An urgent call to address tobacco-related health disparities among sexual and gender minority populations in the COVID-19 pandemic

Andy S.L. Tan, Priscilla K. Gazarian, Elaine Hanby, Sabreen Darwish, Bethany C. Farnham, Jennifer Potter, Suha Ballout

Tobacco-related health disparities are defined as “differences in the patterns, prevention, and treatment of tobacco use; the risk, incidence, morbidity, mortality, and burden of tobacco-related illness that exist among specific population groups in the United States; and related differences in capacity and infrastructure, access to resources, and environmental tobacco smoke exposure”. Tobacco related-health disparities are increasingly concentrated in traditionally marginalized populations including sexual and gender minority (SGM) individuals. There are critical gaps in measuring tobacco-related health disparities and addressing unmet needs of SGM individuals in the context of nicotine and tobacco research and treatment. Recent reports on the disproportionate impacts of the coronavirus disease (COVID-19) among disparity populations including racial and ethnic minorities and individuals experiencing homelessness in the United States warrant examining the intersecting impacts of tobacco and COVID-19 among SGM individuals as well.

The current COVID-19 pandemic amplifies the urgency and significance for tobacco control researchers and practitioners to address tobacco-related health disparities and unmet healthcare needs among SGM populations for a few reasons. First, SGM individuals, recognized in 2016 by the US National Institutes of Health as a special health disparity population, experience unique factors including minority stress, tobacco norms, structural inequities, and discriminatory policies that influence tobacco use behaviors and related health outcomes. These underlying structural and social determinants of health that influence smoking behaviors and poorer health among SGM populations could similarly exacerbate their risks of being disproportionately affected by COVID-19.

Second, recent systematic reviews reported smoking as a risk factor for higher morbidity and mortality among COVID-19 patients. The US CDC reported that COVID-19 patients in the US with underlying smoking-related illnesses such as chronic lung disease and cardiovascular diseases are associated with more severe COVID-19 requiring hospitalization and ICU care compared with those without these conditions. Disparities in tobacco use, related respiratory conditions, and chronic illnesses among SGM populations may therefore increase the morbidity and mortality of individuals who are affected by COVID-19.

Third, social distancing measures in the COVID-19 response increase social isolation among SGM populations due to lack of contact with their social support network and chosen family members. Owing to school closures and loss of employment, SGM individuals may be forced to move in with their family members who do not accept their sexual orientation and gender identity. In addition, psychological distress associated with the economic fallout arising from COVID-19 may increase risks of depression and trigger increased use of substances including alcohol and tobacco during the pandemic. Based on the trauma-informed care literature in SGM populations, we posit that additional COVID-19-related trauma experienced by SGM individuals may have downstream effects on rates of tobacco use, and widen tobacco use and related health disparities among SGM populations long after the pandemic subsides.

Fourth, increased healthcare demands in response to the rising number of patients treated for COVID-19 may displace tobacco use-related prevention and treatment, as well as other SGM-specific healthcare needs. For instance, in our group’s ongoing qualitative study of risk and protective factors of cigarette smoking among transgender and gender expansive individuals (Project SPRING), participants faced increased barriers in accessing healthcare services to obtain hormone treatments and prescriptions as a result of the COVID-19 pandemic, limiting outpatient care. Stress related to not being able to access hormone treatment was in turn associated with increased cigarette smoking.

To summarize, tobacco-related health disparities may worsen COVID-19-related mortality and morbidity among SGM populations. Simultaneously the COVID-19 pandemic and its attendant social, economic and healthcare ramifications threaten to widen tobacco-related health disparities between SGM and non-SGM populations. Data reporting the association between tobacco use, related health conditions, COVID-19 infection rates and illness severity among SGM are lacking. This is in part due to incomplete adoption of practices to document SOGI information in electronic health records in healthcare settings. Consequently, the impact of the COVID-19 pandemic on tobacco use and cessation behaviors remains unknown.

The complex interplay between the COVID-19 pandemic and tobacco-related health disparities in SGM populations means that sexual orientation and gender identity and tobacco use behaviors should be collected routinely in clinical settings. This will enable the timely reporting of COVID-19 infection and disease progression among SGM individuals and comparisons with non-SGM patients. Population studies examining the health and social impacts of the COVID-19 pandemic should include sexual orientation and gender identity questions to determine whether the pandemic has led to increases in tobacco use, and identify challenges to seeking tobacco treatment among SGM individuals. We further urge the monitoring of the long-term consequences of the pandemic on tobacco-related health disparities among SGM populations. These efforts to strengthen collection of sexual orientation and gender identity and tobacco use data are urgently needed to begin to address tobacco-related health disparities and unmet healthcare needs among SGM populations during the pandemic.

Andy S.L. Tan is with the Dana-Farber Cancer Institute and the Harvard T.H. Chan School of Public Health, USA; Elaine Hanby is with the Dana-Farber Cancer Institute, USA; Priscilla K. Gazarian, Sabreen Darwish, Bethany C. Farnham, and Suha Ballout are with the University of Massachusetts Boston, College of Nursing and Health Sciences, USA; Jennifer Potter is with The Fenway Institute and Beth Israel Lahey Health, Department of Medicine, USA. All authors declare no competing interests. Corresponding author:

The authors are supported by funding from the National Cancer Institute’s U54 Cancer Research Partnership Grant (U54 CA156732). The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.

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