“I got tired of being called a sissy”

Transcription

focus group findings on tobacco use in lgbt communities
Affirmations
290 West Nine Mile Road
Ferndale, Michigan | 48220
Phone: (248) 398-7105
www.GoAffirmations.org
Acknowledgements
Through support from Michigan Department of Community Health, this report was developed by
staff and interns at Affirmations. Hilary Armstrong analyzed the focus group data and wrote this
report. Stephanie Soliz and Ryan Stabler assisted with participant recruitment and focus group
implementation.
Thank you to Kalamazoo Gay and Lesbian Resource Center for their assistance with focus group
guide development, participant recruitment and implementation of focus groups on the west
side of Michigan. Thank you to The Center for Sexuality & Health Disparities at the University of
Michigan School of Pubilic Health for graciously sharing their expertise of qualitative research with
Affirmations staff and interns.
About Affirmations
Affirmations is Michigan’s largest community center for lesbian, gay, bisexual & transgender
(LGBT) people and their allies. Affirmations opened in 1989 and is housed in a state-of-the-art,
multi-use-facility in the heart of downtown Ferndale, at the Northern border of the City of Detroit.
Affirmations provides a welcoming space where people of all sexual orientations, gender identities
& expressions, and cultures can find support and unconditional acceptance, and where they can
learn, grow, socialize and have fun. For more information, visit our website: www.GoAffirmations.
org.
Affirmations’ Health & Wellness program area addressess LGBT health disparities through professional
training and development for healthcare providers, LGBT-affirming mental health services,
community education, coalition building, and connecting LGBT people to health resources. These
efforts advance health equity by shining light on the health impacts of stigma, discrimination and
societal inequalities while leveraging community strengths and celebrating resiliency. For more
information about this report or other Affirmations projects, please contact:
Lydia Ahlum Hanson, MSW, MPH
Health & Wellness Manager
Direct Line: 248-677-7223
Email: LHanson@GoAffirmations.org
Table of Contents
Background. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4
Purpose of Study. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Methods. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Analytic Strategy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Summary of Findings . . . . . . . . . . . . . . . . . . . . . . . . . 6
I. Tobacco Use
II. Quit Attempts
III. Attitudes Toward Past Campaigns
IV. Anti-Tobacco Interventons
Limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Policy Recomendations . . . . . . . . . . . . . . . . . . . . . . . 15
Anti-Tobacco Messaging . . . . . . . . . . . . . . . . . . . . . . 17
Recomendations
Best Practices. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
4 | FOCUS GROUP FINDINGS ON TOBACCO USE IN LGBT COMMUNTIES
Focus Group Findings on Tobacco
Use in LGBT Communities
Background
Cigarette smoking is the leading cause
of preventable disease and death in the
United States.1 Rates of tobacco use
are particularly high among lesbian,
gay, bisexual and transgender (LGBT)
youth and adults.2 Though national
and state estimates of tobacco use
by sexual orientation are limited,
systematic reviews of available research
indicate that smoking rates among
gay and bisexual men are 27% to 71%
higher and rates among lesbian and
bisexual women are 70% to 350%
1 U.S. Department of Health and Human Services. The
Health Consequences of Smoking—50 Years of
Progress: A Report of the Surgeon General. Atlanta:
U.S. Department of Health and Human Services,
Centers for Disease Control and Prevention, National
Center for Chronic Disease Prevention and Health
Promotion, Office on Smoking and Health, 2014
[accessed 2014 Jul 14].
2 Corliss, H. L., Wadler, B. M., Jun, H., Rosario, M.,
Wypij, D., Frazier, A. L., et al. Sexual Orientation
Disparities in Cigarette Smoking in a Longitudinal
Cohort Study of Adolescents. Nicotine & Tobacco
Research, 15, 213-222.
higher than the general population.3
Research suggests that LGBT disparities
in tobacco use are fueled by stress
disparities, little research has been
conducted on the effectiveness of antitobacco advertisements, campaigns
Smoking rates among gay and
bisexual men are 27% to 71% higher
and rates among lesbian and
bisexual women are 70% higher than
the general population.
due to stigma and discrimination,
targeting by the tobacco industry
and poor access to effective tobacco
cessation programs. Despite clear
3 American Lung Association. (n.d.). The LGBT
Community: A Priority Population for Tobacco
Control. Retrieved from http://www.lung.org/
stop-smoking/tobacco-control-advocacy/reportsresources/tobacco-policy-trend-reports/lgbt-issuebrief-update.pdf
and treatment programs for the LGBT
population.
FOCUS GROUP FINDINGS ON TOBACCO USE IN LGBT COMMUNITIES | 5
Purpose of Study
In 2013, the Michigan Department of Community Health
(MDCH) provided funding for Affirmations to facilitate
focus group interviews with LGBT-identified individuals
to discuss the effectiveness of anti-tobacco campaigns,
policies and treatment services. This report summarizes
these interview findings and provides recommendations
for creating LGBT culturally competent tobacco cessation
messages and policies that aim to reduce tobacco use
in LGBT communities.
Methods
To be eligible for participation, participants had to be
over 18 years old and previously had used tobacco. This
included current, previous and casual users of all forms
of tobacco. Recruitment efforts relied on the established
networks of the LGBT community centers engaged in
this project. Eligible participants were informed about
the project through email, social media and in-person
contact. Recruitment was conducted by staff and interns
at Affirmations and Kalamazoo Gay Lesbian Resource
Center (KGLRC). An interest questionnaire was distributed
via email and Facebook to gauge participant eligibility,
availability and pertinent demographics. Participants who
were eligible and whom availability aligned with other
participants were contacted by community center staff
and invited to participate (See Appendix for Recruitment
Flyer).
Three focus groups were conducted at Affirmations,
two focus groups and one interview were conducted at
Kalamazoo Gay and Lesbian Resource Center (KGLRC),
two focus groups were held in Ann Arbor (one at the Jim
Toy Community Center and one at an off-site location)
and one focus group was held at Battle Creek Pride. All
focus groups were conducted between July 30, 2012 and
October 17, 2012 (See Appendix for Focus Group Log).
Concerned with adequately representing the diversity
found within LGBT communities, Affirmations and KGLRC
staff assembled the focus groups in order to maximize
the diversity of participants and arranged specific groups
for historically unrepresented populations within LGBT
communities. Affirmations conducted a person of color
specific focus group and a transgender specific focus
group. KGLRC conducted a woman specific interview
when other recruited participants did not attend the
scheduled focus group. (See Appendix for Participant
Demographics).
All focus group facilitators had experience with qualitative
interviewing and group facilitation as well as reflected
the key demographics of the focus group he/she/ze was
facilitating. When necessary, facilitators were contractually
hired. Upon arriving for a focus group, participants received
an information sheet about the project, a confidentiality
form and brief questionnaire of their demographic
information and tobacco use. Participants signed the
confidentiality form, completed the questionnaire and
kept the information sheet for their records. At the end
of each focus group, participants received a $20 gift card
to Meijer.
The focus group guide addressed three main objectives:
(1) Behavior and Attitudes Regarding Tobacco Use, (2)
Tobacco Use Cessation and (3) Awareness of Tobacco Use
Campaigns and Media Messages. To facilitate discussion
about anti-tobacco messaging strategies, participants
were asked to evaluate the effectiveness of three separate
campaigns: (1) one Truth Campaign ad, (2) two CDC Tips
from Former Smokers ads, and (3) two ads sponsored
by The Bill DeFrank LGBT Center and The LGBT Center
Orange County (See Appendix). In the final segment of
the discussion, moderators distributed a diagram of the
Social Ecological Model and explained the theory within
the context of tobacco use. Participants were then asked to
consider which level of influence (individual, relationships,
community and/or policy) would most effectively target
tobacco use in the LGBT community (See Appendix for
Focus Group Questions).
Analytic
Strategy
The results of the focus groups were analyzed by a Master
of Public Health student at the University of Michigan
School of Public Health. Data was analyzed with a
question-driven approach4 through a web-based analysis
software called Dedoose. First, a questions and methods
matrix was created to identify the overarching themes
addressed in the focus group guide (e.g. Tobacco Use,
Quit Attempts, Attitudes toward Ads/Campaigns) and
the questions designed to capture this data (e.g. Why did
you begin using tobacco?). Data analysis then began with
open coding of the transcribed interviews. Open coding
yielded a list of preliminary codes and themes, which were
then collapsed and refined into a final codebook. The
codebook included definitions, examples and inclusion
and exclusion criteria to guide focused coding of the
transcripts. Each interview was coded according to this
final codebook. Code excerpts were then organized to
fit under specific themes, and themes were reviewed to
ensure consistency with overall data. This final report
presents these themes using participant quotes and
provides summary conclusions of the overall data.
4
Patton, M. Q. (2002). Qualitative research and evaluation methods
(3 ed.). Thousand Oaks, Calif.: Sage Publications.
Summary of
Findings
I. Tobacco Use
Age of Debut
In the United States, approximately 70% of current adult
smokers initiate tobacco use before the age of 18. The
majority of smokers initiate tobacco use around the age of
11 and many meet the criteria for addiction by the age of
14.5. In order to understand the developmental stage and
social context in which participants starting using tobacco
products, participants first discussed their age at tobacco
“I wanted to smoke because
I got tired of being called
a sissy. I got tired—I was
one of those kids that you
could tell from the time I
was walking I was really
feminine always. So I got
picked on. I got called
names. So I started smoking
just so I could look tough.”
use debut and the most salient motivations behind their
initiation. The majority of participants reported initiating
tobacco use between the ages of 13 and 18, or during
enrollment in high school, and cited social pressure or
desire to gain acceptance into social circles as a primary
motivation. Slightly fewer participants reported initiating
tobacco use before the age of 13. Interestingly, nearly
half of the participants reporting initiation before age
13 identified as transgender and cited discomfort with
gender identity as a primary motivation:
5
American Lung Association. (2014). What FDA Regulation of Tobacco
Products Really Means. Retrieved from http://www.lung.org/stop-smoking/
tobacco-control-advocacy/federal/fda-regulates-tobacco/what-fda-regulation-of.
html
“I wanted to smoke because I got tired of being called a
sissy. I got tired—I was one of those kids that you could
tell from the time I was walking I was really feminine
always. So I got picked on. I got called names. So I started
smoking just so I could look tough.” (AFF #1)
Additionally, both transgender and non-transgender
participants reporting tobacco use before the age of 13
were most likely to indicate that multiple family members
were active smokers. Many described a home environment
in which tobacco use was highly normalized:
allowed them to initiate tobacco use without strong
resistance from parents, guardians or siblings. Prior to
initiating tobacco use, some participants even reported
being actively enlisted in a family members’ tobacco use:
“Everybody around me smoked basically. Mom did, dad
did, aunt, my uncles all did. And if they didn’t smoke, they
chewed…tobacco use was extremely common.” (AFF #1)
Other participants reported that family tobacco use
enabled greater accessibility to tobacco products that
were regulated outside the home environment:
Fewer participants reported initiating tobacco use after
the age of 18. These participants were more likely to
report initiating tobacco use as a coping mechanism
than any other age group. Coping mechanisms included
using tobacco to manage stress or anxiety or in response
to a traumatic event (e.g. parents’ divorce or end of an
intimate relationship):
“My entire family almost entirely smokes. So the idea of
having a cigarette was not unusual for me. I think I was
probably like 12. Cause I remember hiding. Like I would steal a pack of my step-mother’s cigarettes ‘cause she
always had so many I just knew she wouldn’t just miss
this one.” (JTCC #1)
“Everybody around me
smoked basically. Mom did,
dad did, aunt, my uncles
all did. And if they didn’t
smoke, they chewed…
tobacco use was extremely
common.”
“Then when I was about 19 I went through my first breakup
and that’s when I actually started smoking. Smoking was
one of the avenues that I chose to kind of face the breakup. I tried alcohol and marijuana, just rollercoasters. I
tried different things and smoking was one of the avenues
that I tried to get numb with.” (AAFM #1)
Motivation for Debut
Family members’ tobacco use behaviors were the most
commonly reported motivation for initiating tobacco
use. Many participants reported growing up in home
environments in which tobacco use was very normalized
and acceptable. For some participants, this normalization
“But I mean, as a child, I remember my mom would say—
and I think this is what started it. You’re not really gonna
believe this, but my mom would say, ‘Bring me a cigarette.’
She’d tell me to go get her a cigarette from her pack. ‘Go
get the cigarette from the pack.’ Sometimes she would
even say…’Go ahead and light it.’” (AFF #2)
Tobacco use behaviors of friends and intimate partners
similarly played an important role in motivating tobacco
use. Many participants reported using tobacco as a way
to gain inclusion or acceptance into social circles, to
ease conversation in social interactions, or to bond with
an intimate partner. Social motivation was particularly
salient for transgender participants, who recounted being
excluded from social circles and activities for their chosen
gender expression:
“I was in everybody’s same situation where I got bullied a
lot and whatnot. And then high school came around and
I actually started making some friends. And everybody
was smoking, so I kind of just joined in with that, that
kind of perpetuation. And I guess it’s never stopped since
then.”(AFF #1)
In later discussions, the extent to which participants
used tobacco for social reasons impacted their success in
quitting tobacco. Participants who felt that their smoking
status was largely dependent on the smoking status of
friends or intimate partners reported more successful
quit attempts when their social environment became
less tobacco-friendly. However, participants who began
smoking in the home environment or used tobacco as a
coping mechanism were less likely to quit if their social
surroundings changed.
Feelings about Tobacco Use
In order to identify the factors that facilitate or discourage
continued tobacco use, participants were asked to describe
any positive thoughts, feelings or beliefs about their
past or current tobacco use. Most participants reported
positive feelings about the social aspects of tobacco use,
included easing social interactions with potential friends
or partners, networking with individuals they would
not otherwise meet, and feeling a sense of community
with other tobacco users. A participant who reported
initiating tobacco use in response to the stress of the
college environment said:
“I remember being a freshman in college, and if you
smoked, you instantly had an opportunity to start a
conversation with people, ‘cause everyone from the
dorms would smoke in one area. You could meet people
and start a conversation easily.” (KGLRC #3)
Socially-driven tobacco use was particularly common
in LGBT-specific environments, such as bars and clubs,
where proximity to other smokers significantly increased
the temptation to smoke. Many participants recalled
using tobacco in bars and clubs prior to implementation
of indoor smoking bans and suggested that tobacco use
became closely linked to engagement in the LGBT social
scene, alcohol consumption and other substance use.
In addition to social benefits, many participants expressed
appreciation for the stress-relieving properties of tobacco.
While many participants described stress relief as a
physiological response to nicotine, others suggested
that taking a “smoke break” to leave a stressful work or
social environment also alleviated stress:
Despite identifying some positive aspects of tobacco
use, most participants were more readily able to describe
negative thoughts and feelings about their use. The vast
majority of participants described current or anticipated
health consequences of tobacco use. Participants who
were already experiencing health consequences reported
decreased lung capacity, higher frequency of illness
(e.g. common colds, bronchitis) and diminished fitness
performance. Many told stories of friends or family
members who had struggled with or succumbed to
smoking-related illnesses and how these experiences had
intensified cognitive dissonance about their own tobacco
use behavior. Expressions of cognitive dissonance were
often followed by frustration with the addictive power
of tobacco products. One participant noted:
“You’re an addict. When you’re an addict, all you care
about is that next fix, and it doesn’t matter if it’s alcohol,
meth, cigarettes. They’re a drug. I mean, the addicted
mind is very different than the non-addicted mind. And
even though cigarette smoking is the most socially
acceptable…drug to just do out in the street, around
your kids, and everywhere, it doesn’t mean that those
[aren’t] addicted brains.” (KGLRC #3)
II. Quit Attempts
Motivation for Quitting
Regardless of current smoking status, nearly every
participant reported a desire to quit or a quit attempt
at some point during their smoking history. Participants
who had attempted to quit tobacco cited a wide array of
“It was an opportunity to not have to do something. If motivations. Many reported that influence from family,
things are getting tense, if there’s a lot going on, it was friends, or intimate partners played the most significant
an opportunity to take that quick ten-minute break and role in initiating and following through with a quit attempt.
go back.” (KGLRC #3)
Family influence often included the death of a loved
one due to a smoking-related illness, a desire to protect
family members, particularly children, from the effects
“It was an opportunity to
of second-hand smoke, and strong encouragement from
family members.
not have to do something.
If things are getting tense,
if there’s a lot going on,
it was an opportunity to
take that quick ten-minute
break and go back.”
“What got it for me was my mom’s husband got lung
cancer. And seeing him in the hospital. He could barely
breathe and seeing somebody not being able to breathe
and knowing that you were gonna do that to yourself,
for me, that was the final straw.” (AFF #3)
Other participants suggested that peer influence was a
more powerful motivator. For participants who primarily
enjoyed the social aspects of tobacco use, transitioning
from a smoker-friendly social circle to a less accepting
group of friends was sufficient motivation to quit tobacco.
Similarly, participants who remained within the same
social circle but witnessed close friends quitting tobacco the potential long-term consequences of tobacco use,
found it to be a powerful impetus to attempt quitting: most participants focused on current health issues and
their impact on daily functioning:
“Well, quitting got a lot easier once a lot of my other
friends had quit, ‘cause when I had a big group of friends “So like I’ll wake up three days in a row feeling like chest
who were smoking, I didn’t really feel the need to quit is tight and okay, I gotta stop doing this.” (JTCC #1)
smoking, even though I knew full well that it was bad
for me. But once everybody else started quitting, it got Other participants planned to quit smoking as a step
toward achieving an overall healthier lifestyle. Many
a lot easier.” (KGLRC #3)
participants considered quitting tobacco as the first step
“And seeing him in the
to consuming less alcohol, eating healthier and attaining
greater levels of fitness and athletic performance. For
hospital. He could barely
these participants, family, peer and media influence that
emphasized the potential benefits of quitting tobacco,
breathe and seeing
rather than the negative consequences of continued
use, was more effective at strengthening intention and
somebody not being able to
resolve to quit.
breathe and knowing that
you were gonna do that to
yourself, for me, that was
the final straw.”
Though some participants successfully quit tobacco
based on these sources of motivation, others found
that quitting tobacco for another person or group was
unlikely to be a permanent behavior change. This was
particularly true for participants who had attempted to
quit for an intimate partner:
“The first time I quit was when I was 18, because the
girlfriend I had at the time did not like that I smoked, and
at 18 our relationship was more important than my own
wants and desires, so I quit for her. But then as soon as
we broke up, I started smoking again.” (KGLRC #3)
In many instances, discordant smoking statuses between
intimate partners caused non-smokers to reinitiate use or
led to termination of the relationship. Similarly, participants
who intended to quit tobacco found the process very
difficult if an intimate partner did not simultaneously
make a quit attempt.
In addition to family and peer influence, many participants
cited current or anticipated health consequences as a
motivation to quit. Many participants expressed strong
awareness of the potential outcomes of continued
tobacco use, including increased risk of lung cancer,
stroke and heart attack. However, despite awareness of
“The first time I quit was
when I was 18, because the
girlfriend I had at the time
did not like that I smoked,
and at 18 our relationship
was more important than
my own wants and desires,
so I quit for her. But then
as soon as we broke up, I
started smoking again.”
Method of Quitting
Participants who had attempted to quit tobacco cited a
variety of methods for initiating and sustaining cessation.
A significant majority reported using prescription drugs
(e.g. Chantix, Wellbutrin, Zyban) and other Nicotine
Replacement Therapy (NRT) (e.g. patch, gum, lozenges,
inhalers). A strong determinant of success when using
prescriptions drugs or NRT was the extent to which the
participant experienced negative side effects. Commonly
reported side effects included nausea, dry mouth, irritation
caused by the patch adhesive, headaches and mood
swings. Some participants also faced difficulty when
access to prescriptions or NRT was interrupted due to
insufficient insurance coverage, lapses in medical care, “I know that when I worked at Planned Parenthood our
or housing transience.
health insurance, one of the requirements to get the
cheaper health insurance was that you didn’t smoke, and
In addition to NRT, numerous participants discussed the if you did smoke then to get that cheaper insurance you
growing popularity of electronic cigarettes (e-cigarettes). had to be part of a cessation program where you had
Participants varied on their understanding of the someone, the QuitNic program would call you and check
ingredients and health effects of e-cigarettes and there was up on you and so I know that for many of my co-workers
disagreement as to whether transitioning to e-cigarettes that was a motivation to quit.” (KGLRC #1)
constituted success in quitting tobacco or merely a step
toward complete abstinence. Often, participants reported While some participants found lower insurance premiums
experimenting with many quit methods simultaneously and employer coverage of enrollment costs to be powerful
or across quit attempts:
incentives to quit tobacco, some found that the length
of the program or number of sessions with a cessation
“...to get the cheaper health
counselor were insufficient to initiate permanent change.
Many felt that a long-term and ongoing relationship with
a cessation counselor would create a greater sense of
insurance was that you didn’t
accountability and prevent relapses.
smoke, and if you did smoke
then to get that cheaper
insurance you had to be
part of a cessation program
where you had someone, the
QuitNic program would call
you and check up on you and
so I know that for many of
my co-workers that was a
motivation to quit.”
“I have tried the patch and the gum and the electronic
cigarettes. And I think for me it’s both a combination of
the physical and the psychological. Both are very strong.
So sort of they might help with the physical, but that
doesn’t stop the psychological stuff that will lead me
back or the social like wanting to make friends and bond
with people over smoking.” (JTCC #1)
While some participants reported successfully overcoming
the physiological addiction to nicotine with prescription
drugs and NRT, the need to address the psychological
aspects of nicotine addiction led some participants to enroll
in cessation therapy programs. The majority of participants
who had utilized cessation therapy had been motivated
by employers who offered lower insurance premiums for
non-smokers or smokers enrolled in cessation therapy.
Michigan Quit Line
Awareness of the Michigan Quit Line was consistently
low across all the focus groups. Among participants who
were aware of the Quit Line very few reported a desire
or intention to utilize the service. Many participants felt
that they were unlikely to develop a trusting relationship
with a counselor over the phone, thus decreasing the
likelihood that they would actively engage with the
counselor’s recommendations. Participants who focused
on the counseling and therapy component of the service
felt that they would be more likely to accept the guidance
of a friend, family member, or physician. Additionally,
participants expressed reluctance to solicit advice and
encouragement from a counselor they were unsure had
experienced nicotine addiction and the various challenges
in quitting. Participants who viewed the program as a
source of information and referrals felt that they could easily
find comparable information online. Other participants
expressed skepticism that calling the line would inspire a
quit attempt, yet recognized the potential value of calling
the line after internally committing to quit.
“...there’s some hesitance
to call the general 1-800
numbers among LGBT
folks, just because you
don’t know if the person on
the other line is going to be
an ally or a safe person.”
“I could see myself calling but only after I made some sort
of internal decision. Like I could easily see myself being
like, okay, now’s the time I’m gonna do it. Time to get all
of the resources and go and buy the patch and buy the
gum and set up—and do everything. And I could see
calling some number as part of that.” (JTCC #1)
A few participants directly mentioned reluctance to use
the service out of fear that their counselor would not be
LGBT-friendly and affirming.
“I also think that, in general, there’s some hesitance to call
general 1-800 numbers among LGBT folks, just because
you don’t know if the person on the other line is going to be an ally or a safe person to talk about, and so even
if you’re just talking about needing to quit cigarettes, a
lot of times they inquire why you’re smoking or what stresses or how many times you would talk—if you’re
gonna mention your partner or something.” (KGLRC #3)
III. Attitudes toward Past Campaigns
To facilitate dialogue about the effectiveness of anti-tobacco
campaigns, participants were asked to remember past
campaigns and advertisements that were particularly
appealing or memorable. Participants were then shown
a series of four print advertisements featuring various
messages, identities and imagery in order to focus the
conversation on these aspects of the campaign (See
Appendix). For analysis, participants’ attitudes about
these anti-smoking advertisements and campaigns
were coded as statements about the source or sponsor,
identities represented, target audience, perceived message
undertone or perceived message of the campaign.
Source/Sponsor
Though participants were often unaware of the source of
an advertisement or campaign, many expressed negative
feelings toward campaigns perceived to be sponsored
by governmental agencies:
“It’s just like, ‘Yeah, yeah, yeah, government telling me
something else I’m not supposed to do.’” (KGLRC #1)
For many participants, this reluctance stemmed from
the belief that the government had too often attempted
to force lifestyle and behavioral changes on the LGBT
community. Some participants felt that governmentsponsored messages rarely promote the best interests of
the LGBT community and are therefore easier to discredit.
Interestingly, participants were more willing to accept
information from an agency or organization directly
associated with the message content. For instance,
participants were more responsive to information about
the risks of lung cancer if the ad was sponsored by the
American Lung Association rather than the Centers for
Disease Control and Prevention (CDC).
“...it says it’s from an LGBT
organization, so at least
it’s LGBT people telling me
not to smoke instead of corporate mainstream
society telling me not to
smoke.”
The majority of participants responded more positively
to campaigns perceived to be sponsored by LGBT-specific
or LGBT-friendly organizations:
“So I think one of the reasons that I like this very last one
is because it says it’s from an LGBT organization, so at
least it’s LGBT people telling me not to smoke instead of
corporate mainstream society telling me not to smoke.”
(AAFM #1)
The sentiment that campaigns were more effective if
they were presented by counterculture or “insiders” of the
LGBT community was echoed several times throughout
the focus groups. This positive reception was extended
to musical acts or celebrity figures that were considered
to be part of counterculture. One group discussed the
powerful impact of hearing anti-tobacco messages from
LGBT-identified artists and performers such as Tegan and
Sara and RuPaul.
Representation
Similarly, many participants reported that they were more
like to pay attention to an advertisement or campaign
with characters or spokespeople who were representative
of their identities. When shown three LGBT-specific
advertisements, one depicting a lesbian couple and two
portraying young gay men, many participants agreed
that they were more likely to consider the ad’s message
than if the characters were perceived to be heterosexual.
In addition to identity representation, some participants
argued for the importance of lifestyle representation.
Rather than depicting LGBT-identified characters in settings
stereotypically associated with the LGBT community
(e.g. bars and clubs), characters should be represented
in settings of stability and empowerment (e.g. in the
workplace, at home with family).
“It kind of puts the LGBT community right smack dab
in the middle of normal society, you know? It doesn’t
segregate us out and make us unique because of this. And I’m thinking that the ads should picture us as part
of society and tell our stories from…our perspective as
part of society, as opposed to it being something uniquely different.” (AFF #3)
Participants also stressed the value of showing the diversity
of the LGBT population and avoiding common media
stereotypes about the community. Many participants
emphasized the importance of portraying characters of
varying ages, races, body types and gender expressions.
Some female participants felt that advertisements targeting
the lesbian community played into stereotypes of lesbian
women as masculine, angry and unhealthy, while some
male participants felt that past advertisements had
presented gay men as shallow and hypersexualized.
Participants across all focus groups expressed three main
attitudes about the use of sex and nudity in campaigns.
Some argued that messages containing sexual images or
messages effectively grabbed the audience’s attention, yet
recognized that it was more likely to appeal to younger
audiences.
“This is really more [for] the young gay man because here
you’ve got a hot body. We know sex sells. And I think
that’s actually a very effective ad.” (AFF #1)
Other participants suggested that though sex and
nudity were likely to grab attention, they were ultimately
ineffective because they detracted from the seriousness
of the intended message.
“If what you’re trying to say is totally disregarded because
of how you’re saying it, I don’t think that it’s effective,
regardless of how you do it. I mean like I said, if you like
to see that, that’s great, but are you getting the message
that they’re trying to convey?” (AFF #3)
In many groups, the most impassioned responses came
from participants who felt that it was offensive to use sex
and nudity to target the LGBT population.
“You know just cause I’m a gay person doesn’t mean that
I’m just gonna all of a sudden gravitate toward the sexy
pictures. Cause I got more things that are relevant in my
life than just the sex. You know that’s stereotypical kind
of. Critiquing me as a gay man that all I think about is
sex. Well that’s just not true. We gotta come out of the darkness, you know. We have other things to think about.”
(BCP #1)
It is worth noting that significantly more participants
found sex and nudity to be ineffective and offensive.
Numerous participants expressed strong distaste for the
implication that LGBT individuals could only be reached
through this strategy and suggested that they would
immediately discredit a campaign that depicted nude
or sexually provocative characters. Though this response
was not unanimous, it was apparent that the audience
reached with sex and nudity was significantly smaller
than the audience offended by this strategy.
Message Undertone and Content
Though participants expressed relatively clear and
consistent preferences for the campaign source and
representation, beliefs about the effectiveness of certain
message undertones and content varied significantly
across all groups. While the majority of advertisements
participants recalled from the past contained messages
about the health consequences of tobacco use, participants
disagreed as to whether this content was effective. One
participant stated:
“Cause somehow it doesn’t
faze me at all if somebody
tells me something’s gonna
kill me. But if it’s gonna
make me lose a leg, then I
start listening. I mean for
me I think a big part of that
is being…(21 years old)”
“I mean I think personally that, the ones about the health
issues are the ones that stand out the most. Those are
the ones that are like, oh, yeah, that kind of is what my
lungs look like. And then I mean so that, I don’t really
dismiss that as like, oh, well, whatever. I mean you do
make excuses for yourself just while you’re smoking. But,
you know in the back of your mind you know that you
are whatever the percentage greater of cancer is and you
know all the health issues.” (BCP #1)
Other participants argued that health-based messages
had been used for so many years that they no longer
elicited a fearful response:
“You’ve put lung cancer on the side of my box for the last
12 years; I get it, I get it. It might cause lung cancer but
it apparently hasn’t stopped me—you’ve gotta play to every angle.” (KGLRC #1)
Some participants suggested that health-based messages
would be more effective if they focused on morbidity and
short-term health consequences rather than mortality
and long-term consequences.
“Cause somehow it doesn’t faze me at all if somebody
tells me something’s gonna kill me. But if it’s gonna make
me lose a leg, then I start listening. I mean for me I think
a big part of that is being…21. Like I don’t think that I’m
gonna die. I cognitively know that, but that does not
really mean anything to me. I have no concept of what
that is. But I can imagine what it would be like to not be
able to get out of bed.” (JTCC #1)
“It sounds like ads kind
of underestimate the
intelligence of smokers.
Maybe they just assume
that smoking is dumb and
so they don’t have to play
to your intelligence to get
you to stop.”
Throughout discussion of health-based messages,
participants disagreed on the effectiveness of shock
value and scare tactics. Those who found scare tactics
ineffective argued that it was too easy to dismiss and
distance oneself from overly dramatic and extreme stories
of the health consequences of tobacco use:
“I think a lot of them play on scare tactics, which aren’t
effective and have been shown not to be effective, having
these just extreme points to where you can differentiate
yourself from that individual.” (AAFM #1)
Some participants focused on message undertone rather
than message content. While many were able to recall
advertisements or campaigns that emphasized the
negative consequences of tobacco use, few were able to
think of advertisements that had focused on the potential
benefits of quitting tobacco. Most participants argued
that they were sufficiently aware of the negative effects
of smoking and would rather see how the social, health
and financial benefits of quitting could outweigh the
positive aspects of smoking. One participant suggested:
“The ad that would target me personally would be the
ad that depicted someone who was healthy, someone
working out, someone exercising and wanted to stay on
that track. An ad with some guy running and then he
stops and says, ‘I just ran three miles and I could never
do that if I was smoking.’ That’s the kind of stuff that would hit me.” (AFF #3)
“An ad with some guy
running and then he stops
and says, ‘I just ran three
miles and I could never
do that if I was smoking.’
That’s the kind of stuff that would hit me.”
A preference for pro-health messages was discussed
in nearly every group. Closely tied to this suggestion
was avoidance of blanket directives like “Quit Smoking.”
Participants felt that empowering messages such as “You
Can Quit Smoking,” or detailing the steps individuals could
take to begin the process of quitting tobacco were more
likely to elicit a positive response from individuals who
had already been inundated with other anti-smoking
ad messages.
When discussing message undertone, some participants
focused on the difference between ads and campaigns
using emotional pleas and those that utilized a more
cognitive and intellectual approach. While some felt that
emotional pleas effectively personalized an ad’s message,
others felt that the overuse of emotional advertising
allowed individuals to disregard the message content:
“It sounds like ads kind of underestimate the intelligence
of smokers. Maybe they just assume that smoking is
dumb and so they don’t have to play to your intelligence
to get you to stop, but it definitely seems like they don’t
try to appeal to people on an intellectual level and tend
to make emotional pleas more, which is a lot easier to
ignore for some people.” (AAFM #1)
After discussing attitudes toward past campaigns, participants
were asked to suggest messaging strategies that were most
likely to effectively reach the LGBT community. Participants
across all groups emphasized the value of pro-health, rather
than anti-smoking, messages and placing LGBT characters
in settings of strength and empowerment. Participants
who felt that anti-smoking campaigns overutilized
emotional messaging recommended that advertisements
promote messages that require cognitive processing. One
participant suggested emphasizing the money that could
be saved or directed toward more fulfilling endeavors if
an individual were to quit tobacco. Others felt that the
political activism and social movement aspects of the
Truth campaign were very effective at eliciting cognitive
processing. Finally, some younger participants suggested
that advertisements target adolescent and young adult
tobacco users by depicting the life trajectory of an individual
who begins smoking at a very early age. Rather than
focusing on health consequences likely to occur several
years from now, participants recommended centering on
the effects most likely to impact an adolescent’s quality
of life (e.g. impaired physical fitness, personal hygiene).
Anti-Tobacco Interventions
The Social Ecological Model, developed by Urie Bronfenbrenner
in the 1970’s, theorizes that behavior affects and is affected
by multiple levels of influence. In these focus groups,
moderators explained the theory using four main levels of
influence: individual, relationships, community and policy.
Participants were asked to identify which level of influence
should be targeted in order to most effectively reach the
LGBT population. The resulting discussion highlighted
campaigns and interventions that had been effective and
ineffective in the past and how these interventions could
be improved upon to effect greater change.
Participants’ exposure to different campaigns and
interventions was primarily affected by their age and
employment status. For instance, younger participants
were more likely to cite the effectiveness of school campuswide smoking bans, whereas older participants were more
likely to discuss workplace policies toward smokers. Some
younger participants found that campus-wide smoking
bans, which prohibit tobacco use within close proximity
of school buildings, effectively inconvenience smokers
by forcing them to find smoking-approved locations
further from residence halls or classroom buildings. The
impact of campus-wide smoking bans intensifies during
the winter months when participants are reluctant to
walk greater distances for a smoking break. Participants
generally agreed that smoking bans, combined with free
tobacco cessation programs on campus, had significantly
reduced tobacco use on school campuses.
Older participants often discussed policies toward
smokers in the workplace. Many participants mentioned
organizational policies that offered lower health insurance
premiums to employees who did not use tobacco. For
tobacco-using employees, several companies offered
free tobacco cessation counseling, though sessions were
often capped at four visits and did not allow employees
to establish ongoing relationships with counselors. While
some participants found lower insurance premiums to be
a significant motivator, others felt that the cost differential
for smokers and non-smokers could be increased to add
stronger incentive:
“I think it would have to be a pretty big one on the insurance
because I know for us at work we have…a health and fit
insurance. If you don’t smoke your insurance is $4.00 of your paycheck. If you do I think it’s [only] $8.00.” (KGLRC
#1)
“I think if it was more
socially acceptable for
folks to take a 10-minute
walk, say, instead of a
10-minute cigarette break,
and it was encouraged to
do that by employers or by
organizations or schools…”
In addition to organizational policies, older participants
found that norms around “smoking breaks” during the
work day made it more difficult to quit tobacco.
“When you don’t smoke, you don’t get to take those
breaks during work. When you do smoke, then it’s totally
acceptable to go outside for 7 minutes and stand there
and then come back inside, maybe five times a day. And
so I think if it was more socially acceptable for folks to take
a 10-minute walk, say, instead of a 10-minute cigarette break, and it was encouraged to do that by employers or
by organizations or schools…” (KGLRC #3)
Participants suggested that in addition to health and wellness
insurance premiums, there should be an organizational
shift toward encouraging “wellness” breaks during work
hours to ensure stress relief and maximum productivity.
Older participants were also more likely to discuss the
impact of indoor smoking bans. Many participants
suggested that forcing smokers to leave the workplace, bar
or club to smoke had significantly diminished the sense
of community around smoking and had persuaded many
social smokers to quit tobacco. While many participants
expressed resentment toward the government for
implementing these bans, many also agreed that it had
effectively achieved the goal of reducing tobacco use:
“Am I right that smoking is declining? And I feel that is partly
at least due to the government, or that we as a community,
a bigger community. And through that, the government
is setting policies that are signaling to people that this is
taken seriously as a health risk, whereas it didn’t before.
I think that it is making a difference, because I remember
being able to smoke at my desk at work. Everybody did,
and then slowly—it’s slowly being seen as this is not
acceptable anymore.” (AFF #3)
Conversely, some participants argued that the will to
smoke and the power of addiction ensured that tobacco
users would find ways to adjust to new policies.
“But I think we have adjusted to smoke-free laws, though.
We have adjusted to them in restaurants; I remember
when you used to be able to smoke at ___, now we’ve
just adjusted to how we do it.” (KGLRC #1)
Many participants reported that imposing greater taxes
or raising the price of tobacco was not effective in
encouraging tobacco users to quit. Older participants
expressed frustration over the constantly rising price of
tobacco, yet very few felt that it was significant enough
to motivate behavior change:
“Like I said, you know, for people that started when it was
75 cents, I started when it was $3.50 but I’ve made it okay
to spend $7.00 a day like I do now and it is went up to $8.00 tomorrow I’d pay it and if I move to Chicago next
week I’d figure out how to pay $12.00.” (KGLRC #1)
Across age groups, a significant number of participants
agreed that LGBT-specific tobacco cessation support
groups would provide the strong social necessary to
successfully quit tobacco. Some participants detailed their
experience in other support groups, including Alcoholics
and Narcotics Anonymous, and suggested that a model
of accountability (through sponsorship) was particularly
helpful. Others focused on the importance of establishing
anti-tobacco social and community groups to drive the
cultural shift away from substance use.
Limitations
This project encompassed several limitations. Since
participants were contacted through LGBT community
centers, recruitment was based on LGBT identity versus
behavior or desire. For instance, it is possible that people
who identify as LGB have different opinions about quit
tobacco messages than the much larger group of people
who have same-sex attraction and/or sexual behavior but
do not identify as LGB. This approach eased recruitment
efforts by utilizing established LGBT networks yet also
narrowed the populations sampled. Furthermore, in order
to create a supportive environment for a population that
is marginalized, participants were grouped according
to salient identities (LGB, transgender, person of color).
While this allowed participants to engage with others with
similar experiences, grouping participants by sexual or
gender identity may have decreased the likelihood that
participants would explicitly attribute their experiences to
these identities. This limitation became apparent during
data analysis, when we found that very few participants
specifically cited their sexual or gender identity as the
cause for a particular attitude or behavior. Conversely,
however, we acknowledge that these same individuals
may not have felt comfortable speaking openly about
their sexual/gender identities in a mixed environment.
Although significant effort was made to recruit a diverse
group of participants, it is likely that portions of Michigan’s
LGBT communities were not involved in this project. First,
geographic diversity is limited because all the focus groups
were conducted in the southern half of the Lower Peninsula.
Second, all focus groups were conducted in English, so
non-English speaking populations were not included in
the participant sample. Third, since focus groups were
held at LGBT community centers, individuals living in
rural communities were underrepresented. Fourth, since
recruitment was conducted through email lists, Facebook
and websites, individuals without Internet access were
also left out of this study.
There are also some limitations inherent to focus group
methodology. Perhaps the most important limitation is
the ability of the moderator to guide conversation without
directing it. Though all moderators in this study followed
the same focus group guide, interview transcription
revealed slight differences in question prompts and
follow-up commentary. Another limitation inherent
to the social structure of focus groups is the presence
of “groupthink,” in which participants’ desire for group
harmony and consensus minimizes elicitation of a wide
range of attitudes and beliefs about a particular issue.
This social process can allow more outspoken voices to
dominate the conversation and encourage consensus
from more reserved participants where it does not
naturally exist. Finally, as focus groups do not take place
in a naturalistic environment, it can be difficult to measure
the discrepancy between a participant’s hypothetical
reaction to a specific advertisement and what might
actually occur. However, participants’ commentary on
message content, representation and overall themes
can be usefully integrated into strategies for improving
the reach and relevance of advertisements for the LGBT
community.
Finally, the focus group interviews were not transcribed
with participant tracking, so it was difficult to follow each
participant longitudinally throughout the interview. This
minimized the extent to which conclusions about past or
current tobacco use could be linked to age or context of
tobacco initiation. Further research, such as individual
in-depth interviews, would be necessary in order to
obtain more specific information regarding individual
participant trajectories.
Policy
Recommendations
The following recommendations were developed through
analysis of participants’ personal experiences with tobacco
use and statements about effective anti-tobacco policy
interventions.
1. Address Tobacco Industry Targeting of
the LGBT Community
Several focus group participants discussed the effects
of LGBT community targeting by the tobacco industry.
The National LGBT Tobacco Control Network has
identified three primary ways in which the tobacco
industry targets the LGBT population: (1) Direct
Advertising (advertising in LGBT-specific magazines
or media outlets), (2) Indirect Advertising (advertising
in media outlets with high LGBT readership), and (3)
Event/Program Sponsorship (providing funding for
LGBT-specific initiatives, publications or programs).6
Organizations serving the LGBT community should
strive to identify alternative funding sources to
tobacco industry advertisements and sponsorship,
thereby decreasing the industry’s financial hold on
the community and minimizing community exposure
to pro-tobacco messages.
6
Stevens, P. LGBT Populations and Tobacco [PowerPoint slides].
Retrieved from http://www.lgbttobacco.org/files/LGBT2ndedition.pdf
2. Expand Tobacco-Free Laws to Include
Electronic Cigarettes and Smoking in
Casinos
Many participants noted the effectiveness of campuswide, workplace environment and indoor smoking bans.
A recent report from the Campaign for Tobacco-Free
Kids cited conclusions from more than ten studies
that smoke-free laws were effective in reducing
tobacco use.7 While Michigan’s Dr. Ron Davis Smoke
Free Air Law effectively banned cigarette smoking in
businesses, restaurants and bars, it does not address
the growing prevalence of electronic cigarettes.
Currently, businesses are allowed to implement their
own policies regarding electronic cigarette use. Patrons,
public health officials and state policy makers should
encourage businesses to include electronic cigarettes
in their tobacco-free policies.
Furthermore, casinos established before May 1,
2010 and those operating under the Indian gaming
regulatory act are exempt from smoke-free bans.8
While legislation impacting businesses on tribal land
is inherently difficult to enact, policy makers should
advocate for elimination of the exemption for casinos
established prior to implementation of the Smoke
Free Air Law.
3. Encourage Schools and Community Centers
to Host Parent-Child Tobacco Prevention
Education Workshops
A significant number of focus group participants,
particularly those who initiated tobacco use before
the age of 13, reported having multiple family
members who were active smokers. While Michigan’s
tobacco prevention education begins as early as
kindergarten, the curriculum does not include parents
and authority figures in the learning process. Children
who are taught to avoid tobacco yet live in a home
environment in which tobacco use is normalized
and acceptable may experience confusion and fail
to internalize the message. Requiring parents and
guardians to attend tobacco prevention workshops
with their children could serve the dual purpose of
educating children about tobacco use and intervening
with family tobacco use.
4. Support Employers and Insurance Companies
in Increasing the Cost Differential in Health
7
Campaign for Tobacco-Free Kids. (2014). Smoke-Free Laws Encourage
Smokers to Quit and Discourage Youth from Starting. Retrieved from http://
www.tobaccofreekids.org/research/factsheets/pdf/0198.pdf
8
Mulder, M. (2010 February 4). Michigan Smoking Ban Exemptions
and Enforcement. Michigan Policy Network: Health Care. Retrieved from
http://www.michiganpolicy.com/index.php?option=com_content&view=article&
id=693:michigan-smoking-ban-exemptions-and-enforcement&catid=43:healthcare-policy-briefs&Itemid=159
Insurance Premiums for Smokers and
Non-Smokers
In discussions on quit attempts, some participants
described higher insurance premiums for smokers
than for non-smokers. Most participants agreed that
this financial penalty would be more effective in
reducing tobacco use if the cost differential increased
drastically. Under the Affordable Care Act, beginning
in 2015 health insurance companies will be allowed
to charge smokers 50 percent higher premiums
than nonsmokers for new insurance policies sold
to individuals and small employer groups. Though
health and policy analysts disagree as to whether
this financial penalty will have the intended effect
of reducing tobacco use,9 pairing the penalty with
increased employer coverage and expansion of tobacco
cessation counseling could increase the likelihood
than employees will initiate tobacco cessation.
5. Expand Employer-Coverage for Tobacco
Cessation Counseling Programs
Participants who had enrolled in an employersponsored tobacco cessation program in order to
lower their health insurance premiums felt that there
were not enough sessions to establish a trusting
relationship with a counselor that would promote
long-term cessation success. Though all employersponsored insurance plans must cover tobacco
cessation treatment, coverage can vary across plans.10
In order to increase the effectiveness of increasing
health insurance premiums for smokers, employers
should commit to providing comprehensive coverage
to individuals who decide to quit tobacco.
6. Increase the Visibility of LGBT-Friendly
and Affirming Spaces That Do Not Involve
Substance Use
Historically, bars and clubs have been some of the few
safe and affirming spaces for the LGBT community.
As a result, tobacco use and alcohol consumption
are closely linked to social bonding within the
community. Increasing the visibility and funding
of non-substance related events and venues (e.g.
LGBT sports leagues, community centers and cafes)
could facilitate a cultural shift toward substance-free
events and activities.
7. Establish and Promote Tobacco Cessation
9
Andrews, M. (2013 July 16). A Handful of State Marketplaces Opt
Not to Charge Smokers More for Premiums. Kaiser Health News. Retrieved from
http://www.kaiserhealthnews.org/features/insuring-your-health/2013/071613michelle-andrews-column-on-premiums-for-smokers.aspx
10
American Lung Association. (2004). Tobacco Cessation Treatment:
What Is Covered? Retrieved from http://www.lung.org/stop-smoking/tobaccocontrol-advocacy/reports-resources/tobacco-cessation-affordable-care-act/
what-is-covered.html
Support Groups for LGBT Communities
Participants consistently expressed a desire for
LGBT-specific tobacco cessation support groups.
Though many universities offer tobacco cessation
counseling groups to students, very few programs
are open to the general public. Organizations that
primarily serve LGBT communities should conduct
needs assessments to determine interest and
need for tobacco cessation support groups in their
catchment area.
8. Promote Michigan Quit Line as LGBT-Friendly
and Affirming
A significant barrier for LGBT individuals accessing
preventive and curative health care is discriminatory
treatment from providers. Focus group participants
who expressed hesitance in contacting the Michigan
Quit Line noted that they would be more likely to
access the service if they knew counselors would be
LGBT-friendly and affirming. MDCH should evaluate
the cultural competency of the program and its
counselors, make necessary improvements, and
actively advertise the service as open and affirming
to LGBT clients.
9. Expand Public Insurance Coverage of
Tobacco Cessation Programs
Various structural barriers, including discrimination
in employment, can prevent an LGBT-identified
individual from accessing health insurance. While
expanding employer-based insurance coverage
for tobacco cessation programs is beneficial to
employed individuals, steps must also be taken to
expand coverage under public insurance programs.
Michigan’s Medicaid program does not currently
provide comprehensive coverage of all treatments,
including some Nicotine Replacement Therapy
(NRT) options and group counseling.11 Expanding
Medicaid coverage for all empirically-supported
tobacco cessation treatments could significantly
increase the number of lower income individuals
who are able to receive treatment.
10. Improve Data Collection on Sexual
Orientation and Gender Identity in Health
Surveys
Though some nationwide health surveys are starting
to include sexual orientation questions to measure
health disparities among the LGBT population, there
is still very little data on tobacco use among this
population. Increasing our understanding of tobacco
11
Centers for Disease Control and Prevention. (2014). State Tobacco
Activities Tracking and Evaluation (STATE) Program. Retrieved from http://apps.
nccd.cdc.gov/statesystem/HighlightReport/HighlightReport.aspx?FromHome
Page=Y&StateName=Michigan&StateId=MI#MED
use among the LGBT population will inform future
funding allocations and program development.
Anti-Tobacco
Messaging
Recommendations
The following recommendations were developed through
analysis of participants’ statements about the source,
representation, audience and message of anti-tobacco
campaigns and advertisements.
1. Provide Grants or Resources for LGBT-Specific
Organizations To Produce and Sponsor
Tobacco Cessation Ads
Several participants expressed opposition to ads
perceived to be sponsored by government agencies.
This opposition was targeted at agencies most
commonly associated with anti-tobacco messages,
including the CDC and American Lung Association.
However, many participants suggested that they
were more likely to consider the message of an ad
that was produced or sponsored by an LGBT-specific
organization. By providing financial support to
reputable and respected LGBT organizations to
produce messages tailored to their primary audience,
MDCH could increase the relevance, reach and impact
of anti-tobacco messages for the LGBT community.
2. Focus On Pro-Health Messages Rather
than Anti-Smoking Messages
The vast majority of tobacco cessation campaigns
focus on the negative health consequences of
tobacco use. Participants, however, suggested that
it would be more effective for campaigns to focus
on the positive health outcomes of successfully
quitting tobacco. For instance, participants expressed
interest in seeing advertisements about improved
lung capacity, increased physical fitness, and overall
stronger organ function. Building upon the primary
motivations participants cited for quitting tobacco,
family/friends and health consequences, pro-health
advertisements could depict a former smoker who
has regained their health and are now able to dance
at their child’s wedding or run a race with friends.
3. Focus Health-Based Messages on Morbidity
Rather than Mortality
Messages focusing on the negative health consequences
of tobacco use often present statistics about death
from smoking-related illness. These messages are
largely ineffective for younger audiences, whose sense
of invincibility allows them to distance themselves
from the message. Some participants suggested
that while it is difficult to conceptualize death, it is
easier to understand disability. Rather than focusing
on individuals who have died as a result of smokingrelated illness, ads should focus on individuals who
are permanently disabled (e.g. requiring a speaking
valve after tracheostomy, leg amputation due to
vascular disease).
4. Depict LGBT Individuals in Contexts of
Healthy Living and Empowerment
Participants expressed interest in seeing LGBT
characters in healthy living environments. Rather
than showing LGBT individuals at bars and clubs,
participants hoped to see them at gyms, parks, or
grocery stores. This sentiment was closely linked to
a desire to be shown in environments comparable to
those of heterosexual characters. For instance, one
participant imagined an ad in which an LGBT family
was shown at the park playing with their children
along side heterosexual families.
5. Present Characters Who Represent the
Entirety of the LGBT Spectrum
Ads targeting the LGBT community often present
stereotypical images of hypersexualized and physically
fit men. Many participants argued that this image
is not representative of the entire LGBT population
and can isolate individuals that do not look similarly.
Portraying a diverse range of characters from the entire
LGBT spectrum will extend the reach and relevance
of ads targeting the LGBT community.
Best Practices
After analyzing the focus group findings and building recommendations from the data, literature was
reviewed about nationwide best practices for reducing tobacco use among the LGBT community.
The most comprehensive report on best practices was published by the Network for LGBT Health
Equity and entitled MPowered: Best and Promising Practices for LGBT Tobacco Prevention and
Control. Review of our findings against the backdrop of proposed nationwide strategies showed
that our data provides substantial qualitative support for many of these recommendations
and expand upon new strategies for strengthening tobacco prevention education in schools,
addressing barriers to cessation treatment, and reaching the LGBT population through tobacco
cessation advertisements. Similarities in policy recommendations include increasing nationwide,
state and local surveillance of tobacco use among the LGBT community, expanding tobacco-free
policies, improving cultural competency of statewide cessation services, enforcing bans on tobacco
industry advertisements and sponsorships, and tailoring anti-tobacco advertisements to the LGBT
community. The compatibility of these recommendations suggests that practices endorsed at the
national level could be feasible and appropriate within the context of Southeastern Michigan.
Conclusion
In the summer and fall of 2013, eight focus groups and one interview were conducted to explore
tobacco use among the LGBT-identified Michiganders and provide recommendations to the
Michigan Department of Community Health on how to implement culturally competent anti-tobacco
campaigns and policies among this population. Findings from these focus groups not only provide
strong support for nationwide best practices recommendations, but also present new ideas for
addressing tobacco-related health disparities among the LGBT community.
Perhaps one of the most important conclusions to be drawn from this report is that the habits and
behaviors surrounding tobacco use among LGBT-identified individuals is not significantly different
from those of heterosexual individuals. A significant disparity nevertheless persists, commanding
the attention of public health authorities. Given this paradox, it is critical to recognize and understand
the structural determinants, such as stigma and
discrimination, which are fueling tobacco-related
Structural, interpersonal,
disparities in LGBT communities. Structural,
and internalized transphobia
interpersonal and internalized transphobia and
and homophobia necessitate
homophobia necessitate a variety of coping
a variety of coping
mechanisms that often include substance use.
mechanisms that often
Individual-level cessation efforts that thoughtfully
include substance use.
incorporate an analysis of structural determinants
Individual-level cessation
will be most effective with LGBT communities.
efforts that thoughtfully
Additionally, targeting the structural conditions that
incorporate an analysis of
adversely impact LGBT communities could not only
structural determinants will
decrease tobacco-related disparities, but all health
be most effective with LGBT
disparities affecting this population. Addressing
communities.
the root causes of stigma and discrimination and
working toward complete LGBT equity may ultimately be the most powerful strategy for mitigating
or eliminating LGBT tobacco-related health disparities.
20 | APPENDIX
APPENDIX | 21
Recruitment Flyer
Have experience with tobacco? Identify as LGBTQ?
Affirmations is conducting focus groups to learn more about tobacco use and effective quit tobacco messages in the LGBTQ
community. We want to hear about your experiences with tobacco use and quit messages!
In appreciation for your time, thoughts and ideas, participants will receive a $20 gift certificate. Food will also be provided at
the focus group.
Interested? Please click on the link and fill out the survey.
A few more details…
What are these focus groups?
These focus groups are an opportunity for you to talk about tobacco use in a small group discussion. This is a way for us to learn
about your personal experiences with using tobacco. You will be asked questions about any previous or current use of tobacco,
as well as any experiences with quitting. We’ll also talk about some quit tobacco campaigns - what works and what doesn’t.
Who can participate?
Anyone who has ever used tobacco! This includes current or previous users, and casual users of all forms of tobacco (i.e. cigarettes,
cigars, hookah, chew tobacco, etc.).
When are the focus groups?
Focus groups will be held during the last week of July/first week of August (July 29th through August 4th).
How long will they last?
Participants will need to commit about two hours of their time. This includes time to sign-in, meet the other participants and
have the focus group discussion. The focus group discussion will last approximately an hour and a half (90 minutes).
Where will these focus groups be held?
Focus groups will be held at Affirmations Community Center (290 W. Nine Mile Rd., Ferndale, MI).
Why is this important?
Your thoughts about tobacco use and quit tobacco messages will help the Michigan Department of Community Health develop
quit messages that are tailored to LGBTQ communities.
And finally, are there incentives?
Yes! All those who participate will receive a $20 gift card. Food will also be provided at each focus group session.
If you have any questions, please contact:
Lydia Ahlum Hanson, MSW, MPH
Health & Wellness Manager
Email: lhanson@goaffirmations.org
Direct line: (248) 677-7223
22 | APPENDIX
APPENDIX | 21
Log of Focus Groups Conducted
Date focus
group was
conducted
CCN Partner
Location of
focus group
Population
Number of
participants
Facilitator
7/30/13
N/A
Affirmations
Trans-specific
8
Ryan Oliver
8/1/13
N/A
Affirmations
LGB-specific
8
Lydia Ahlum Hanson
8/22/13
KGLRC
KGLRC
LGB-specific
7
Jay Maddock
9/11/13
KGLRC
KGLRC
Woman-specific
1
Kirsten White
9/21/13
N/A
Affirmations
POC-specific
6
Victor Walker
10/16/13
Jim Toy
Community
Center
Ann Arbor
Friends Meeting
LGBT
6
D. Alvarez
(scheduling conflict
with JTCC space)
10/17/13
Jim Toy
Community
Center
Jim Toy
Community
Center
LGBT
3
D. Alvarez
10/1/13
Battle Creek
Pride
Battle Creek
Pride Center
LGB-specific
8
Jay Maddock
10/9/13
KGLRC
KGLRC
LGBT
4
Kirsten White
APPENDIX | 23
22 | APPENDIX
Participant Demographics
Demographic
Race *
# of Participants
% of Total
White
Black or African American
Native Hawaiian or other Pacific Islander
American Indian or Alaska Native
Asian
Middle Eastern/Arab
Other
Ethnicity
40
8
0
4
2
0
0
80%
16%
0%
8%
4%
0%
0%
Hispanic
Non-Hispanic
Age
5
43
10%
90%
20-29 years
30-39 years
40-49 years
50-59 years
60-69 years
Sex/Gender *
16
14
7
8
3
32%
28%
14%
16%
6%
Male
Female
Trans (male to female)
Trans (female to male)
Intersex
Genderqueer
Other
Sexual Orientation *
25
17
10
1
0
1
2
49%
33%
20%
2%
0%
2%
4%
2
34
6
6
9
5
0
4%
68%
12%
12%
18%
10%
0%
Heterosexual
Gay/Lesbian
Bisexual/Bi-Attractional
Pansexual
Queer
Same Gender Loving
Other
APPENDIX | 23
24 | APPENDIX
Participant Demographics Continued
Education Level *
Less than HS Diploma
High School Diploma
General Education Diploma (GED)
Vocational Certificate
Some College/No Degree
Associate’s Degree
Bachelor’s Degree
Master’s Degree
Post-Master’s Degree (Specialist Degree)
Doctoral Degree
Income
1
3
1
7
16
6
12
8
0
0
2%
6%
2%
14%
31%
12%
24%
16%
0%
0%
<$15,000
$15,000-25,000
$25,000-35,000
$35,000-45,000
$45,000-55,000
$55,000-65,000
$65,000-75,000
$75,000-85,000
$85,000-95,000
Employment Status *
4
12
10
6
8
2
0
2
2
9%
26%
21%
13%
17%
4%
0%
4%
4%
25
9
6
10
4
3
2
4
53%
19%
13%
21%
9%
6%
4%
9%
Employed Full-Time
Employed Part-Time
Self-Employed
Student
On Disability
Retired
Homemaker
Out of work > 1 year
* Indicates some participants selected more than one option.
24 | APPENDIX
APPENDIX | 25
Focus Group Questions
Participant Eligibility
Focus group participants will have had some experience with tobacco use. This includes any former or current users of tobacco, as well as casual users of tobacco.
Tobacco Use Focus Group Questions
Welcome and Introductions- Participants will engage in an icebreaker in which they will give their name and a little
known fact about themselves (or some other icebreaker). Confidentiality will also be discussed here.
Our discussion tonight will have three parts: First, we’ll discuss your current and past tobacco use.Then, we’ll move on
to talk about any experiences you’ve had with quitting tobacco. And lastly, we’ll discuss quit tobacco campaigns and
messages – what works and what doesn’t.
Objective 1: Behavior and Attitudes Regarding Tobacco Use
So to begin, let’s talk about why you started using tobacco.
8:45pm
15 mins - until
• Tell us a little about why you first started using tobacco…
• What forms of tobacco have you used?
o PROBE: Cigarettes, cigars, chewing tobacco, hookah
• When are some times when you may be more likely to use tobacco?
o What do (or did) you like about using tobacco?
o What do (or did) you dislike about it?
• In general, how do you feel about your tobacco use habits?
Objective 2: Tobacco Use Cessation
Let’s move on to talking about quitting….
15 mins – until 9pm
• Have you ever tried quitting?
• For those who have tried quitting, what particular methods worked for you?
o PROBE: Patches, gums, nasal sprays, etc.
o Which methods didn’t work?
• What made you think about quitting? What helped you be successful?
The Michigan Tobacco Quit Line is 1-800 number that was created to provide support and resources for individuals
26 | APPENDIX
APPENDIX | 25
who are thinking about quitting.
• Have you ever called (or would you consider calling) the Quit Line? Why or why not?
Objective 3: Awareness of Tobacco Use Campaigns and Media Messages
Now let’s talk about tobacco prevention and quit campaigns and messages.
15 mins – until 9:15pm
• Can you think of some campaigns that focus on reducing tobacco use? If so, could you describe them?
o PROBE: TV ads, billboards, posters in bars
• What did you like about these campaigns? What didn’t you like about them?
Here’s some examples of quit campaign images. (Distribute campaign images).
• Which type of campaign do you think works best for the LGBT community?
o PROBE: What messages DO NOT work?
There are different levels in society that impact an individual’s decision to use tobacco or not. Individual factors, as
well as societal factors affect one’s decision. Here is a diagram that demonstrates this concept:
(Distribute diagram to focus group participants)
Policy
Smoke-free laws, taxes on tobacco, higher insurance rates
“Cigarettes are getting too expensive, so I’m thinking about quitting.”
Community
Smoke-free homes, schools, workplaces, bars & clubs
“Whenever I’m at the bar and want a cigarette, I have to go outside
to smoke. My friends won’t join me, so I’m thinking about quitting.”
Relationships
Family, friends, partners
“My best friend makes fun of me for smoking, so I’m thinking
about quitting.”
Individual
Knowledge, beliefs, attitudes
“I know that smoking is bad for me, so I’m
thinking about quitting.”
• When creating quit tobacco campaigns and messages, which levels should be focused on in order to be most effective?
o PROBE: Why is that level most effective?
Closing- Thanks to participants for time, insights, ideas, and thoughts.
26 | APPENDIX
Campaign Images
This is from the Truth campaign:
This is from the CDC’s campaign, Tips from Former Smokers:
APPENDIX | 27
28 | APPENDIX
APPENDIX | 27
This is also from the CDC’s campaign, Tips from
Former Smokers:
“Ellie’s severe asthma attacks were triggered by
secondhand smoke at work. She and her partner
have to live with its effects forever. If you or someone you know wants free help to quit smoking, call
1-800-QUIT-NOW.”
These images are from a LGBT organization that encourages community members to live smoke-free:
“I fought hatred, survived
coming out, protect myself
against HIV, and demand I be
treated equal… All so I can die
from lung cancer? I quit.”

“I got tired of being called a sissy”

Transcription

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