Reactions to Targeted Tobacco Control Messaging: Transgender and Gender Diverse Young Adult Perspectives

Abstract

Introduction

Tobacco interventions specifically created for transgender and gender diverse young adults appear almost non-existent. The Food and Drug Administration’s This Free Life is the first large scale campaign specifically designed to address the smoking disparities of sexual and gender minority (SGM) young adults. The purpose of this study was to gauge the reactions and receptivity to This Free Life from a gender diverse young adult sample using interviews conducted in spring and summer 2018.

Methods

Participants were 25 young adults recruited in Austin, Texas (M age=23.2, 64.0% non-Hispanic White, 70% assigned female at birth) for semi-structured one-on-one interviews as part of a larger project focusing on the reasons and settings for tobacco use. Data in the current study pertain to attitudes and reactions to online video content from This Free Life.

Results

Positive reactions to video content related to visible queer representation and depictions of gender non-conformity in videos that were positive and affirming in tone. Negative reactions related to what was perceived as sexist stereotypes perpetuated in videos, and an over-reliance on cisgender gay bar culture. Some participants felt that messaging discouraging social/occasional smoking did not take into account their own important reasons for smoking.

Conclusions

Transgender and gender diverse young adults have been overlooked in many efforts to address SGM smoking disparities. Targeted efforts such as This Free Life have the potential to help curb the disproportionate tobacco burden of gender diverse young adults by including diverse gender representation in affirming messages that emphasize freedom and autonomy.

1.1. Introduction

Tobacco interventions specifically created for the sexual and gender minority (SGM) community are scarce, though interventions customized for lesbian, gay, bisexual and transgender (LGBT) audiences appear to deliver success rates at least comparable to mainstream smoking cessation efforts.^1,2 However, the body of evidence is limited, and barriers specific to SGM populations may exist in accessing these treatments.^2–4 Furthermore, there is evidence that customized, culturally-relevant content is preferred by SGM participants,^5–7 which may influence their willingness to participate in tobacco interventions. Targeted interventions have the ability to address unique reasons a disproportionate amount of SGM individuals use tobacco,^8–10 including experiences of minority stress,¹¹ more mental health concerns,^12,13 and barriers to tobacco cessation treatments^2–4 that are not usually experienced by heterosexual individuals.

Individuals who do not identify with the sex they were assigned at birth, known as transgender and gender diverse (TGD) individuals, are sometimes included in the titles and design of SGM-targeted tobacco interventions. However, a prevailing criticism in SGM-focused health research is that it often conflates sexual and gender minority identities, subsuming transgender peoples’ experiences under the larger SGM umbrella without specific consideration for their unique lived experiences. Findings related to smoking outcomes for transgender participants in tobacco interventions are almost zero, and when they are included, results are frequently combined with sexual minority samples.^2,5 This is concerning, as there is a limited but growing body of evidence that more transgender individuals smoke cigarettes, ^10,14,15 cigars, ¹⁰ and use more electronic cigarettes (e-cigarettes)¹⁰ than their cisgender counterparts, although findings are not always consistent after controlling for covariates.^16,17 In their systematic review of smoking cessation programs targeted for lesbian, gay, bisexual, transgender, and intersex people, Berger and colleagues¹⁸ noted that of the 19 included studies, only five sought to include transgender individuals, often in cursory sociodemographic measures. To our knowledge, no tobacco interventions examined outcomes by gender minority identity or included specific elements relevant to TGD people, and research examining effective intervention elements specifically for transgender people is limited.¹⁹ In fact, there appear to be no tobacco cessation interventions specifically focused on transgender individuals, despite evidence of heavy tobacco use in the TGD community.

In May of 2016, the U.S. Food and Drug Administration (FDA) launched This Free Life, a national campaign designed to address SGM young adults’ disproportionate tobacco burden, and to prevent the progression from occasional to daily smoking. This Free Life targeted occasional smokers ages 18–24,²⁰ and was designed around themes demonstrated to resonate with young adult SGM audiences, including freedom of expression, pride in one’s identity, tight knit community, self-acceptance, and freedom from judgement.²¹ Campaign messages were paired with community messengers (e.g., famous drag performers, recognizable musicians), and designed to shift the normative expectation that SGM culture and tobacco use are inextricably linked, promoting the notion that the community as a whole can be proud to be free from the burden of tobacco.^20,21

This Free Life’s targeted outcome measures are the focus of the ongoing RESPECT evaluation, or the Research and Evaluation Survey for the Public Education Campaign on Tobacco among LGBT Young Adults.²¹ In their study using the campaign’s evaluation data, Navarro and colleagues²¹ reported a positive association between LGBT identity affirmation, LGBT identity centrality, and identification with the LGBT community and the perceived effectiveness of the campaign, lending support to a focus on relevant and relatable messages that appealed to LGBT young adults. Guillory and colleagues²⁰ found that This Free Life achieved higher brand awareness among LGBT young adults in treatment cities compared to control cities. There are no evaluations of how relevant or appropriate transgender and other gender diverse young adults may find the campaign, and no explorations of what elements viewers may find particularly appealing or effective.

The purpose of this study was to relay TGD young adults’ perceptions of and reactions to video content from the FDA’s This Free Life campaign. We aimed to center the first-person feedback of TGD young adults and allow them to articulate their reactions to the targeted tobacco messaging. Gauging TGD young adults’ receptivity to LGBT-focused health communications will help future campaigns develop inclusive and effective content that addresses unique aspects of TGD young adults’ lives.

2.1. Methods

2.2. Participants

Participants in this study were twenty-five tobacco-experienced TGD young adults from 18 to 29 years old (M age=23.2, 64.0% non-Hispanic White, 70% assigned female at birth) who took part in a larger study focusing on the reasons, settings, and motivations for tobacco use. Eighty-four percent of the 25 participants (n=21) reported past 30-day use of at least one tobacco product, and 60% were multiple tobacco product users, or polytobacco users. The most popular tobacco product used in the past 30-days was cigarettes (72%), followed by e-cigarettes (60%), with few participants reporting other product use (cigars, hookah, or smokeless tobacco). The one-on-one semi-structured interviews took place in the spring and summer of 2018 in Austin, Texas, and participant quotations are presented here with pseudonyms assigned for confidentiality.

2.3. Procedures

The Institutional Review Board (IRB) of the University conducting the study approved all procedures prior to recruiting or interviewing participants, and informed consent was discussed and obtained before each interview was conducted.

A purposive sample of tobacco-experienced gender diverse young adults was recruited with flyers hung at various locations on and around the campus and nearby bus routes of a major public university in Texas. Digital flyers and announcements were placed in the campus-wide email listservs for LGBT students, daily campus-wide event calendar postings, and local LGBT-focused Facebook groups.

Data used in the current study pertain to the portion of each interview with the first author where two to three videos from This Free Life were watched and then discussed. Videos included in this study are listed in Table 1. Standard, predetermined questions were used to gain initial impressions (see Table 2), and probes for elaboration followed in the resulting discussions related to the video content. All participants were compensated with $50 cash. At the conclusion of each interview, snowball sampling was used by asking participants if they knew any friends or acquaintances who might also be interested in the study. The first author provided additional flyers to participants who might notify their interested acquaintances to contact the study for participation. Participants were not compensated for referring potential participants.

Table 1:

This Free Life Videos Discussed

- Authentic and Non-Toxic

- Be Known for Your Flawless

- Bold and Non-Toxic

- Confident and Non-Toxic

- Get Ready for Anything

- Let Love In

- Love, Me With Lila

- Portraits of Pride with JD Samson

- Self-Made and Non-Toxic

- The Flawless Experiment

- The Moment

- Tip the Scale

- Unapologetic and Non-Toxic

Note: 2–3 videos were discussed in each interview.

Table 2:

Interview Items Related to This Free Life Campaign

- Are you familiar with any tobacco quitting or prevention campaigns?

- What are your thoughts on those?

- Are you familiar with This Free Life? [Watch videos]

- What are your thoughts on the ads?

- Do you feel you are in the target audience? (What makes you say that?)

- How effective do you think the ads will be?

- What influence would this campaign have on your tobacco use behaviors?

2.4. Data Analysis

2.4.1. Epistemological Considerations

The authors were guided by a relativist ontology,²² which included acknowledging that conversations and the resulting data generated were co-created in dialogue with participants. As such, the findings from this study are not wholly replicable or representative, nor are they free from bias. Both prior to the start of interviews and throughout the data collection process, the first author engaged in bracketing through reflexive note taking and reflexive critical discussion with the second author in an attempt to identify preconceived notions, bias, and to ensure participants’ findings stood apart from the authors’ own motivations for conducting the study. This bracketing entailed the first author acknowledging their queer identity and identification with the larger SGM community, particularly gender expansive people with identities outside of the traditional binary. Bracketing also entailed the first and second authors documenting their familiarity with tobacco control messaging through experiences actively conducting tobacco research. Thus, these reflexive notes and discussions helped inform the initial project’s research questions and the a priori codebook used for preliminary coding, while ensuring the authors documented their reasons for conducting the study.

2.4.2. Transcript Analyses

Immediately following each interview, field notes and a debriefing worksheet were completed by the interviewer. Field notes included general impressions of major themes, as well as nonverbal data not captured in audio recordings, like participant gestures and facial expressions. These notes allowed the first and second author to look for repeated and common themes across interviews and examine the interview process itself for improvements that could be made as interviews progressed. Debriefing worksheets were a uniform sheet that documented interview data such as date/time, duration, and any unique notes that would be useful to the coder in analyzing the data. Interviews were audio recorded, transcribed, checked for accuracy, and then thematically and iteratively double coded by independent raters (the first and second authors) using NVIVO version 11.²³ The a priori codebook contained broad descriptive categories based on anticipated responses, such as “positive” and “negative” reactions to videos. Coders then each fully coded one interview, expanding the a priori codebook to more specific subcategories and groupings via descriptive and interpretive codes. Coders also reviewed field notes and debriefing worksheets from each interview, and met to confer on their assigned codes. Findings were compared, and consensus was established on the new codes that emerged and were added to the coding scheme. From there, the authors each independently coded a second interview with the updated coding scheme, and again met to ensure consensus on the assigned codes and any new themes or codes that emerged. After double-coding and reviewing a third interview, the 22 remaining interviews were divided between the two primary coders. A third, senior “tie breaker” coder was planned in the event of ambiguity or disagreement about the assignment of codes, though this was never necessary.

Debriefing worksheets also included space to consider if the data collected had yet reached saturation in the scope of the larger project, defined as the point at which no new information was being collected.²⁴ At 20 interviews, there were many common themes in participant responses, and by 25 interviews, most of the discussion content overlapped significantly with previous interviews. Thus, saturation was considered reached at the completion of interview 25, and data collection ceased.

3.1. Results

Of the 25 participants in the current study, four had seen campaign ads, videos, or memes. Three were unsure if they had ever seen This Free Life Content, and 18 had no familiarity with the campaign. Overall, This Free Life video content elicited both positive and negative reactions, with mixed responses to the perceived relevance of campaign messaging, all of which are explored below.

3.1.1. Positive Reactions to Content: Affirming and Encouraging Tone

Most participants expressed positive reactions to This Free Life videos, making direct mention of how the encouraging, positive tone felt affirming, not only of their identities, but of the idea that they would one day be tobacco-free. Many participants also emphasized that the genuine, uplifting tone of the videos was preferable to other tobacco cessation campaigns, which often vilified or shamed smokers. Framing the choice to be tobacco free as one aligned with autonomy and freedom resonated with participants and contributed to their overall positive reception to the campaign.

“I like that this is framed in a freedom to be tobacco free. It is about choice. It’s about deciding whether or not you want to do it...If you don’t want to put it in your body, don’t put it in your body. But it’s not shaming people who do...That’s why I like that this is framed about freedom…It’s kind of putting the power in the person…If you want to choose not to, we support that, rather than like, ‘Look at those terrible queers over there who are smoking cigarettes.’” – Tanner, 25, she/her, non-Hispanic White

3.1.2. Positive Reactions to Content: Visible Queer Representation & Gender Non-conformity

Many participants were responsive to the clear and deliberate representation of non-cisgender and/or non-heterosexual actors in the videos. As one participant noted,

“I love seeing groups of people…you look at them and you’re like yes, you know they get it… they’re very obviously part of the trans community or just very queer, I guess, [it’s] very obvious. And, I just love it…seeing people who are very open make me really happy.” – Sasha, 19, she/her or they/them, non-Hispanic White

Other participants specifically noted drag entertainers as an appealing part of the campaign. While they acknowledged that drag performers did not wholly represent the transgender community, the performers were mentioned as being among their favorite entertainers and “an obvious way to signify queer identities.”

Overall, This Free Life’s specific targeting of the SGM young adult community was highlighted as an engaging part of the campaign, and contributed to the general appeal and positive reception of many study participants to This Free Life.

“You never see anything about tobacco use in the LGBT community, even though I know a lot of people in the LGBT community have resorted to using a lot of drugs and stuff, including tobacco...And I feel like I’ve never seen any campaigns or anything specifically talking to the LGBT community so, I think this was a good idea.” – Jon, 19, they/them, Asian

3.1.3. Negative Reactions to Content: Sexist Stereotypes of Beauty

For some participants, videos that emphasized negative physical effects of smoking were characterized as offensive or misguided, particularly those that were nested in feminine standards of beauty or appearance.

“The beauty-standards thing bothers me…I am a little repulsed at it, you know…I like wrinkles. Wrinkles are nice-looking…I think there’s this kind of weird implication, it’s used in anti-tobacco ads of, like, you’re ugly if you smoke…like equating it to physical standards of beauty seems weird.” – Riley, 24, they/them, non-Hispanic White

3.1.4. Negative Reactions to Content: General Distrust or Opposition to Tobacco Messaging

Some of the negative reactions to videos could be framed as coming from participants who opposed tobacco control messaging more generally. Frequently their criticisms focused on the fact that they already knew smoking was harmful. When probed on what messaging they might find more convincing, no participants volunteered any message they felt could persuade them to stop smoking. Additionally, multiple participants described the messages as pandering, or “corny.” Frequently this mindset was paired with a general distrust of the messenger (in this case, the FDA), although no participants elaborated on what parts of the campaign they specifically did not trust.

“It’s a little bit of just rolling my eyes at it. I’d be like ‘Yeah, cigarettes are bad. Okay, got it.’” – Leslie, 29, they/them, non-Hispanic White

Reactions to the campaign’s emphasis on eliminating “toxic” behaviors including smoking were met with mixed responses. One participant described her aversion to the use of toxic as pseudoscientific:

“I guess part of what…is bothering me is the word ‘toxic.’ There’s so much pseudoscientific stuff out there, that really focuses on toxicity or toxins…Like when people harp on, like, ‘Don’t put toxic things in your body,’ like, I don’t know, I feel like they’re going to sell me colloidal silver or something [laughing]…It’s just not something that speaks to me, personally.” – Aiden, 25, she/her, non-Hispanic White

Conversely, other participants found the use of the word toxic clever or engaging. One participant liked the bridge between the way they usually heard “toxic” used (in attitudes or relationships) and how the campaign used it more literally, equating removing toxic tobacco chemicals with improving bodily health. Another participant felt that focusing on bodily health and autonomy was particularly salient for SGM young adults:

“Attempting to connect a body positive message by emphasizing ‘don’t put toxic things in your body’ to this community, that I think has a lot of trouble with their bodies…is interesting…this is also really emphasizing…like bodily autonomy….That you are in charge of it, you get to decide things about it.” – Lennox, 28, they/them, non-Hispanic White

3.1.5. Negative Reactions to Content: Discouraging Coping Skills

A few participants framed their smoking behaviors as a method of harm reduction, where smoking cigarettes was more acceptable and less harmful than potentially more serious or consequential behaviors like drug use or relapse.

“People turn to this when they don’t really have other means to medicate… I mean, maybe they’re recovering alcoholics and smoking helps them stay calm. Or other addicts, you know, and they’re just trying to recover from that…that duality of smoking confuses me. Like, I know it’s a negative thing…So, I mean, if I were a medical professional, I’d always tell somebody, ‘Don’t smoke,’ right? But as someone in the community, I’d be like, ‘You do what you need to do to keep yourself safe.’” – Yael, 27, she/her or they/them, non-Hispanic White

3.1.6. Relevance to TGD Young Adults

There were wide-ranging perceptions of the overall relevance of This Free Life’s messaging. The campaign’s focus on social or occasional smoking was highlighted as applicable for multiple participants, especially in light of the fact that like many young adults, they still sometimes engaged in smoking behaviors despite not considering themselves smokers:

“I think mentioning bumming one on the patio is…definitely I think an experience that resonates. I think it is like a strong descriptor of how I or people I know smoke, even when they’re not ‘smoking’ anymore.” – Lennox, 28, they/them, non-Hispanic White

“The thing that catches me with both videos, it’s ‘even the occasional cigarette on the patio.’ I’m like, man, that was so directed at me, it’s like ridiculous…I’ll go outside and there are people smoking, and like it’s very easy, like, ‘Hey, can I bum a cigarette?’” – Sasha, 19, she/her or they/them, non-Hispanic White

Some participants suggested that a better campaign focus would be heavier, regular smokers. The participants making these suggestions were themselves social or occasional smokers, who like many young adults, did not consider their behaviors long-term or harmful.

In the same way that focusing on social smoking drew mixed responses, so did the common context of smoking at bars or clubs. Some participants enjoyed the familiar settings, paralleling their own experiences with those depicted. However, other participants did not see themselves reflected in the public gatherings represented in the videos. They specifically referenced the fact that they and their friends did not fit into the club scenes portrayed, both because they were non-cisgender and because they generally could not afford it:

“Those people…seem like there was absolutely nothing wrong with their place in society. They’re just like at the bar, chilling, looking good…it’s not me.” – Scout, 21, she/her, Latinx

“The people I’m with, it’s less going to bars and more like, getting drunk at house parties, because we’re all poor.” – Aiden, 25, she/her, non-Hispanic White

Drag performers were highlighted as another indicator of whether participants felt the campaign was relevant to them and their behaviors. Some enjoyed seeing campaign messages delivered by recognizable performers, while others felt it created an indication that the target audience was cisgender gay men.

“I feel like this is definitely targeted to kind of cis gay men primarily. I feel that’s who drag is kind of usually targeted towards. I mean, I like drag…It’s the same way things are marketed towards women as like an appeal-to-beauty-standards kind of thing. It’s the same thing to…young gay men of like, you want your skin perfect and your, you know, everything perfect.” – Riley, 24, they/them, non-Hispanic White

4.1. Discussion

This is among the first studies to gauge the relevance of and receptivity to SGM-targeted tobacco control messaging among transgender and other gender diverse young adults. Tobacco prevention and control best practices have specifically emphasized the need to engage transgender communities in initiatives geared toward reducing disparate tobacco use in these populations.²⁵ Using qualitative methods, we demonstrated that multiple elements of the FDA’s This Free Life campaign were well-received and viewed as relevant to a gender diverse sample of tobacco-experienced young adults.

The positive and affirming tone of the campaign stood out as the most frequently recurring theme in participant responses. They described the videos as encouraging and uplifting, emphasizing that the tactic of not shaming smoking behaviors made the overall messaging much more palatable. Themes of freedom and autonomy seemed particularly salient for this group, whose existence outside of the traditional patriarchal gender binary frequently sets them at odds with larger society. Videos that simultaneously affirmed participants’ identities while delivering positive messages about tobacco-free futures appeared to be among the foremost strengths of This Free Life, as expressed by participants in the current study.

Messages with clear depictions of gender non-conformity and transgender inclusion were also well-received. As noted by Berger and colleagues, not all content created for the broad SGM population resonates across its many diverse identities. For example, customization that is limited to images of explicitly gay people may alienate TGD people,¹⁸ as frequently TGD identities are subsumed under the larger SGM umbrella without representation of diverse gender identities and expressions.^13,19 Participants noted that the videos signaled inclusion with deliberate, visible representation of queer and gender diverse actors and portrayals, which were met with enthusiasm and appreciation.

Other components of the campaign were less well-received. Some participants were put off by what they perceived to be an over-reliance on stereotypes in promoting tobacco cessation messages in the “Flawless” ads. Videos that focused on the physical effects of smoking (wrinkles, yellow teeth) were sometimes viewed as prescriptive and sexist. Perhaps paralleling some of these findings, Navarro and colleagues’²¹ study of This Free Life demonstrated that gender minority participants were significantly less likely than cisgender gay men to find the “Flawless” ads effective. Indeed, young adults everywhere are bombarded with dogmatic standards of physical beauty and social conformity; TGD young adults must additionally navigate gender identities that often reside outside of the gender binary and traditional gender roles,²⁶ frequently at their peril. Messaging that promotes adherence to biased standards of physical beauty may backfire with this particular audience.

Some participants perceived an over-emphasis on bar culture that they view as primarily reserved for cisgender sexual minority audiences, while other participants enjoyed seeing the social scenes portrayed. Adding portrayals of more intimate house party settings or depictions of smaller groups in homes and backyards may resonate more with TGD young adults, where many of these participants described most frequently using tobacco.

A few participants viewed occasional or social smoking a less harmful behavior that may take the place of more serious or dangerous behaviors like illicit drug use or substance use relapse, which we framed here as harm reduction behaviors. These participants felt that the focus on deterring light smoking might eliminate a coping mechanism for frequent stressors TGD young adults face, including violence, discrimination, and harassment.^15,27 Messaging that can incorporate an acknowledgement of the wide variety of reasons young adults smoke while providing valuable alternatives will likely resonate with TGD young adults, whose tobacco behaviors are not limited to social use.

Finally, some reactions to This Free Life appeared unrelated to TGD identity. Some participants felt that occasional or social smoking itself was not a behavior worth addressing with a tobacco cessation campaign. This speaks to the very necessity of targeting social smokers, as even low levels of use may increase the likelihood of nicotine addiction and sustained use,²⁸ despite the fact that many young adult smokers do not adopt a smokers identity or view themselves as smokers.²⁹

4.2. Limitations

Findings from this study should be considered in light of some limitations. This was not a formal evaluation of the campaign; that work is underway.²¹ A limited number of videos were discussed with participants, and only online content that was available in the spring and summer of 2018 was viewed or discussed (see Table 1). Furthermore, the present study’s convenience sample was recruited in Austin, Texas, which was named a control city in This Free Life’s design. With a majority of the campaign’s content available online, spillover into control markets was cited as a hindrance to the campaign’s treatment-control evaluation design.²⁰ Importantly, this study’s findings cannot be generalized to larger, more diverse TGD audiences, particularly more racially/ethnically diverse samples. However, this was an opportunity for independent assessment of reactions to the campaign in a sociodemographic group that is intentionally included in the target audience of This Free Life. It is our hope that while this study does not comprise a replicable “final answer” in assessments of targeted tobacco messaging for TDG young adults, it may be used to inform future interventions and assessments aimed at improving tobacco outcomes among gender diverse audiences.

Lastly, many participants in the present study also reported sexual minority (SM) identities. Discussions were focused on TGD identity and its association with campaign relevance and appeal, however it is impossible to definitively separate critiques that are based on only one sector of identity. Future studies should explore how the appeal of SGM-targeted campaigns may change across various intersecting identities, as well as different levels of LGBT-identity centrality.

4.3. Conclusion

Targeted tobacco control messaging like that in This Free Life has the potential to help curb the disproportionate tobacco burden in SGM communities. While the campaign aimed for both broad and nuanced approaches to addressing SGM social smoking,²¹ findings from the present study suggest that a more nuanced inclusion of TGD young adults might increase their engagement with the campaign, and potentially improve their tobacco outcomes.

Messaging that uses a wide range of visible and diverse gender expressions while focusing on themes of autonomy and freedom will likely resonate with TGD audiences. Additionally, future tobacco control messaging should explore the less visible social contexts of some TGD young adult tobacco use outside of bars/clubs, while acknowledging that some TGD young adults may smoke cigarettes to make cope with gender-related stressors and as an alternative to drug use.

Highlights.

• Targeting for sexual minority smokers may not be relevant to transgender audiences.

• Messaging with clear depictions of gender non-conformity were well-received.

• Promoting gendered standards of beauty may backfire with gender diverse audiences.