalence rates

of anxiety and depression render TGD individuals particularly vulnerable to smoking cessation difficulties. A tailored smoking cessation intervention that builds cognitive behavioral skills for cessation as well as reduces gender minority stress and associated anxiety and depression symptoms has strong

potential to mitigate tobacco use disparities among TGD individuals. We propose to adapt an existing smoking cessation intervention (known as QUIT16) to address the unique needs of TGD people. In focus groups with TGD individuals who use tobacco (N = up to 32) and providers (N = 8), we will explore the ways in which

gender minority stressors and associated anxiety/depression compromise cessation as well as identify content in the current version of the QUIT intervention that does and does not meet their needs. Providers will also comment on anticipated implementation barriers. Following the ADAPT-ITT model, the qualitative data will inform

the adaptation of the intervention. We will then test the feasibility and acceptability of the adapted intervention (QUIT+) in a pilot RCT (N = 60); we will also assess for signals of clinically meaningful change in biologically verified 7-day point prevalence abstinence, average number of cigarettes smoked, gender minority stress,

anxiety and depression symptoms, and distress tolerance. If deemed to be feasible and acceptable, the intervention will be ready for a hybrid efficacy/effectiveness trial.