LGBTQ Youth and Young Adult Perspectives on a Culturally Tailored Group Smoking Cessation Program.

INTRODUCTION: The prevalence of smoking among LGBTQ youth and young adults (YYAs) is much higher than that of non-LGBTQ young people. The current study explored LGBTQ YYA perceptions of a culturally tailored group smoking cessation counselling program, along with how the intervention could be improved.
METHODS: We conducted focus groups (n = 24) with 204 LGBTQ YYAs in Toronto and Ottawa, Canada. Open-ended questions focused on their feelings, likes and dislikes, concerns and additional ideas for a culturally tailored group cessation counselling intervention. Focus group transcripts were coded thematically and analyzed.
RESULTS: Overall, YYAs were ambivalent towards the concept of a culturally tailored, group cessation counselling program. Although several participants were attracted to the LGBTQ friendly and social benefits of such a program (eg, good support system), many also had concerns. Particularly, the possibility that other group members might trigger them to smoke was a frequently stated issue. Focus group members also noted lack of motivation to attend the group, and that the group program may be inaccessible depending on where and when the program was offered. Several suggestions were made as to how to ameliorate the expressed issues related to inaccessibility or lack of attractiveness.
CONCLUSIONS: This study is among the first to gain the perspectives of LGBTQ YYAs on culturally tailored group cessation strategies in Canada. We identified components of group cessation programs that are both favored and not favored among LGBTQ YYAs, as well as suggestions as to how to make group cessation programs more appealing. IMPLICATIONS: This study is particularly relevant as smoking cessation programs are one of the most commonly offered and published cessation interventions for the LGBTQ community, yet little is understood in terms of preferences of LGBTQ YYA smokers. Given the disparity in the prevalence of smoking among LGBTQ young people compared to their non-LGBTQ peers, research on effective intervention strategies for this population is needed. Findings from this study can assist practitioners and researchers in designing interventions.

Introduction

Smoking is the leading cause of death in Ontario.[1,2] Although overall smoking rates have declined in Canada,[3,4] the smoking prevalence remains high among youth and young adults: especially among those who identify as lesbian, gay, bisexual, transgender, or queer (LGBTQ).[5] According to the 2014 Canadian Community Health Survey, the daily and occasional smoking rate among homosexual and bisexual 18–24 year olds is 34% and 35.1%, respectively. This is significantly higher than the heterosexual 18–24 year old daily and occasional smoking rate of 23.3%.[5] Furthermore, twice as many lesbian, gay, and bisexual adolescents report using tobacco daily compared to their non-LGB peers (22% of LGB adolescents, 11% non-LGB adolescents).[6] Other studies have also shown the high burden of smoking within the LGBTQ community, estimating that the smoking prevalence among LGBTQ people to range from 24% to 45% with striking within-community differences such as high smoking rates among the bisexual (45%) and gender-queer community (44%).[7]

There are several risk factors for high LGBTQ smoking rates that are common to the general population but experienced at potentially higher rates by sexual and gender minorities including: minority stress (victimization and discrimination), stigma, depression, mental health, social smoking, peer-pressure, frequenting bars and nightclubs, alcohol, substance use, and tobacco industry marketing towards sexual minorities and youth.[8-11] Moreover, LGBTQ smokers begin smoking earlier in life compared to non-LGBTQ smokers[11,12] and victimization experienced as youth, such as verbal or physical harassment due to being LGBTQ, is longitudinally associated with LGBTQ smoking status.[13] Further, interviews with LGBTQ youths about smoking have highlighted smoking in managing stressors and stress reactions,[8] although other data suggest that smoking can amplify the association between stress burden and subsequent psychological distress.[14] Given the serious health consequences associated with smoking and the high prevalence of smoking among LGBTQ people, there is a need for smoking prevention and cessation interventions for LGBTQ youth and young adults (YYAs).

A meta-analysis of 50 randomized controlled trials found that behavioral interventions such as group cessation counselling result in significantly greater odds of smoking abstinence.[15] However, there is a paucity of smoking cessation interventions targeted towards LGBTQ YYAs. A scoping review of peer-reviewed literature pertaining to this topic identified 13 smoking cessation group programs that were either tailored towards LGBTQ people or assessed for effectiveness within the LGBTQ community.[16] Among the programs identified were: The Last Drag, Stop Dragging Your Butt, and Queer Quit.[17-20] The majority of these studies did not undergo rigorous evaluation: only two studies used biomedical measures (eg, carbon monoxide monitoring) to confirm smoking abstinence, ten studies relied on self-reported data, and one article was a descriptive paper on the implementation process. None of the programs evaluated were targeted specifically to LGBTQ YYAs.

There is debate over the value of cultural tailoring. Cultural tailoring refers to “the development of interventions, strategies, messages, and materials to conform with specific cultural characteristics.”[21] Grady et al.[22] and Covey et al.[23] did not find differences in quit rates between sexual minority and non-sexual minority individuals after the implementation of a non-tailored smoking cessation intervention. However, in several other studies such as Walls et al.[19] and Schwappach,[24] participants reported that it was important to adapt programing to the LGBTQ community and host programs in LGBTQ-friendly spaces. For example, Walls et al. evaluated the effectiveness of a smoking cessation course tailored to meet the needs of the LGBT community and documented the importance of the cultural appropriateness of the course content and having cessation classes in LGBT-identified contexts.[19] Of the studies which adapted their programs by including a culturally competent facilitator, addressing LGBTQ-specific topics, and/or hosting programs in LGBTQ-friendly spaces, the quit rate ranged from 29% to 89%.[18,19,25] Similarly, studies have documented higher rates of smoking among LGB youth as compared to adults and that cessation interventions should be targeted and be age specific[26] as smoking initiation occurs earlier among sexual minority youth.[11] The scant amount of evidence and literature evaluating age and LGBTQ-specific smoking programs for youth and young adults limits the ability of practitioners to properly develop and implement effective prevention and cessation strategies for this underserved community.

We address this gap in the literature by focusing on this priority population. The current study explored LGBTQ youth and young adult perspectives towards a culturally-tailored group counselling cessation program.

Methods

Design and Recruitment

We conducted a total of 24 focus groups among LGBTQ YYAs in Toronto, ON (n = 18 groups) and Ottawa, ON (n = 6 groups) from March to May, 2015. To better reach LGBTQ YYAs, recruitment occurred via purposive and snowball sampling methods: posting flyers and verbal announcements in spaces frequented by LGBTQ people; Facebook posts on LGBTQ-friendly group pages; paid Facebook advertisements; listserv e-mails and social media call-outs from LGBTQ agencies; physical recruitment at bars and nightclubs; and participant referrals to eligible peers.[27]

Participants contacted the project coordinator via e-mail, were provided information about the study, and completed an electronic demographic intake questionnaire to determine study eligibility. Physical questionnaires were available for those unable to complete the electronic form. Eligible participants were 16–29 years old, identified as a sexual and/or gender minority individual, and were current smokers or recent quitters (defined as having not quit for more than 6 months prior to completing the intake questionnaire). 275 eligible participants were triaged into city, age group, and LGBTQ sub-groups. The triaging was done by age and LGBTQ status as homogeneity is key to maximizing disclosure among focus group participants.[28] Two hundred and four of the eligible participants attended a focus group (74% participation rate). Participants provided signed consent and this study was approved by a University of Waterloo Research Ethics Committee.

Focus Group Procedures

Facilitators and note takers were trained to conduct the focus groups and instructed to follow the focus group protocols and semi-structured interview guide (see Table 1). Facilitators and note takers identified as members of the LGBTQ community. Focus groups were conducted in LGBTQ community health centres where LGBTQ YYAs receive services. Participants were asked to share their input regarding the culturally tailored, group cessation counselling program as part of a broader program of research to explore potential interventions and attitudes towards smoking and quitting for LGBTQ YYAs. The intervention idea was handed out on paper to each participant, as well as verbally read out, and participants were provided with a pen and notepad to jot-down their thoughts about the intervention.

Table 1.

Focus Group Materials

Scenario

Questions asked by facilitator

Imagine that every week you could meet with other [LGBTQ/lesbian/ bisexual/gay/transgender/queer], youth and young adults who want to quit smoking. A LGBTQ-friendly counsellor would run the meetings in a safe and accepting space. The counsellor would share trusted information on how to quit and stay smoke-free, but would leave time for group members to talk about personal experiences with smoking and quitting. Examples of information that might be shared include isolation, loneliness, body image, lifestyle changes, the need for positive support, stressors like the coming-out process, triggers and self-esteem. These groups could be a way to connect with others your age with similar experiences, and promote LGBTQ people supporting LGBTQ people to overcome smoking. The group would also encourage participants to buddy-up with other members so that during the week, people would be able to support each other to stay smoke-free. The group sessions would be 6–8 weeks and have 8–15 people.

How do you feel about a group cessation program for people your own age who are also [LGBTQ/lesbian/bisexual/gay/transgender/queer], who smoke, and who want to quit smoking? Can you imagine yourself attending such a program to help you quit smoking? Why or why not? What are some things that you like about a group program? What are some things that you don’t like about it?

The focus groups were comprised of 3–17 participants and lasted for approximately 90 minutes. Participants were remunerated with a $50 cash incentive. All focus groups were audio-recorded and professionally transcribed. Transcripts were not returned to participants for comment.

Group Cessation Counselling Scenario

The scenario intervention was a culturally-tailored, group cessation counselling program (see Table 1) that was based on guidelines for group cessation counselling[29] and developed with input from a LGBTQ service provider agency. Participants were presented with a description of a group cessation counselling intervention that was tailored, led by a counsellor, incorporated a “buddy” system, and allowed for discussion of topics relevant to LGBTQ YYAs.

Data Analysis

We analyzed the data using a Richie and Lewis framework analysis technique[30] in order to analyze emergent themes identified by the researchers.

To validate coding, the second and third authors (AS & KWF) independently coded the first focus group responses and then compared the coding performed for consistency. Any discrepancies in coding were discussed and resolved with the first author (NB). In this way, each author was able to critically challenge one another on differing perspectives and any potential biases.

A thematic framework[30] was developed by generating major themes and subthemes in relation to the focus group questions and categorizing the associated responses iteratively. To maintain the context of focus group participant responses, they were listed under the questions from which they were derived and then categorized separately as a type of response. Throughout the coding process, regular meetings were held between three of the authors to discuss and refine the thematic framework. Indexing was accomplished by coding each response in NVivo 10, with reliability checked by the second (AS) and third (KWF) author through review of the NVivo file. At the final stage, the original responses were grouped according to the finalized themes and subthemes. Saturation was attained by the 15th transcript. Member checking was completed with 14 participants to confirm findings. Representative quotes were selected from the focus group responses to illustrate key themes and subthemes. The results of LGBTQ youth perspectives on group cessation counselling were examined in-depth for the purpose of this article.

We used the Consolidated Criteria for Reporting Qualitative Research (COREQ) guideline statement to assist in the reporting of the study.[31]

Results

Participant Demographics

The sample included 204 respondents with a mean age of 23 years. With regards to gender, 39% identified as female, 27% identified as male, 11% identified as either trans male or trans female, and 15% identified as gender-queer. In terms of sexual identity, 13% identified as lesbian, 26% identified as gay, 27% identified as bisexual, 24% identified as queer, and 5% identified as pansexual. With regards to education, 12% were currently enrolled in high school, 10% had some high school but were not currently enrolled, 38% had completed high school, 37% had either completed or were currently enrolled in college or university, and 2% had completed a Masters or PhD program. Table 2 provides a detailed summary of the focus group participants’ demographic information and smoking characteristics.

Table 2.

Focus Group Participant Smoking and Demographic Information

Focus group participants (N = 204)
Characteristics	Number (percent)	Characteristics	Number (percent)
Age		City
16–17	18 (8.8)	Toronto	156 (76.5)
18–29	186 (91.2)	Ottawa	43 (21.1)
Total	204 (100.0)	Other	2 (1.0)
Mean Age	22.97	Missing	3 (1.5)
		Total	204 (100.0)
Gender
Female	85 (39.0)	Sexual orientation
Male	58 (26.6)	Lesbian	27 (12.9)
Trans Female	8 (3.7)	Gay	54 (25.8)
Trans Male	15 (6.9)	Bisexual	57 (27.4)
Two-Spirit	9 (4.1)	Queer	51 (24.5)
Gender-Queer	32 (14.7)	Transgendered heterosexual	5 (2.4)
Intersex	1 (0.5)	Pansexuala	10 (4.8)
Other	10 (4.6)	Other	4 (1.9)
Totalb	218 (100.0)	Totalb	208 (100.0)
Ethnicity		Housing
Aboriginal	25 (10.4)	Living with parent	59 (25.2)
Black/African/Caribbean	46 (19.1)	Rented or owned	118 (50.4)
Central Asian	1 (0.4)	Homeless	12 (5.1)
East/South East Asian	16 (6.6)	Social Housing	17 (7.3)
Latin America	12 (5.0)	Couch-Surfing	25 (10.7)
Middle Eastern	7 (2.9)	University/College Residence	3 (1.3)
South Asian	11 (4.6)	Totalb	234 (100.0)
White	115 (47.7)
Other	8 (3.3)	Education
Totalb	241 (100.0)	Some high school (currently enrolled)	25 (12.3)
		Some high school (not currently enrolled)	21 (10.3)
Years Lived in Canada		High school diploma	78 (38.2)
0–1 years	12 (5.9)	College degreec	35 (17.2)
2–5 years	17 (8.3)	University degreec	40 (19.6)
6–10 years	12 (5.9)	Graduate degree (Masters or PhD)	4 (2.0)
Over 10 years	163 (79.9)	Missing	1 (0.5)
Total	204 (100.0)	Total	204 (100.0)
Currently Smoke?		How soon after waking do you smoke?
Daily	113 (55.4)	<5 minutes	25 (12.3)
Occasionally	58 (28.4)	6–30 minutes	50 (24.5)
Recent quitter	30 (14.7)	31–60 minutes	31 (15.2)
Missing	3 (1.5)	>60 minutes	64 (31.4)
Total	204 (100.0)	I don’t smoke	17 (8.3)
		Missing	17 (8.3)
Intend to quit in the next 30 days		Total	204 (100.0)
Yes	53 (26.0)
No	32 (15.7)	Have you smoked 100 cigarettes?
Don’t know	89 (43.6)	Yes	186 (91.2)
N/A	13 (6.4)	No	16 (7.8)
Missing	17 (8.3)	Missing	2 (1.0)
Total	204 (100.0)	Total	204 (100.0)

aIncluded grey-A pansexual and pansexual demi-sexual.

bThe total number reflects the number of responses; some participants selected more than one response.

cThose who said “some college” or “some university” were recoded into “college” or “university.”

Overall Reaction to Culturally Tailored, Group Cessation Programing Scenario

Participants in this study expressed mixed feelings about the desirability and potential effectiveness of a group cessation counselling program. The range of responses used to describe the program spanned from “brilliant,” “amazing,” “foolproof,” “great idea,” to “too hard-core,” “not super effective,” and “wouldn’t work.” The key themes that emerged in support of a culturally tailored group cessation program included it being social in nature and delivered by a LGBTQ friendly counsellor. Perceived barriers of group cessation counselling included motivation to attend sessions, social anxiety, inaccessibility issues such as location and scheduling of sessions, potential stigmatization, and concerns about the effectiveness of a once-a-week program. Improvements to the hypothetical counselling program included running it as a drop-in style program to help address issues of inaccessibility due to participants’ busy schedules.

Theme 1: LGBTQ Friendly and Safe Space

Participants overwhelmingly expressed support for a group cessation program held in a LGBTQ friendly and safe place.

“If I was in a group with just trans people, I feel like there would be so many different things to do together and talk about together and support each other. I think it would be a great idea.” [Trans group participant]

“You meet at a place where you already feel comfortable and you’re with people who, hopefully, you feel a sense of community or shared identity with.” [Queer group participant]

Theme 2: The Social Aspects of Group Programs Are “Good” or “Would Be Helpful”

Participants who liked and felt the program would work favored the social nature of a group program. The following positive social benefits were noted: the program is a good way to meet people and obtain support, and there is a positive shared purpose. It was commonly expressed that a group program would especially benefit those who like to be a part of a group setting.

“I think the idea of having a group is really good because it’s such a social thing smoking…If it were a group of people that you grew closer with or saw regularly then it would make sense to support each other. So I feel like something would come out of that, yes.” [Mixed group participant]

“I think that definitely connecting and networking with other people who are on the track to be smoke-free would be encouraging. I also work really well in group settings, so you can motivate me.” [Queer group participant]

“When you’re in groups, there is [an] ability for validation, and feeling that support and group validation is always nice. [K]nowing that you’re not alone and that sense of solidarity in community is also really important too.” [Mixed group participant]

Theme 3: Success Is Dependent on Personal Attributes

Overwhelmingly, participants commented that the program sounded good in theory, but would not work in reality: “It sounds like a goodidea in theory, but I don’t think just talking about it is really going todo anything.” [Trans group participant]

Several reasons were offered as to why a group cessation program would not work. Many of the hypothetical reasons centered on personal motivation and commitment to quit smoking or attend a group program. As well, participants stated that people would lose motivation to attend the weekly sessions over time and be unable to handle cravings between sessions.

“[T]he turnout may be good for the first few weeks, but…in reality, when [people] have those cravings…they won’t have that support…[W]hen the craving comes later, they may just resort to smoking.” [Trans group participant]

“[Y]ou have to decide for yourself that you don’t want to do something that’s gross...I just don’t feel like meetings for that kind of stuff are that effective.” [Trans group participant]

Some participants felt that the program would work for certain people but not for others. They specified that the success of a group cessation counselling program in helping a smoker successfully quit smoking is dependent on their personality, motivation to quit smoking, commitment to attending the sessions, and whether they make the most of it. Typically, when a participant said that the usefulness of the program depended on the person, they also commented that the program would work for other people, but not for themselves.

Me personally, probably not, because I don’t do well in group settings. But I think that people who are comfortable with talking in groups and [with] people they don’t know, I think it would be a good idea.” [Queer group participant]

Some members revealed that their shyness or social anxiety would restrict or inhibit them from attending group sessions.

“Groups can be a little bit daunting to me and can definitely trigger my social anxiety which can make me fall back to smoking even more.” [Mixed group participant]

Theme 4: Groups May Be Inaccessible Due to Location, Time, and Required Commitment

Several participants expressed that they did not like the idea of a group counselling program due to perceived inaccessibility and voiced their issues with this intervention idea.

“I’m really busy, so it would be really hard to find a regular time…time and location would be an issue. I’d be less likely to go if it was at a time that was difficult for me, or [at] a location that was too far.” [Bisexual group participant]

“I go to school full-time, and, like, I work part-time, so, like, it would be, like, super difficult and, like, I live all the way… anyway, but, like, so, yes, I totally agree with it. I think it’s really difficult to, like, commit to, like, a certain time every week.” [Mixed group participant]

Theme 5: Group Influence

Other concerns brought up by participants revolved around the influence of other group members. Several participants felt that other group members would trigger them to smoke and become new “smoking buddies.”

“I would also be afraid that it would turn into too much of a social thing with that many people, and [that] we [would] become friends and start going out together. It just takes a couple of people to fall off the bandwagon and then you’re all like, “oh, let’s all go for a smoke together.” [Lesbian group participant]

Nobody would be helping each other quit, you’d all just be smoking together and you’d be making new friends through smoking.” [Trans group participant]

Many participants also voiced that they did not want to buddy up with other group members, and stated that other group members may make them feel bad through shaming and guilt-tripping.

“In terms of buddying up with other people, I would…be kind of nervous about who I was assigned with. Maybe I’m not very good at making connections…I don’t know if I’d be that comfortable being vulnerable with someone I don’t know. Like, “hey, I really want a cigarette now, but I don’t even know your middle name.” [Mixed group participant]

“I don’t like [that] it’s in a group setting because I feel like quitting smoking [is] such a personal thing, and if I want peer pressure I’ve had enough from other people. I don’t need a group of people who are there and [are] like, ‘oh, I quit last week.’ I don’t like people asking me questions and putting pressure on me.” [Lesbian group participant]

Theme 6: Concerns About the Effectiveness of a Group Program

A few participants outright questioned the effectiveness of a group program, and remarked that a once-a-week program would not address cravings to smoke outside of sessions.

“[T]o go to a group on a day for probably like an hour just to talk about how much you want to stop smoking is redundant, you just stop smoking…It’s just kind of stupid.” [Mixed group participant]

“I’m not too sure how this is going to help me if I wanted to quit—not that I’m particularly in need of quitting—but I almost feel like quitting smoking is a very personal thing…You smoke when you want and you need to smoke and thus it becomes more of like a compulsion when you have to smoke…So I’m not sure how this kind of group will be effective.” [Trans group participant]

“I feel like it would be nice, but not super-effective… So it would be nice and might be a bit helpful, but I don’t know if it’s going to be like a good option to kind of get people to stop smoking.” [Gay group participant]

Theme 7: Concerns About the Stigma Associated With a Group Program

Some participants were apprehensive that the program was too similar to Alcoholics Anonymous or Narcotics Anonymous, which they did not like.

“ … it’s a little bit too much like AA, because the description is so much like AA that it actually deters me from going to something like that [group cessation counselling]. AA means drugs or alcohol which are so far worse than smoking cigarettes and it makes you feel even worse about yourself as a person.” [Lesbian group participant]

Theme 8: Suggestions to Improve Group Programs for LGBTQ YYAs

Lastly, although many participants were not interested in attending the group counselling and pointed out potential issues, several people offered suggestions as to how to improve the program to make it either more effective or attractive. The most frequently mentioned suggestion was to develop an ongoing “drop-in” style program, rather than time-limited weekly sessions.

“I think it would work better as, like, a drop-in type, like, for people who are trying to quit. But like I feel like having that…oh I need to go to this group every week type thing might add, like, stress to people who are trying to quit. I feel like it would be really beneficial if you know that, like, oh hey if I do need this space where I can be distracted or whatever, it’s there but like I don’t have to go.” [Trans group participant]

“I think that’s something that this would be better run if it was…drop in if you want to...because it’s, stopping cigarettes is not something that’s first of all a one-time thing. People often try to quit multiple times before they do it and also it doesn’t happen at a specific time of the year. So if it’s a closed group or something that’s happening at a specific time it’s not going to work.” [Mixed group participant]

Other considerations for improvements to group counselling included pairing the group counselling with another activity (such as a fitness program); separating groups according to stage of readiness; providing incentives to attend, and providing online access.

“I feel like doing active stuff would be really good like come to the group and then go and run around the block or something. Basically, like when I do active stuff I can’t smoke, like I would throw up if I started to smoke after I did like a bike ride or a run or anything like that.” [Mixed group participant]

“I agree…that it should be separated. People who have already quit smoking should be able to do activities together and do stuff that keeps them not smoking...I think that would be the most successful idea.” [Trans group participant]

“I think there should be kind of like a reward based system. I’m not sure how that will be implemented, but there could be a way to motivate people there has to be something they’re gaining out it. Sure you’re gaining the fact that you’re not smoking anymore and you’ll become healthier and you’re not spending money uselessly on cigarettes, but I think there should be another factor there that motivates people.” [Mixed group participant]

“I like the virtual idea just because it seems like something that doesn’t seem like a lot of effort. I find that going somewhere can stress me out more and then I’ll smoke more, but if it was virtual I could sit at home and just hang out there. That would be cool.” [Mixed group participant].

“I think if I was to Skype in every week that might actually work for me to just remotely get in, especially in this kind of weather. I doubt I would even show up one week in a row.” [Mixed group participant].

Discussion

This study is the first that aims to gain the perspective from a large group of LGBTQ young people regarding their opinions on a hypothetical culturally tailored group cessation counselling program, within a Canadian context. This paper specifically focuses on sharing the findings from LGBTQ YYAs’ perspectives on this intervention idea. Additionally, we included focus group participants’ suggestions as to how to make such a program more accessible, attractive, and successful for this community. This study is particularly relevant as group cessation counselling is one of the most common interventions found in the literature to help the LGBTQ community quit smoking.[16,32,33]

Our results indicate that LGBTQ YYAs had mixed reactions towards the idea of a tailored group cessation program. Despite expressed reservations towards cessation programs, culturally tailored quit smoking programs such as “Queer Quit” have had high participant satisfaction.[24] Other qualitative research has also found that smokers appreciated quit smoking support groups; however, these experiences are from those who actually partook in a group cessation class.[34] From our study, it is unclear whether the participants would attend the hypothetical program as described in the scenario and if they did attend, their reactions to such group programing is unknown.

Aspects of the group cessation program that were liked have important implications for recruitment into the program. For example, many liked the idea of the program being LGBTQ specific and having access to a counsellor that is a member of the community.[19,24] In addition to the perceived social benefits participants would gain by attending the group, the ability to discuss stresses or smoking triggers that are unique to the LGBTQ community such as victimization, isolation, loneliness, and the coming-out process was important. Many thought that the group would provide a great support system, would be a great place to meet people, and would be a good source of encouragement.

Many participants said that a group program was a good idea theoretically, but would not work realistically. Proffered reasons as to why the group would not help them successfully quit smoking included: hypothesized lack of motivation to join or attend each session; aversion to the perceived level of commitment required; potential lack of accessibility in terms of time and location; and the potential negative impact that other members may have on participant’s smoking habits or attendance. Previous research has indicated that young persons are skeptical about group cessation counselling[35] and many smokers actually prefer unassisted quitting as the best method.[36] However, group cessation counselling is recognized as a key evidence-based and highly effective intervention for helping people quit smoking.[29] Two components of counselling are especially effective—providing problem solving/skills training and social support as a part of treatment. Some concerns about group cessation counselling expressed by participants, such as the potential negative impact of other group members, appear to not be supported by evidence.[37,38] Although group cessation counselling is an effective intervention for quitting smoking, overall effectiveness at the population level is best attained when a significant proportion of the target population is reached.[39] Several factors can impact the reach of programs including funding, promotion, capacity of practitioners, and accessibility. The lack of broad reach can reduce the population level impact of cessation counselling.

Several important considerations for practitioners developing programs for LTBTQ youth arose from the focus groups. One of the key issues that the participants had with the program relates to the issue of accessibility. Participants stated that depending on the time and location, they may have trouble getting to the program location or making the program fit into their schedule. Accessibility barriers are not a unique finding to this study and has been replicated in previous research.[34,35,37,40] In our study, the majority of participants were not motivated to quit as only 26% of participants indicated an intention to quit smoking in the next 30 days. Other research has found that those more motivated to quit smoking overcome barriers in order to attend a group program as compared to those who were less motivated.[37] Participants in the present study suggested that a program hosted online would make it easier for them to attend.[41] Moving the program online would also reduce smoking triggers such as smelling smoke on people who attend the group sessions and the desire to smoke socially as well as expand the reach of the program. There were several other suggestions as to how to increase reach by making the program more attractive and accessible. Many participants said they would be more likely to attend a group program if it involved an activity other than smoking cessation or was an extension of an existing group, or if the program was held in a “drop-in” style. Similarly, another study found that college-aged students would prefer interventions that were not centered on smoking, but those that provided personal and social opportunities.[42] All these ideas are worthy of implementation and further study.

This study had several limitations. First, the perceptions shared by focus group participants were discussions of a hypothetical group counselling program situated in a particular timeframe. It is unknown whether these perceptions may change upon participation in an actual group cessation counselling program. Second, we did not probe participants on specific aspects of group counselling nor on the acceptability of tailoring by sexual or gender identity but allowed discussion to evolve organically so that participants could identify what was most important to them. However, participants in various focus groups many have initiated conversation on aspects that others never spoke of. Third, despite attaining 204 participants, we were unable to attract an equal number of lesbian, gay, bisexual, transgender, and queer participants, as well as youth aged 16–17 years. Fourth, we were unable to analyze responses by select characteristics such as intention to quit smoking that may influence perceptions toward a group cessation counselling program. Fifth, the described group cessation scenario was intentionally brief and did not include all possible components of group cessation counselling such as skills training and this may have influenced the perceptions of participants. Lastly, it is unknown if the LGBTQ YYAs in our sample will generalize to LGBTQ smokers in other communities and countries as the context of our sample came from urban areas where services are typically available for those identifying as LGBTQ. However, due to the paucity of research on youth and young adults who identify as LGBTQ, this research sheds light on the perceptions and opinions of this sub-population group.

Conclusion

This study is among the first to gain the perspectives of LGBTQ YYAs on culturally tailored cessation strategies in Canada. We identified components of group cessation programs that are both favoured and not favoured among LGBTQ YYAs as well as participant suggestions as to how to make group cessation programs more appealing and successful in reaching LGBTQ YYAs.

This study is particularly relevant, as smoking cessation programs are one of the most commonly reported methods to culturally tailor smoking cessation interventions towards the LGBTQ community. However, given the lack of consideration in the literature of LGBTQ youth and young adult cessation interventions, this formative research contributes to knowledge in regards to what this population sees as important and beneficial in quitting smoking. Given the health disparity among LGBTQ young people because of the disproportionate prevalence of smoking in relation to their non-LGBTQ minority peers, both formative and summative research on intervention strategies for this population is needed.

Funding

This research was funded by the Ontario Ministry of Health and Long-term Care, Health Services Research Grant no. 06696 and the Canadian Cancer Society (grant #701019). Analysis of the Canadian Community Health Survey (CCHS) was supported by funds to the Canadian Research Data Centre Network (CRDCN) from the Social Sciences and Humanities Research Council (SSHRC), the Canadian Institute for Health Research (CIHR), the Canadian Foundation for Innovation (CFI) and Statistics Canada. Although estimates are based on data from Statistics Canada, the opinions expressed do not represent the views of Statistics Canada.

Declaration of Interests

None declared.