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Published in final edited form as: J Subst Use Addict Treat. 2024 Nov 30;169:209590. doi: 10.1016/j.josat.2024.209590

Gaps in Smoking Cessation Counseling Administered by Healthcare Providers to BIPOC Gay Men Who Smoke Daily in the U.S.

Natalie Kelley 1, Dale Dagar Maglalang 2,*, Riley Suh 3, Mariel S Bello 3, Cora de Leon 2, Ethan Moitra 4, Jasjit S Ahluwalia 1,3,5
PMCID: PMC11769732  NIHMSID: NIHMS2040010  PMID: 39622436

Abstract

Background:

Black, Indigenous, and People of Color (BIPOC) racial/ethnic groups, sexual minorities (SM), and men have higher odds of smoking, less access to smoking cessation education and services, and lower smoking cessation rates than their white, heterosexual, and women counterparts. The purpose of this study is to examine the experiences of BIPOC gay men in accessing smoking cessation counseling from their healthcare providers and understand the facilitators and barriers to smoking cessation.

Methods:

This study analyzed data from BIPOC gay men who smoke daily via social media and organizational listservs throughout the United States and conducted semi-structured individual qualitative interviews. Two trained coders used thematic analysis to analyze the data.

Results:

Findings identified three overarching themes: 1) Sources of Information, 2) Facilitators and Barriers, and 3) Areas of Improvement for Smoking Cessation Counseling. Participants reported trusting advice from community members over healthcare providers regarding smoking cessation counseling. They also felt that the smoking cessation advice received from healthcare providers was, at times, confusing and inadequate. Identity concordance between patient and healthcare provider helped participants feel seen by their provider, which motivated them to engage in smoking cessation counseling. Finally, participants suggested improvements for smoking cessation counseling for BIPOC gay men such as integrating mental health support in smoking cessation services, accountability for patients, and providing harm reduction alternatives instead of smoking cessation only.

Conclusion:

BIPOC gay men who smoke daily value the importance of receiving culturally adaptive and gender-affirming care from healthcare providers who share their identities when receiving smoking cessation and harm reduction counseling.

Keywords: people of color, gay, men, smoking cessation, cigarette use

1. Introduction

Tobacco use is the leading cause of preventable death in the United States (U.S.) (Cornelius et al., 2023). In 2021 approximately 46 million U.S. adults reported using any tobacco product with 28.3 million who used combustible cigarettes (CC), and 11.1 million who used Electronic Nicotine Delivery System (ENDS) products (e.g., vape and electronic cigarettes [e-cigarettes]) every day or some days at the time of the study, respectively (Cornelius et al., 2023). The highly addictive nature of nicotine and the persuasiveness of cigarette advertisements contribute to smoking, despite widespread public health campaigns about its negative health consequences (Cornelius et al., 2023).

According to national data, smoking disparities persist in the U.S. population by sex, sexual orientation, and racial/ethnic groups (Cornelius et al., 2023). The prevalence of CC (13% vs 10%) and ENDS (5.1% vs 4%) use is higher among men than women. Lesbian, gay, and bisexual (LGB) adults also use CC (15.3%) and ENDS (13.2%) at higher rates than heterosexual adults (11.4% & 4.1%, respectively). By racial/ethnic groups, use of CC (14.9%) was highest in non-Hispanic (NH) adults of other racial/ethnic identities, categorized as NH American Indian/Alaska Native and NH multi-racial, followed by NH white (12.9%), NH Black, (11.7%), Hispanic (7.7%) and NH Asian (5.4%) (Cornelius et al., 2023). Similarly, ENDS use was also highest in NH other (8.9%) followed by NH white (5.2%), Hispanic (3.3%), NH Asian (2.9%), and NH Black (2.4%) individuals (Cornelius et al., 2023).

When accounting for people’s intersecting identities, specifically, their sex, sexual orientation, and race/ethnicity, a national sample of U.S. adults found that compared to heterosexual NH Black men, gay NH Black men had higher odds of using CC, and compared to heterosexual NH Black women, lesbian and bisexual NH Black women had higher odds of using CC (King et al., 2021). This finding was also similar for the NH white population for both sexes but was not evident for other racial/ethnic groups. Studies that focus on racial disparities within sexual minority (SM) U.S. adults who use ENDS are limited. However, a study on U.S. youth found that SM Black girls and SM mixed race girls use e-cigarettes at higher rates than SM white girls (Lee & Tan, 2022). Such findings may provide some insight into what the prevalence of ENDS use might look like for U.S. adults in the future. Nevertheless, studies that examine the intersectionality of people’s identities show potential disparities within sub-groups that may be overlooked when people’s demographic characteristics are evaluated separately. More importantly, it underscores the increased health burden of smoking-attributable mortality and morbidity, including cancer, chronic obstructive pulmonary disease (COPD), and cardiovascular disease impacting racial/ethnic and SM populations (Caceres et al., 2017; Max et al., 2019).

The Minority Stress Theory (MST) and intersectionality framework can help situate the phenomenon of smoking disparities in Black, Indigenous, and People of Color (BIPOC) SM. The MST posits that stress experienced by individuals with minoritized identities exacerbates negative mental health outcomes (Meyer, 1995). Further, studies have extended this theory to investigate the connection between mental health outcomes and substance use, suggesting a link between MST and substance use (Blosnich et al., 2011; Corliss et al., 2014; Parent et al., 2019). Intersectionality, which arose from Black feminist legal theory, is an understanding that the experience of holding multiple identities creates a unique experience of oppression depending on the context and setting (Bowleg, 2008; Crenshaw, 1991). It is through the framework of MST and intersectionality that this study will examine the experiences of BIPOC gay men who smoke.

As documented in the Surgeon’s General Report on Smoking Cessation, widespread evidence established that smoking cessation improves health outcomes (United States Public Health Service Office of the Surgeon General & National Center for Chronic Disease Prevention and Health Promotion (US) Office on Smoking and Health, 2020). Among many forms of intervention, physician counseling is an effective tool in smoking cessation when compared to no physician counseling. Often, physician counseling involves a discussion on smoking behavior as well as pharmacotherapy (Patnode et al., 2021). However, there are disparities in smoking cessation counseling provided by healthcare providers. For example, the Surgeon’s General Report showed that men (55.2%) were less likely to receive smoking cessation counseling provided by a health professional than women (59.3%). Additionally, among adults who use tobacco products, NH white U.S. adults (60.2%) were most likely to receive cessation counseling from a health professional, compared to NH Black (55.7%), NH Asian (34.2%), American Indian/Alaska Native (38.1%), and Hispanic (38.1%) individuals.

Identifying the causes of this difference are complex, as factors of discrimination, likelihood of seeing a physician, medical mistrust, and disclosure of smoking behaviors may all play a role (Hooper et al., 2017). Despite this, the Surgeon’s General Report highlighted that Black individuals who smoke attempt to quit at about the same rate as white people who smoke but are less successful. Furthermore, among LGB populations, interests in quitting and past-year quit attempts are comparable to their heterosexual counterparts (Fallin et al., 2015, 2016; United States Public Health Service Office of the Surgeon General & National Center for Chronic Disease Prevention and Health Promotion (US) Office on Smoking and Health, 2020). However, the use of cessation counseling and medications in LGB individuals who smoke (14.5%) was approximately half of heterosexual individuals who smoke (31.7%). These data suggest that despite high smoking rates, people who are BIPOC and LGB possibly may have less access to effective and relevant smoking cessation interventions. Moreover, when they engage in cessation efforts, quit rates are lower compared to their white, cisgender, and heterosexual counterparts. Studies found several reasons that may explain these discrepancies (Baker et al., 2022). Research showed mixed results when pharmacotherapy is offered. For example, one study found pharmacotherapy does not appear to have the same success rates in Black individuals as it does in White individuals (Hooper et al., 2017). Another study found that Black individuals utilizing varenicline with counseling showed higher rates compared to Black individuals given a placebo and counseling (Cox et al., 2022). Early smoking cessation interventions on Lesbian, Gay, Bisexual, and Transgender plus (LGBTQ+) indicated higher efficacy rates of smoking cessation among LGBTQ+ than the general population (Berger & Mooney-Somers, 2016). Research examining smoking cessation through an intersectional lens is limited and more work is needed to understand how compounding minoritized identities can influence smoking cessation and counseling (Berger & Mooney-Somers, 2016).

1.1. Aim of current study

Improved understanding of how the intersecting identities of BIPOC gay men who smoke influence their interactions with their healthcare providers may inform the improvement of services to alleviate the disparities in smoking cessation counseling for this population. Further, developing methods to provide culturally sensitive and gender affirming smoking cessation interventions are needed to address the smoking disparity among BIPOC gay men. This study aims to address these research gaps through the following steps: (1) examine experiences of BIPOC gay men who smoke daily in receiving smoking cessation counseling from healthcare providers, (2) understand facilitators and barriers to engagement in smoking cessation interventions, and (3) identify areas for improvement for smoking cessation counseling by healthcare providers.

2. Methods

2.1. Sample

This study is part of a larger study on experiences of stigma and smoking in BIPOC gay men. The primary study focused on understanding the decision-making process of experiencing stigma and how it influences the use of tobacco and nicotine products in BIPOC gay men who smoke daily. In addition, it also sought to identify potential protective factors that may mitigate the negative effects of stigma on using tobacco and nicotine products. The study recruited prospective participants using listservs from national organizations serving sexual and gender minority (SGM) populations, physical flyers in the Northeast region, and online and social media platforms (e.g., Craigslist, Reddit, and X [formerly known as Twitter]). Interested participants completed a survey via Qualtrics to determine their eligibility. Research staff reviewed the participants’ responses and scheduled interviews with those who met inclusion criteria via email while ineligible participants received an email with the National Smoking Quitline number (1-800-QUIT-NOW) which uses personalized and free services including counseling, nicotine replacement therapy (NRT), and medications (Centers for Disease Control and Prevention, 2023).

Inclusion criteria were: 1) 21 years old or older, 2) assigned male at birth, 3) identifies as gay, 4) identifies as Black, Indigenous, or People of Color (BIPOC), 5) reads and speaks English, 6) lives in the U.S., 7) has access to a computer or mobile device with Zoom capabilities, 8) self-report current use of CC and/or ENDS devices (e.g., e-cigarettes, hookah pen, etc.) for at least 25 days or more in the last 30 days as done in prior work (Fish et al., 2015; Nollen et al., 2023).

A total of 701 prospective participants completed the screening survey. The study deemed about 332 entries ineligible because they either did not meet eligibility criteria or were categorized as bots or individuals who were making multiple entries using different names and email addresses within minutes of submission and identical geotag locations. As a result, 369 were eligible and contacted to schedule an interview, and of these, 16 participants were interviewed for the study. The difference between those who were eligible and not interviewed versus those who were interviewed, was a result of primarily eligible participants who stopped responding to email requests to schedule their interview. The study recruited and interviewed participants from April through August 2023. This study only used data from 13 participants who either only used CC exclusively (n=4) or dually used CC and ENDS (n=9). Participants who used ENDS exclusively (n=3) were excluded from the analysis because ENDS is not a combustible tobacco product, and this study is examining smoking cessation from CC.

2.2. Study procedures

The study interviewed scheduled eligible participants via Zoom. Participants were encouraged to situate themselves in a private space where they felt comfortable and safe to participate in the study. Research staff conducted the interview in a locked private room in the university where the study was being conducted. After obtaining informed consent, research staff then asked participants questions about sociodemographic information, tobacco use history and exposure, current tobacco and nicotine use, use of other substances, and discrimination related to their sexual orientation. The second portion of the appointment involved a semi-structured in-depth individual interview about the participant’s experiences of stigma, smoking, and experiences with obtaining smoking cessation counseling from healthcare providers. For the purposes of this study, we only analyzed questions regarding the participant’s experiences with healthcare providers. All the interviews were scheduled for a total of 75 minutes. Participants received a $40 gift card that was mailed to their preferred U.S. address.

The study recorded the interviews over Zoom and uploaded them to a secured password-protected university online network. After transcription using NVivo Transcription, a trained transcriber checked transcripts for errors, de-identified and updated them. The Brown University Institutional Review Board approved the study (IRB: #2023003547).

2.3. Data analysis

Research staff analyzed data using thematic analysis (Braun & Clarke, 2006). Thematic analysis was chosen for data analysis because it provides researchers the flexibility to actively engage, develop, and interpret patterned meanings that can help produce rich and complex interpretations of the data (Braun & Clarke, 2006, 2022). Following the phases of thematic analysis, first, two trained coders (NK & DM) immersed themselves in the transcripts to familiarize themselves with their content and briefly note any initial ideas or insights about the data based on the research question posited. Second, the coders iteratively coded the transcripts independently to develop a codebook which then led to additional rounds of coding using semantic and latent-level codes. The coders met routinely to discuss their codes, not to reconcile every code discrepancy, but to collaboratively gain a deeper and nuanced understanding of the data (Braun & Clarke, 2022). Third, the coders collated the codes and began identifying shared patterned meaning in the transcripts to develop candidate themes. Fourth, the coders evaluated if the candidate themes fit the rest of the data in relation to the study’s proposed research question. Fifth, the coders refined the candidate themes and assessed if the themes were centered around a core concept and if it reflected the overall story of the data. Finally, the coders selected the most compelling examples from the transcripts and ensured that the themes, examples, and overall narrative of the results respond to the research question. Coders used NVivo 14 to conduct the analysis of the data. Assigned pseudonyms protect participants’ identities.

3. Results

Of the 13 participants, the mean age was 34 years old (Standard Deviation[SD] = 9.89). Nine (69%) identified as Black or African American, two (15%) as mixed race both as Black or African American and Native American, one (8%) as Asian American, and one (8%) as Latine/x. Nine 9 (69%) dually used both CC and ENDS and 4 (31%) used CC exclusively. Ten (77%) rent a home, condo, or an apartment, and three (23%) own a home or a condo. Considering their own income and the income from any other people who help them, their personal financial situation showed that six (46%) meet basic expenses with a little left, three (23%) meet basic expenses with more than a little left, three (23%) just meet basic expenses, and one (8%) don’t meet basic expenses. Regarding the participant’s educational attainment, seven (54%) have a college degree, five (38%) have some college or 2-year degree, and one (8%) have a high school degree. Eight (62%) are employed full-time, three (23%) are employed part-time, and two (15%) are unemployed.

As shown in Figure 1, three main themes were identified: (1) Sources of Information, (2) Facilitators and Barriers, and (3) Areas of Improvement for Smoking Cessation Counseling.

Figure 1.

Figure 1.

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Schematic model of the experiences of BIPOC gay men who smoke in receiving smoking cessation counseling from their healthcare providers, facilitators and barriers to engaging in smoking cessation interventions, and ideas for improvement for smoking cessation counseling.

3.1. Sources of Information

3.1.1. Preferred Trust in Community Members

Participants reported receiving information about smoking cessation from a plethora of resources, both through digital and interpersonal means: from healthcare providers, friends, family, flyers, school, advertisements, social media, and online community forums. However, participants felt that this information was more trustworthy when they receive it from friends, family, and those who also identify as BIPOC, SM, or both. Charles, a 24-year-old mixed race (Black or African American and Native American) man who uses both CC and ENDS shared that they never received smoking cessation counseling from their healthcare provider, and it was not until they were in a Lesbian, Gay, Bisexual, Transgender, and Queer (LGBTQ) community center where they finally received information about smoking cessation:

I didn't know where to ask. But I recently went to a group where they spoke about it, another LGBTQ space, and they were somewhat from another LGBTQ space who works with addiction reduction. And I got in contact with them… After finding where to find those resources it made it a little easier… People in the community [LGBTQ+] seem to care more about my health.

3.1.2. Patient Education Needs Improvement

While some of the participants were asked by their healthcare provider about their smoking behavior, the participants noted that the quality of education on smoking cessation counseling provided needed further improvement. For instance, Joe, a 31-year-old Latine/x man who uses both CC and ENDS, recalled that although they were asked about their smoking habits, there was no education concerning smoking cessation:

There would just be like the typical questions that they ask… and I'd write the amount [of cigarettes I smoke per day]. There was nothing on their end for preventative measures or reductions. It was just another tally on their sheet, in a sense.

Among those that received smoking cessation counseling from their healthcare providers, these individuals noted that the information provided was confusing and inadequate:

I didn't understand what the point of the patches was [or] like the amount of grams they had. And I didn't understand the different ones. I don't know which one I should use. It was just confusing to me. So, when I'm confused… I'm going to go smoke a cigarette because it's too much confusion. And that's what happened.

- Clay (38-year-old, Black or African American man who uses both CC and ENDS)

3.2. Facilitators and Barriers

3.2.1. Identity concordance matters

Participants spoke about how identity concordance with their healthcare provider improved their perception and experience regarding their healthcare treatment. Chris, a 25-year-old Black or African man who uses both CC and ENDS, juxtaposed their experiences when their healthcare provider is Black compared to when they do not have a Black doctor:

My healthcare provider is… always ready to listen. But you know… the Black doctor there, he advises me more. [He] treats me like a brother, so he talks to me. When I don't see the Black doctor' I know, I'm not going to be treated well. And you know, so they pay more attention to other people than me most of the times. When the Black doctor is with me, he treats me very fine and.… he, you know, encourages me. He advises me and tells me what to do and what not to do, you know.

The positive relationship fostered through identity congruence further strengthened potential adherence to smoking cessation counseling because some participants deemed that their shared identity with their healthcare provider made them feel seen and supported, which may make them more likely to agree with or believe their healthcare providers concerning treatment recommendations:

I met a doctor who was also gay, and he encouraged me a lot. [He] speaks to me like “whatever you do in life, don't let anyone talk down on you” and stuff like that. The counseling person spoke to me… like we've known [each other] for a long time. Spoke to me like someone who has been in my condition before. So, I could literally understand him perfectly well, and he could understand me perfectly well. So, we had a connection. We had a connection so he could relay whatever counseling he was offering to me perfectly well. They talked me into reducing my level of tobacco and… [trying] to use e-cigarettes.

- Richard (33-year-old Black or African American man who uses CC and ENDS)

3.3. Areas of Improvement for Smoking Cessation Counseling

3.3.1. Integrating Mental Health Support

Participants suggested components they would like to see incorporated into smoking cessation counseling. A primary suggestion that participants identified is integrating mental health support in smoking cessation counseling to help them understand the root causes of why they smoke:

Sexual and gender minorities come off maybe a little more normal to people if they have a cigarette… So, I think that counseling with as far as understanding… that thought process throughout the connection of why you're smoking, understanding the reasonings like what started it and the habits and the patterns and figuring out like where those moments went and how to resolve those issues to reduce or eliminate smoking completely.

- Joe

If the root causes of smoking were to be identified, participants suggested that mental health counseling could be of further assistance by helping them change behavior patterns. Chris reflected on how the intersection of their identity influenced their smoking behavior and the positive impact that mental health counseling may provide:

Like when I’m at my lowest, you know, I just wish I can smoke when… people you know, talk down at me. So that’s the point, because that is the main reason why I smoke, why I get high, because of … what people say about me. So, if I can actually see a kind of counseling that can make me understand, you know it can make me feel like I don't have to [smoke] irrespective of what people say. I’d really love that.

3.3.2. People Want to be Held Accountable

When asked about factors that may help with smoking cessation, participants discussed the importance of a consistent accountability partner. The emphasis on community and support was described by a participant:

Checkups would be nice. [An] accountability partner in that sense. If I really wanted to go full force and stop this, I want that person on my side supporting me, helping me when I fall down. I want them to go on this [smoking cessation] process with me. They're actually there to support, like the full support system and encouragement when I falter.

- Joe

Participants further emphasized that, in addition to being held accountable by their healthcare provider, they also wanted them to be able to explain the process of quitting smoking and show a genuine commitment to their success. When asked about what they want from their healthcare provider concerning smoking cessation counseling or other smoking alternatives, Clay explained how they envisioned accountability in improving their attempt to quit:

Well, what I need is someone that's going to call me. I mean, I know somebody is going to be one-on-one who's really going to be there for you and really explain everything… I need to have a motivator for me, you know, especially if I'm unclear. [If] I don't know any other way of trying to get around it or I don't know anywhere to ask help from, I just give up. I [need] somebody who is really going to tell me… step by step by step for me at least, especially for something like this. What’s going on? How is [this intervention] going to affect me and things like that, you know?

3.3.3. Harm Reduction is More Accessible Than Smoking Cessation

Participants expressed a stronger interest in harm reduction than complete smoking cessation. David, a 50-year-old Asian American man who uses CC exclusively, shared having an interest in opting for a harm reduction approach:

I would probably be interested in you know, maybe something that was more harm reduction focused than smoking cessation. Because I do think the number of… cigarettes that you smoke definitely connects to the health impacts. I'm not necessarily super interested in completely quitting but I'd love to reduce that number. So, maybe if there was something that was sort of customized that could get me you know, that was focused on reducing the amount of smoking, not quitting entirely.

4. Discussion

This study explored the experiences of BIPOC gay men who smoke daily and their experiences with their healthcare providers regarding smoking cessation counseling. Participants emphasized the importance of community social networks as trusted information sources and the inadequacy of information regarding smoking cessation counseling that they have received from healthcare providers. While investigating the facilitators and barriers to smoking cessation counseling and other smoking alternatives from healthcare providers, participants discussed the importance of identity concordance to their experiences. Qualitative themes regarding areas of improvement for smoking cessation counseling and other smoking alternatives by healthcare providers included the addition of a mental health counseling component, accountability from healthcare providers or other trusted peers, and emphasizing harm reduction strategies rather than complete smoking cessation alone.

An overarching theme from the findings is the influence and quality of the sources of information for smoking cessation counseling and other smoking alternatives that participants received. Participants shared that they were more likely to trust information from their social network than healthcare providers because they felt more taken care of, and taken seriously by, people from their community. Such experiences of medical mistrust have been well documented in populations like BIPOC communities that have endured systemic racism in healthcare settings (Benkert et al., 2019; Morgan et al., 2023). When participants do receive smoking cessation information from their healthcare provider, they found that the information being given to them about smoking cessation were, at times, inadequate, confusing, and needing improvement. Numerous studies of smoking cessation counseling among healthcare providers have shown inconsistencies in providing smoking cessation counseling to patients, despite patients communicating that they smoke and providing adequate information about their smoking behavior (Buchbinder et al., 2014; Kruger et al., 2016). This suggests a need to standardize smoking cessation counseling in medical education and in healthcare settings across providers to ensure that patients are receiving comprehensive smoking cessation education that can inform their smoking behaviors choices.

Participants noted that identity concordance with their healthcare providers influenced their willingness to engage in discussions about smoking cessation. These conversations could be primary facilitators or barriers depending on how identity-affirming the interaction was perceived. Consistent with the existing body of literature that found that identity concordance between healthcare providers and their patients improves the healthcare experience (Shen et al., 2018), participants in this study discussed having healthcare providers who share their racial and/or sexual orientation identities made them feel that their healthcare provider genuinely cared about their well-being. Furthermore, the rapport building, the inclusive environment of the healthcare facility, and providing comprehensive care made patients more amenable to receiving smoking cessation counseling and committing to changing their health behavior. These findings stress the importance of a diverse healthcare environment that actively works towards representation among healthcare providers. Efforts to increase diversity in healthcare and promoting gender affirming and culturally sensitive care contribute to more positive and effective healthcare experiences and outcomes for BIPOC SGM (Eckstrand et al., 2017).

Participants offered valuable suggestions for enhancing smoking cessation counseling for BIPOC gay men who smoke daily including integrating mental health support, being held accountable, and offering harm reduction alternatives. Participants emphasized the importance of understanding the root causes of smoking, addressing emotional triggers, and incorporating mental health components into counseling sessions. This demonstrates the interconnectedness of mental health and smoking behavior, highlighting the need for comprehensive interventions that consider the psychological aspects of smoking. Research indicates that a combination of behavioral (e.g. cognitive behavioral therapy, group counseling, quitlines, web-based interventions, smartphone applications) and pharmacological interventions (e.g. nicotine replacement therapy, bupropion, varenicline) is the most effective in promoting smoking cessation (National Center for Chronic Disease Prevention and Health Promotion (US) Office on Smoking and Health, 2014). However, data exploring efficacy of these treatments specifically in SGM populations are sparse.

In addition to integrating mental health support with smoking cessation counseling, participants also emphasized the role of social support and ongoing engagement in promoting successful smoking cessation outcomes in BIPOC gay men. Other studies have found that regular check-ins and having support systems like accountability buddies, can enhance participant motivation and commitment to successfully quit smoking (Kenny et al., 2021; Lepore et al., 2021). Some participants also emphasized that they would be interested in harm reduction approaches to smoking cessation by trying out alternative harm reduction options like e-cigarettes. Tobacco harm reduction approaches are gaining increased attention in the literature, given that a substantial proportion of individuals who smoke express little to no desire in quitting smoking or believe that they are unable to quit due to repeated unsuccessful cessation attempts (Hatsukami et al., 2004; McNeill, 2004). Emerging research comparing the effectiveness of specific tobacco harm reduction strategies (e.g., use of pharmacotherapy for smoking cessation [NRT; medications], smokeless tobacco [snus], e-cigarettes) have shown that using NRT significantly reduced cigarette consumption per day and increased the likelihood of quitting smoking (Lindson-Hawley et al., 2016), whereas the use of snus, e-cigarettes, or medications (i.e., bupropion, varenicline) facilitated temporary smoking abstinence (Lindson-Hawley et al., 2016). Furthermore, some studies have found that smoking cigarettes with reduced levels of tar, carbon, and nicotine may result in modest reductions in toxicant exposure; however, it is still unknown as to whether this would reduce the risk of harm from smoking (Lindson-Hawley et al., 2016). Furthermore, while controversial, a growing body of evidence suggests that e-cigarette use and the use of other ENDS products can be effective in helping people who smoke quit successfully (Ashour, 2023; Auer et al., 2024; Balfour et al., 2021; Lindson et al., 2024). Given the high use of e-cigarettes among SM individuals compared to heterosexual individuals, potentially considering ENDS products as a harm reduction option may be effective in helping BIPOC gay men successfully quit smoking.

4.1. Limitations

This study has some limitations. First, the study received many participant entries that were considered bots. This issue is part of a growing problem in conducting recruitment online through social media and public forums where predatory individuals take advantage of research studies to make a profit (Pozzar et al., 2020). Nevertheless, conducting the study over Zoom with the camera on for both research staff and participant, confirming their identities with a valid identification document, and providing a U.S. home address to mail their gift card helped ensure that our participants were verified individuals. Second, the surveys administered by research staff were self-reported by participants. There can be limitations when participants self-report their use of substances and experiences of discrimination, specifically, recall bias and social desirability bias that may overestimate or underestimate the number of events that occurred (Althubaiti, 2016). However, a systematic review comparing self-reported smoking and cotinine verified smoking status did find that there is an underestimation in the prevalence of smoking when participants self-report (Gorber et al., 2009). Third, the study also focused specifically on gay BIPOC men which limits the understanding of how other groups who identify as SGM might experience smoking cessation counseling from their healthcare providers. Future studies should consider implementing this study to a broader population within the SGM community that considers the intersections of sex, gender, race/ethnicity, sexual orientation, and other identities to gain better insight of the similarities and differences in smoking cessation counseling to inform culturally responsive and gender affirming services. Fourth, we terminated data collection based on data saturation from the larger study. However, the research team was conducting simultaneous data analysis of this study and the larger study, and when comparing the findings from the results, there was no new information being discussed by the participants in either study based on the posited research questions. Fifth, while there are many advantages to thematic analysis, it also has some disadvantages. Scholars have argued that while its method allows for flexibility, it can also confuse researchers on what part of the data to focus on (Braun & Clarke, 2006). Furthermore, unlike other types of qualitative methods like narrative and ethnography research, it does not provide continuity that can provide more in-depth data (Braun & Clarke, 2006). Nevertheless, the research team that qualitatively analyzed the data has extensive experience in analyzing qualitative data using thematic analysis, and choosing the method to analyze qualitative data should be based on the research question, which based on our posited research aims is most appropriate for thematic analysis.

5. Conclusion

The identified themes in this study highlight the need for inclusive, culturally adaptive, and individualized approaches to smoking cessation interventions for BIPOC gay men who smoke daily. The implications of this research extend to healthcare policy, practice, and education. Efforts to increase diversity in the healthcare workforce, enhance cultural humility and gender affirming training, improve patient education on smoking cessation, integrate mental health components into counseling, and provide ongoing support are essential in closing the gap on successful smoking cessation rates especially in BIPOC SGM populations.

Supplementary Material

1

Highlights.

  • BIPOC gay men trusted people in their community about smoking cessation advice.

  • Identity concordance with their primary healthcare providers is important.

  • Smoking cessation should include mental health counseling.

Funding:

Drs. Maglalang and Ahluwalia were supported in part by P20GM130414 (PI: Monti), a National Institutes of Health (NIH) funded Center of Biomedical Research Excellence (COBRE). Dr. Bello was supported by the National Institute on Drug Abuse (NIDA) T32 DA016184 (MPI: Rohsenow & Tidey). Natalie Kelley was supported by the National Heart, Lung, and Blood Institute (NHLBI) T32 HL094308 (PI: Harrington)

Footnotes

CRediT authorship contribution statement: Natalie Kelley – Conceptualization, Data curation, Formal Analysis, Investigation, Writing – original draft, Writing – review & editing. Dale Dagar Maglalang – Conceptualization, Data curation, Formal Analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Supervision, Writing – original draft, Writing – review & editing. Riley Suh – Investigation, Writing – original draft, Writing – review & editing. Mariel Bello – Formal Analysis, Writing – original draft, Writing – review & editing. Cora de Leon – Formal Analysis, Writing – original draft, Writing – review & editing. Ethan Moitra – Supervision, Writing – original draft, Writing – review & editing. Jasjit S. Ahluwalia – Conceptualization, Funding acquisition, Investigation, Supervision, Writing – original draft, Writing – review & editing.

Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

Disclosure: Dr. Ahluwalia received sponsored funds for travel expenses as a speaker for the 2021, 2022, and 2023 annual GTNF conference. Dr. Ahluwalia also serves as a consultant and has equity in a start-up company, Qnovia. Qnovia is a start-up company that is developing a nicotine replacement therapy prescription product. Preclinical work has been completed and the plan is to begin Phase I clinical trial work. The rest of the authors have no competing interests to declare.

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