There are the calming effect, the pleasurable feeling, the cool and rebellious look of it, the weight maintenance, and the addiction are some of the reasons given that make smoking a "bitch to quit." While interacting with LGBTQ smokers in Howard Brown Health Center's ( HBHC ) Bitch To Quit, the only LGBTQ smoking-cessation study in Chicago, Dr. Phoenix Matthews, Ph.D., hears every reason imaginable as to why participants smoke and have a difficult time quitting.
Matthews—along with Dr. Andrea King, Ph.D., from the University of Chicago—serves as the principal investigator of Bitch To Quit. A grant from the National Institute of Drug Abuse funds the study for a span of five years, allowing the group to investigate the effectiveness of smoking interventions for LGBTQ smokers. Currently in its third year, the study is an adaptation of the Respiratory Health Association's Courage To Quit and is collaboration between University of Illinois Chicago ( UIC ), HBHC and University of Chicago.
"I feel really pleased we were able to bring so many stakeholders to the table to be able to offer what I believe is a really good treatment intervention for the community," Matthews said. "I'm particularly pleased with the study because of the collaboration of LGBTQ and non-LGBTQ organizations that have helped to bring this together, but also we are moving beyond just describing a problem. We know that tobacco use is a problem among the LGBTQ communities and we're moving in the right direction at trying to develop solutions for having people quit when they're ready to quit."
According to Matthews, there are very few studies in existence that include large numbers of LGBTQ smokers or that are specifically tailored to help LGBTQ smokers quit; as a result, little information is known about the smoking cessation needs of the community in terms of what strategies work best to assist community members in quitting. The mission behind the study is to be able to answer the question of what the quit rates are among LGBTQ smokers who participate in group-based and evidence-based treatments. The second question the study aims to answer which of two types of treatments are better for helping LGBTQ smokers quit.
The group-based treatment program operates within six weekly sessions where individuals participate with other LGBTQ smokers and a facilitator. In addition to the group sessions, participants receive four individualized telephone counseling sessions and access to free nicotine replacement patches. Matthews explains the program is based on established methods for aiding smokers to quit including social support, goal setting, stress reduction, nicotine replacement, knowledge building, and strengthening motivation and belief in one's ability to quit smoking.
As the program has the nature of a research project, a follow-up with group participants is conducted for 12 months after the completion of their group counseling sessions. Matthews said the ability to stay in touch with the participants for the entire following year is critical for understanding the long-term benefits of the treatment program. LGBTQ smokers over the age of 18 are potentially eligible for the study. Diversity within the study is desired, Matthews said, and hoping to reach a total of 400 participants in the study, recruitment is ongoing. With the same established, familiar name as HBHC's 10-year-long clinical services program, the piece that sets this program apart is the heavy focus on research.
"At this point we're running the intervention we developed and we won't know until all the data is collected about the effectiveness," said Matthews. "We are collecting data in the ways we anticipated and we'll k now at the end of the study what the findings are. We need to make sure the groups are run effectively, they're culturally competent and we are doing everything we can to make this a good experience for the participants."
Matthews is a licensed clinical psychologist and associate professor at UIC in the College of Nursing. Most recently, Matthews was appointed to sit on the Chicago LGBTQ Health Advisory Council. The focus of Matthews' research is on the reduction of cancer disparities among underserved populations including racial/ethnic minorities and members of the LGBTQ communities. Examining the factors associated with physical and mental health disparities among members of marginalized social groups, Matthews has examined topics of cancer survivorship, cancer prevention, health care utilization, mental illness stigma and depression.
Hailing from a small town in Ohio, Matthews came to Chicago to complete training in psychology. In the health field since 1995, when Matthews received a Ph.D., Matthews said the thought of using psychological concepts to improve individuals' health outcomes, whether it be working with individuals who are diagnosed with health issues such as cancer or helping individuals quit smoking, or changing other types of risk behaviors was intriguing.
"Some people want to be in the lab and I don't want to be in the lab," said Matthews. "I want to be in the community. I see the community as my lab. Understanding how to work in the community is the best means for doing the work that is important to me and hopefully important to the rest of the community as well."
During graduate school—at the height of the AIDS epidemic—all work in the LGBTQ community at that time was focused on HIV and AIDS comprehension and risk reduction. As Matthews started off working in those areas, an interest in sexual minority women's health, specifically in cancer prevention, cervical and breast cancer prevention, and cancer screening developed.
"They say all of research is 'me'-search," said Matthews of why this area of research was of interest. "It's either directly in my life because it's what I observed in my community, or in my family, or something I struggled with personally and I wanted to overcome. To do research you have to have something that instills passion. Thinking about the level of stigma and discrimination based on race and ethnicity, based on sexual orientation, based on gender presentation and try to be the person who provides the current generation and the next generation ways of getting out from under the burden of societal stigma is something that's important to me."
Matthews said typically people automatically think of HIV as the main and only concern in the LGBTQ community health landscape. However, smoking is a large health risk the public has not been aware of or attune to in that community. Matthews confirmed members of the LGBTQ community smoke at two to three times the rate of heterosexual individuals. The combination between HIV-positive people and smoking is also something people do not tend to know about either.
"That's significant because it does interact with HIV in that HIV-positive individuals that also smoke have poor health outcomes directly associated with their HIV," said Matthews. "It reduces the effectiveness of their anti-HIV medications, but it also puts them at risk for other non-HIV related illnesses such as cancer and respiratory illnesses."
Many factors contribute to the higher rates of smoking within the LGBTQ community. One of the largest components in LGBTQ health risks, Matthews stated, is high rates of direct marketing targeting the LGBTQ community by the tobacco industry with smoking-related advertisements. According to Matthews, the tobacco industry spends millions of dollars each year to advertise in LGBTQ media and sponsors events such as pride festivals and LGBTQ organizations.
"When the tobacco industry is directly targeting and there's this financial input into the community from the tobacco industry, it does a couple things," said Matthews. "It reduces the likelihood that there are these anti-tobacco campaigns that are put in place. It also gives the perception that the tobacco industry is our friend because they're in some ways one of the few industries that's actually willing to pay attention to us—they put people in ads, etc. It is a form of manipulation and direct targeting for those additional dollars and it's been effective. We do see those high rates of smoking."
Matthews noted another risk factor leading to smoking is higher rates of stress due to stigma and discrimination based on sexual orientation and gender identity. According to Matthews, stress is strongly associated with smoking and difficulty quitting.
Social settings, such as bars, also have an effect on smoking habits. Especially among younger participants in the study, it was voiced that smoking is a major way of making a social connection with peers in the LGBTQ community. Approaching someone with a cigarette creates a commonality and allows for a conversation to start more easily creating a less stressful situation.
"It starts for many people as stress reduction," said Matthews. "Social smoking then becomes progressive to an addiction and then all the things that go along with trying to stop a substance that is both legal, that's common in their environment, helps reduce boredom, stress, and enhances pleasure and is also addictive. That becomes a very difficult thing to do. Studies have shown that stopping smoking is as difficult if not more difficult than quitting heroin or cocaine due to the level of addictiveness, but there are other elements of it being legal, pervasive, and it doesn't impair your ability to do your day-to-day activities."
According to The National Network for LGBTQ Health Equity's website, LGBTQ communities smoke at rates 40 percent to almost 200 percent higher than the general population. Matthews elaborates explaining that sexual-minority women smoke at higher rates than gay and bisexual men, while bisexual men smoke at about same rates as heterosexual men. Gay men smoke a little bit higher than heterosexual men, while some of the highest rates are among lesbian, bisexual women and transgender individuals.
Matthews expressed that although smoking-cessation treatments are helpful, public policy has had some of the strongest impacts on smoking behaviors, reducing the rates at which people smoke. One example of effective public policies Matthews lists is higher levels of taxation on cigarettes and tobacco products. Many people who are price point-sensitive—such as youth, lower income people and people who cannot afford the expense—are then no longer willing to pay.
Additionally, clean-air laws that restrict people from smoking in public places dramatically lower the smoking rate. Individuals who do not quit as a result of clean-air laws, Matthews said, end up smoking less than they had previously due to having to exit the building ( and sometimes the property entirely ) to be able to smoke.
Suggesting actions to be taken to make progress in the LGBTQ health field, Matthews said to use the creativity the community possesses to develop messages, develop public health campaigns specific to the LGBTQ community that would work to undo much of what has been done by the tobacco industry.
To help curb smoking, Matthews advised using helpful resources such as evidence-based treatments, which research has shown to be effective including methods such as counseling concentrating on skill building; using forms of stop smoking medications, obtaining social support for quitting; working on stress reduction; and persistence.
"I can't say enough about persistence as key to becoming a non-smoker," said Matthews. "It will take the majority of smokers several attempts before they are able to quit for good. The majority of the participants who come to our groups have tried to quit before. We believe that we can help provide the skills and support to help them quit for good or move one huge step closer to that eventual goal."
To learn more about Bitch To Quit or to become a participant, visit www.bitchtoquit.org or call 773-388-8868.
