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Published in final edited form as: Explore (NY). 2021 Nov 17;19(1):131–135. doi: 10.1016/j.explore.2021.11.005

“I’m a transgender man… I have to quit smoking for treatment and surgery”: Describing the experience of a Latino transgender man during his attempt to quit smoking

Francisco Cartujano-Barrera 1, Lisa Sanderson Cox 2, Delwyn Catley 3, Zainab Shah 1, Ash B Alpert 1, Ana Paula Cupertino 1
PMCID: PMC9110554  NIHMSID: NIHMS1759029  PMID: 34823998

Abstract

Objective:

To describe the experience of a Latino transgender man during his attempt to quit smoking using a text messaging intervention.

Methods:

A Latino transgender man enrolled in a smoking cessation randomized controlled trial for Latino smokers. The participant was randomized to Decídetexto, a smoking cessation mobile intervention. The participant received a 24-week text messaging intervention. We assessed text messaging interactivity with the program, satisfaction, and self-reported abstinence at Week 12 and Month 6.

Results:

During the 24-week intervention period, the participant sent a total of 287 text messages to the program. When analyzing the content of the text messages sent by the participants, four important themes were identified: 1) gender identity, 2) low social support, 3) stressors (e.g., gender dysphoria), and 4) gender affirmation surgery as a reason to quit smoking. At both Week 12 and Month 6, the participant reported being extremely satisfied with the intervention and self-reported cigarette use.

Conclusion:

A smoking cessation mobile intervention generated high satisfaction and frequent interactivity among a Latino transgender man. This case report provides important insights into the experience of one Latino transgender man during his attempt to quit smoking. There is an urgent need to develop or adapt existing smoking cessation interventions to better meet the needs of transgender people.

INTRODUCTION

Transgender is an umbrella term for persons whose gender identity, gender expression, and/or behavior does not conform to that typically associated with the sex to which they were assigned at birth.1 Approximately one million individuals in the United States (U.S.) identify as transgender.2 According to the National Transgender Discrimination Survey Report on Health and Health Care and the 2015 U.S. Transgender Survey, smoking rates are higher among transgender people compared to the general population (30% and 22% respectively compared to 20.6%).3–5 Stress and normalization of smoking behavior are some of the multiple risk factors contributing to the increased smoking rate among transgender individuals.6–7 Furthermore, transgender people often experience multiple barriers to healthcare access and treatment that may further contribute to the high prevalence of cigarette smoking including increased poverty and unemployment in the transgender community when compared with the general population.4 Moreover, nearly one-third of transgender individuals report not seeking health care due to financial constraints.4 In addition, 33% of transgender people had negative experiences related to their gender identity in the healthcare setting and 23% cited fear of mistreatment due to their gender identity as a reason for not seeking necessary medical care.4 These findings highlight the need for culturally appropriate smoking cessation interventions that are accessible and meet the needs of transgender people.

As highlighted in the 2020 Smoking Cessation Report of the U.S. Surgeon General, culturally appropriate interventions are needed to advance tobacco cessation treatment among the transgender community.8 A systematic review of smoking cessation programs for lesbian, gay, bisexual, transgender, (LGBT) and intersex people found that LGBT-tailored interventions appear to be effective.9 However, in this systematic review only 3% of participants were transgender.9 More research is necessary as data are limited regarding transgender people, particularly transgender people who are from racial and ethnic minority groups. The striking health disparities and the clear gaps in the literature strongly support the need for further studies to understand and address the unique tobacco-related disparities among the transgender community, especially those from racial and ethnic minority groups. The purpose of this case report is to describe the experience of a Latino transgender man during his attempt to quit smoking using a text messaging intervention.

METHODS

Case presentation

A 30-year-old Latino transgender man enrolled in a smoking cessation randomized controlled trial (RCT) for Latino smokers. Details of the RCT are described in a previous publication.10 The participant was randomized to Decídetexto, a smoking cessation mobile intervention described below. Written informed consent was obtained from the participant. Study procedures were approved and monitored by Hackensack University Medical Center, the University of Rochester Medical Center, and the University of Kansas Medical Center Institutional Review Boards.

Intervention

Decídetexto is a smoking cessation mobile intervention that encompasses three integrated components: (1) a tablet-based software that collects smoking-related information to support the development of an individualized smoking cessation plan and guides the ensuing text messaging program; (2) a 24-week text messaging counseling program with interactive capabilities; and (3) pharmacotherapy support (provision of nicotine replacement therapy at no cost). The details of the intervention are described thoroughly in a previous publication.10 The text messaging system delivered these messages according to an algorithm based on four sequential phases that support the personalized quit plan: (1) Pre-quit (30 days), (2) Quit-Day, (3) Post-quit Intensive (28 days), and (4) Post-quit Maintenance (20 weeks). The library also included a Relapse Track (8 days). Decídetexto automated text messages encouraged participants to text any concerns and/or questions to the program. A trained tobacco treatment specialist answered these messages following standard protocols (e.g., answering questions on pharmacotherapy delivery, use, adherence, and side effects). The tobacco treatment specialist monitored and triaged queries daily, responding within one business day of receipt of text messages. The tobacco treatment specialist participated in weekly supervision meetings led by clinical psychologists with expertise in tobacco use treatment.

Measures

Trained research staff conducted an in-person baseline assessment that collected sociodemographic variables such as gender and age. Gender was assessed with the following question: What is your gender? Answer choices included: 1) Male, 2) female, 3) other, 4) participant does not know the answer, and 5) participant refuses to answer. Smoking-related variables collected at baseline included number of cigarettes per day, use of menthol cigarettes, and time to first cigarette. Twelve weeks and 6 months after enrollment, follow-up assessments were conducted by trained research staff. The Week 12 assessment was conducted over the phone and the Month 6 assessment was conducted in person. Relevant to this case report, both assessments collected data on 7-day point prevalence abstinence (not smoking any cigarettes in the past seven days), utilization of pharmacotherapy, satisfaction with the intervention, and self-reported smoking lapse. Participant’s text messaging interactions with the program were monitored throughout the entire 6-month intervention, including the number of times the participant relapsed.

Analysis

Consistent with previous studies assessing engagement in smoking cessation interventions delivered via text messaging,11–12 the participant’s text messaging interactions with the program were retrospectively analyzed to explore his experience with the intervention. Text messages were imported into Microsoft Excel for qualitative thematic analysis. Two coders independently analyzed the data using a process of inductive thematic analysis. Subsequently, themes were grouped and a code map was developed. The two coders met weekly and compared findings to identify similarities and differences with the codes. A third coder provided in-depth feedback in the codebook development and joined for in-depth discussion if differences in coding were found between the two coders.

RESULTS

The participant selected English as his language of preference to complete the assessments and intervention. At baseline, the participant was 30 years old and self-identified as male. On average, the participant smoked 11 menthol cigarettes per day and smoked his first cigarette within five minutes of waking up. At both Week 12 and Month 6, the participant self-reported cigarette use. The participant requested nicotine patches at baseline and self-reported high pharmacotherapy adherence (utilization of nicotine patches for 10 weeks) at Week 12. At both Week 12 and Month 6, the participant reported being extremely satisfied with the intervention.

During the 24-week intervention period, the participant sent a total of 287 text messages to the program. The participant reported 12 smoking relapses via text messages. When analyzing the content of the text messages sent by the participants, four important themes were identified: 1) gender identity, 2) low social support, 3) stressors, and 4) gender affirmation surgery as a reason to quit smoking.

Gender identity

The participant described his gender identity in an effort to contextualize one of his smoking relapses and share his main reason to quit smoking:

Decídetexto: What made you smoke again? Thinking about how to deal with this situation will help you avoid relapsing in the future.

Participant: I legally change my name to [Participant’s name]. I’m an HRT [hormone replacement therapy] transgender man. So, I’m battling with all my downs and I have to quit smoking for treatment and surgery.

Decídetexto: Thank you for sharing that with us. We support you and are here for you during this process. Please count on us to help you quit smoking!

Low social support

The participant reported low social support from friends and family, even when he reached out for it. The participant stated that he received more support from the intervention than his friends and family.

Decídetexto: Tell your loved ones that you are still determined to quit cigarettes. They are in this battle with you and will celebrate your victory.

Participant: I have, I think. They lost faith in me to be honest.

Decídetexto: Text a friend! Talking to them about how you feel will be a great support!

Participant: Just did. I get no responses back though lol [laughing out loud].

Decídetexto: Good morning, [Name of participant]. Think about all the positive things that come from quitting smoking. This will help you stay strong.

Participant: Thank you for all this support. I have more support from you guys than fam [family] and friends.

Stressors

The participant reported multiple stressors that made his quit attempts difficult. The selected message below shows two stressors reported by the participant (gender dysphoria and his romantic relationship).

Decídetexto: What made you smoke again? Thinking about how to deal with this situation will help you avoid relapsing in the future.

Participant: Job, bills, elderly parents, my dysphoria, my love life, etc.

Gender affirmation surgery as a reason to quit smoking

The participant reported in multiple text messages that his main reason to quit smoking was his gender affirmation surgery. The participant also shared with us his process for gender affirmation surgery (e.g., doctor appointments).

Decídetexto: [Participant’s name], you have important reasons to quit smoking. Remember them!

Participant: Yeah, tomorrow is the consultant for the surgery. So, I’m staying with [the nicotine] patches…

Decídetexto: Remember the main reason why you quit smoking, it will help you in difficult moments!

Participant: Surgery always top of my mind.

DISCUSSION

To the best of our knowledge, this is the first report of text messaging interactivity among a Latino transgender man enrolled in a text messaging smoking cessation program. The participant was highly engaged the program; the participant sent a total of 287 text messages to the program. Previous studies have assessed participant interactivity in smoking cessation text messaging programs.11–15 A smoking cessation study conducted in Puerto Rico reported the highest text messaging interactivity to date: 42.9 text messages per participant during a 6-month period.15 The participant in this case report had a high level of interactivity, including the reported smoking relapses, is promising as it suggests that the participant relied on the text messaging intervention for psychosocial support. Importantly, the participant decided to disclose his gender identity via a text message. Emergent evidence suggests that mobile health interventions may be appropriate for transgender individuals as they are used to navigate and develop identities, access resources, and engage with communities.16–17 Moreover, mobile health interventions may enable authentic self-expression, not always possible offline, among transgender people.18 There is a need to evaluate mobile health interventions for smoking cessation among transgender individuals.

This case report provides important insights into the experience of one Latino transgender man during his attempt to quit smoking. The participant reported low support from his family and friends. Social support plays a critical role as interpersonal relationships often motivate behavioral changes.19 Transgender individuals frequently suffer from lack of “primary group member” support, that is, support provided by those close to them who have experienced and overcome similar stigma or stressors.20–21 For example, in contrast to the experiences of individuals from other stigmatized groups (e.g., those who experience discrimination based on race/ethnicity, socioeconomic status, and/or religion), transgender individuals and their family members do not typically possess a shared stigmatized identity.20–21 Moreover, data suggest that a significant proportion of transgender individuals experience explicit rejection from family members as a result of family members’ transphobia.22–25 Sexual and gender minority-specific family rejection has been associated with cigarette smoking.26 This highlights the ways in which social support may increase the risk of smoking behaviors among transgender individuals and should be addressed in smoking cessation treatment.

Two important unique stressors reported by the participant were gender dysphoria and his romantic relationship. Gender dysphoria is the discomfort with the mismatch between one’s body and gender presentation and one’s gender identity.27 There is limited data on gender dysphoria and smoking behaviors among transgender individuals. Menino et al. analyzed electronic health record data from transgender youth and young adults to examine whether longer duration from transgender identity recognition to hormone initiation was associated with smoking behaviors.28 The study found that longer duration from age of identity recognition to age of hormone therapy initiation was associated with increased odds of current and lifetime smoking.28 Although this study did not include measures of gender dysphoria, it is possible that longer duration between identity recognition and hormone initiation may prolong and/or exacerbate this stressor.28 Regarding romantic relationships, our finding is consistent with studies showing that transgender individuals face unique challenges within several different aspects of relationships, including finding partners, disclosing their gender identity to partners, and maintaining relationships.29 Additionally, the relationship partners of transgender individuals face unique experiences like questioning their own gender identities and/or sexual orientations.30–31 Future research should examine how to address both the stress related to gender dysphoria and romantic relationships in smoking cessation treatment among Latino transgender men.

As noted by the participant in this case report, gender affirmation surgery may be an important reason for quitting smoking among the transgender community. This perspective is particularly relevant as Kidd et al. found that “trans-masculine” individuals who had undergone gender-affirming surgery were less likely to smoke, compared to individuals who had not taken these steps.32 This association may be explained by the fact that surgeons more readily offer preoperative smoking cessation counseling to avoid surgical complications.33 Alternatively, it is also possible that transgender individuals who smoke may be less likely to receive gender-affirming surgery because of concerns about smoking-related complications. In this scenario, smoking would then serve as a barrier to accessing gender-affirming healthcare, and offering culturally appropriate smoking cessation interventions could help to improve access to treatment.

Past research describes that transgender individuals who report transphobia and stigma from healthcare providers abandon substance abuse treatment prematurely.34 In contrast, transgender individuals who feel included and respected report positive treatment experiences.34 The participant described in this case report completed the treatment and follow-up assessments. Moreover, the participant reported being extremely satisfied with the intervention at Week 12 and Month 6. This result reaffirms that ensuring transgender individual experience inclusivity and having their gender identity respected in smoking cessation treatment may have a positive impact in treatment completion and satisfaction.

Many providers who treat patients with substance use disorders report lack of knowledge regarding the experiences faced by transgender individuals.35 This study found a number of important experiences faced by a Latino transgender man during his attempt to quit smoking. In particular, it illustrates the urgent need to develop or adapt existing smoking cessation interventions to better meet the needs of this unique population. These results provide concrete operational strategies to address smoking disparities among Latino transgender men. Further research is needed on how best to integrate these experiences into effective smoking cessation interventions.

Assessment of gender identity in tobacco control research has increased, yet its measurements remain inconsistent, hindering the ability to integrate findings.36 In this study, gender was only assessed with the question “What is your gender?” Answer choices included: 1) Male, 2) female, 3) other, 4) participant does not know the answer, and 5) participant refuses to answer. This question and its answer choices may not capture if a participant is transgender or not. In this case study, that information was captured because the participant described his gender identity in an effort to contextualize one of his smoking relapses and share his main reason to quit smoking. As described by Puckett et al., some transgender and gender diverse people suggest that to properly ask about gender, the “What is your gender?” question should be followed-up by the question “Are you transgender?” to capture transgender or cisgender experiences.37 Questions that allow participants to self-identify as transgender or not are critically important to identify and quantify health disparities and to develop effective interventions to reduce them.38

There are several limitations to this study. First, this case report examines the experience of only one Latino transgender man, and thus may not be generalizable to other transgender men. However, this case report provides concrete experiences to take into account to address smoking disparities among Latino transgender men. Second, this study does not address the experience of Latina transgender women nor Latinx non-binary individuals, who may face unique experiences that contribute to smoking-related disparities. For example, a study conducted by Gamarel et al. concluded that Black transgender women who smoke report higher levels of transgender-based discrimination compared to transgender women who do not smoke.39 The impact of transgender-based discrimination on smoking among Latina transgender women is unknown and warrants further research. Third, the participant described in this case report appeared to be highly-acculturated given that he completed the assessments and intervention in English. As described by Castro et al., acculturation differentially affects abstinence rates in treatment-seeking Latino smokers during a quit attempt.40 Specifically, acculturation is positively associated with smoking abstinence among Latino men, and is unrelated to abstinence among Latina women.40 Future smoking cessation research should include transgender individuals with varied acculturations levels, and study the role of acculturation in smoking cessation among this population. Lastly, the intervention was not designed to recognize the experiences and preferences of non-binary smokers (e.g., the inclusion of the gender-neutral messages and pronouns). This limitation is particularly important for interventions developed in Spanish as, in Spanish, every adjective, noun, and article are all either masculine or feminine. Many people who prefer gender-neutral options for Spanish have had ideas for how to speak and/or write Spanish in a gender-neutral way when necessary. For example, it is common for people to write “Latinx”, “Latine”, or “Latino@” as a gender-inclusive version of “Latino” and “Latina”. However, more research is needed on the specific preferences of non-binary Latinos in the U.S.

CONCLUSION

A smoking cessation mobile intervention generated high satisfaction and frequent interactivity among a Latino transgender man. This case report provides important insights into the experience of one Latino transgender man during his attempt to quit smoking. There is an urgent need to develop or adapt existing smoking cessation interventions to better meet the needs of transgender people.

FUNDING

This work was supported by the National Cancer Institute (NCI) under grant R01CA212189. The content is the sole responsibility of the authors and does not necessarily represent the official views of the NCI.

Footnotes

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DATA AVAILABILITY STATEMENT

The datasets generated for this study are available on request to the corresponding author.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

The datasets generated for this study are available on request to the corresponding author.

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