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1.  Iranian Audience Poll on Smoking Scenes in Persian Movies in 2011 
Background:
Scenes depicting smoking are among the causes of smoking initiation in youth. The present study was the first in Iran to collect some primary information regarding the presence of smoking scenes in movies and propagation of tobacco use.
Methods:
This cross-sectional study was conducted by polling audience about smoking scenes in Persian movies on theaters in 2011. Data were collected using a questionnaire. A total of 2000 subjects were selected for questioning. The questioning for all movies was carried out 2 weeks after the movie premiered at 4 different times including twice during the week and twice at weekends.
Results:
A total of 39 movies were selected for further assessment. In general, 2,129 viewers participated in the study. General opinion of 676 subjects (31.8%) was that these movies can lead to initiation or continuation of smoking in viewers. Women significantly thought that these movies can lead to initiation of smoking (37.4% vs. 29%). This belief was stronger among non-smokers as well (33.7% vs. 26%).
Conclusions:
Despite the prohibition of cigarette advertisements in the mass media and movies, we still witness scenes depicting smoking by the good or bad characters of the movies so more observation in this field is needed.
PMCID: PMC3950738  PMID: 24627742
Initiation; movies; scenes; smoking
2.  Menthol Cigarette Smoking among Lesbian, Gay, Bisexual, and Transgender Adults 
Background
Menthol can mask the harshness and taste of tobacco, making menthol cigarettes easier to use and increasing their appeal among vulnerable populations. The tobacco industry has targeted youth, women, and racial minorities with menthol cigarettes, and these groups smoke menthol cigarettes at higher rates. The tobacco industry has also targeted the lesbian, gay, bisexual, and transgender (LGBT) communities with tobacco product marketing.
Purpose
To assess current menthol cigarette smoking by sexual orientation among a nationally representative sample of U.S. adults.
Methods
Data were obtained from the 2009–2010 National Adult Tobacco Survey, a national landline and cellular telephone survey of non-institutionalized U.S. adults aged ≥18 years, to compare current menthol cigarette smoking between LGBT (n=2,431) and heterosexual/straight (n=110,841) adults. Data were analyzed during January–April 2014 using descriptive statistics and logistic regression adjusted for sex, age, race, and educational attainment.
Results
Among all current cigarette smokers, 29.6% reported usually smoking menthol cigarettes in the past 30 days. Menthol use was significantly higher among LGBT smokers, with 36.3% reporting that the cigarettes they usually smoked were menthol compared to 29.3% of heterosexual/straight smokers (p<0.05); this difference was particularly prominent among LGBT females (42.9%) compared to heterosexual/straight women (32.4%) (p<0.05). Following adjustment, LGBT smokers had greater odds of usually smoking menthol cigarettes than heterosexual/straight smokers (OR=1.31, 95% CI=1.09, 1.57).
Conclusions
These findings suggest that efforts to reduce menthol cigarette use may have the potential to reduce tobacco use and tobacco-related disease and death among LGBT adults.
doi:10.1016/j.amepre.2014.07.044
PMCID: PMC4454462  PMID: 25245795
3.  Promoting Tobacco Use Cessation for Lesbian, Gay, Bisexual, and Transgender People 
Context
Lesbian, gay, bisexual, and transgender (LGBT) people are at increased risk for the adverse effects of tobacco use given their high prevalence of use, especially smoking. Evidence regarding cessation is limited. To determine if efficacious interventions are available and to aid the development of interventions, a systematic review was conducted of gray and peer-reviewed literature describing clinical, community, and policy interventions as well as knowledge, attitudes, and behaviors regarding tobacco use cessation among LGBT people.
Evidence acquisition
Eight databases for articles from 1987 to April 23, 2014 were searched. In February–November 2013, authors and researchers were contacted to identify gray literature.
Evidence synthesis
The search identified 57 records, of which 51 were relevant and 22 were from the gray literature; these were abstracted into evidence tables, and a narrative synthesis was conducted in October–May 2014. Group cessation curricula tailored for LGBT populations were found feasible to implement and show evidence of effectiveness. Community interventions have been implemented by and for LGBT communities; although these interventions showed feasibility, no rigorous outcome evaluations exist. Clinical interventions show little difference between LGBT and heterosexual people. Focus groups suggest that care is needed in selecting messaging used in media campaigns.
Conclusions
LGBT-serving organizations should implement existing evidence-based tobacco dependence treatment and clinical systems to support treatment of tobacco use. A clear commitment from government and funders is needed to investigate whether sexual orientation and gender identity moderate the impacts of policy interventions, media campaigns, and clinical interventions.
doi:10.1016/j.amepre.2014.07.051
PMCID: PMC4255587  PMID: 25455123
4.  The National LGBT Cancer Action Plan: A White Paper of the 2014 National Summit on Cancer in the LGBT Communities 
LGBT Health  2016;3(1):19-31.
Abstract
Despite growing social acceptance of lesbians, gay men, bisexuals, and transgender (LGBT) persons and the extension of marriage rights for same-sex couples, LGBT persons experience stigma and discrimination, including within the healthcare system. Each population within the LGBT umbrella term is likely at elevated risk for cancer due to prevalent, significant cancer risk factors, such as tobacco use and human immunodeficiency virus infection; however, cancer incidence and mortality data among LGBT persons are lacking. This absence of cancer incidence data impedes research and policy development, LGBT communities' awareness and activation, and interventions to address cancer disparities. In this context, in 2014, a 2-day National Summit on Cancer in the LGBT Communities was convened by a planning committee for the purpose of accelerating progress in identifying and addressing the LGBT communities' concerns and needs in the spheres of cancer research, clinical cancer care, healthcare policy, and advocacy for cancer survivorship and LGBT health equity. Summit participants were 56 invited persons from the United States, United Kingdom, and Canada, representatives of diverse identities, experiences, and knowledge about LGBT communities and cancer. Participants shared lessons learned and identified gaps and remedies regarding LGBT cancer concerns across the cancer care continuum from prevention to survivorship. This white paper presents background on each of the Summit themes and 16 recommendations covering the following: sexual orientation and gender identity data collection in national and state health surveys and research on LGBT communities and cancer, the clinical care of LGBT persons, and the education and training of healthcare providers.
doi:10.1089/lgbt.2015.0118
PMCID: PMC4770841
cancer; cancer disparities; lesbians; gay men; bisexuals; and transgender (LGBT)
5.  Prevalence of smoking among major movie characters: 1996–2004 
Tobacco Control  2006;15(6):442-446.
Background
Reports of a relationship between watching smoking in movies and smoking among adolescents have prompted greater scrutiny of smoking in movies by the public health community.
Objective
To assess the smoking prevalence among adult and adolescent movie characters, examine trends in smoking in movies over time, and compare the data with actual smoking prevalence among US adults and adolescents.
Design and methods
Smoking status of all major human adolescent and adult movie characters in the top 100 box office hits from 1996 to 2004 (900 movies) was assessed, and smoking prevalence was examined by Motion Picture Association of America (MPAA) rating and year of release.
Results
The movies contained 5944 major characters, of whom 4911 were adults and 466 were adolescents. Among adult movie characters, the overall smoking prevalence was 20.6%; smoking was more common in men than in women (22.6% v 16.1%, respectively, p<0.001), and was related to MPAA rating category (26.9% for movies rated R (restricted, people aged <17 years require accompanying adult), 17.9% for PG‐13 (parents strongly cautioned that some material might be inappropriate for children) and 10.4% for G/PG (general audiences, all ages; parental guidance suggested for children), p<0.001). In 1996, the smoking prevalence for major adult movie characters (25.7%) was similar to that in the actual US population (24.7%). Smoking prevalence among adult movie characters declined to 18.4% in 2004 (p for trend <0.001), slightly below that for the US population for that year (20.9%). Examination of trends by MPAA rating showed that the downward trend in smoking among adult movie characters was statistically significant in movies rated G/PG and R, but not in those rated PG‐13. A downward trend over time was also found for smoking among adolescent movie characters. There was no smoking among adult characters in 43.3% of the movies; however, in 39% of the movies, smoking prevalence among adult characters was higher than that in the US adult population in the year of release.
Conclusions
Smoking prevalence among major adolescent and adult movie characters is declining, with the downward trend among adult characters weakest for PG‐13‐rated movies. Although many movies depict no adult smoking, more than one third depict smoking as more prevalent than that among US adults at the time of release.
doi:10.1136/tc.2005.015586
PMCID: PMC2563673  PMID: 17130372
6.  Did limits on payments for tobacco placements in US movies affect how movies are made? 
Tobacco control  2016;26(1):105-108.
Objective
To compare how smoking was depicted in Hollywood movies before and after an intervention limiting paid product placement for cigarette brands.
Design
Correlational analysis.
Setting/Participants
Top box office hits released in the USA primarily between 1988 and 2011 (n=2134).
Intervention
The Master Settlement Agreement (MSA), implemented in 1998.
Main outcome measures
This study analyses trends for whether or not movies depicted smoking, and among movies with smoking, counts for character smoking scenes and average smoking scene duration.
Results
There was no detectable trend for any measure prior to the MSA. In 1999, 79% of movies contained smoking, and movies with smoking contained 8 scenes of character smoking, with the average duration of a character smoking scene being 81 s. After the MSA, there were significant negative post-MSA changes (p<0.05) for linear trends in proportion of movies with any smoking (which declined to 41% by 2011) and, in movies with smoking, counts of character smoking scenes (which declined to 4 by 2011). Between 1999 and 2000, there was an immediate and dramatic drop in average length of a character smoking scene, which decreased to 19 s, and remained there for the duration of the study. The probability that the drop of −62.5 (95% CI −55.1 to −70.0) seconds was due to chance was p<10−16.
Conclusions
This study’s correlational data suggest that restricting payments for tobacco product placement coincided with profound changes in the duration of smoking depictions in movies.
doi:10.1136/tobaccocontrol-2015-052400
PMCID: PMC4965330  PMID: 26822189
7.  Did limits on payments for tobacco placements in US movies affect how movies are made? 
Tobacco Control  2016;26(1):105-108.
Objective
To compare how smoking was depicted in Hollywood movies before and after an intervention limiting paid product placement for cigarette brands.
Design
Correlational analysis.
Setting/Participants
Top box office hits released in the USA primarily between 1988 and 2011 (n=2134).
Intervention
The Master Settlement Agreement (MSA), implemented in 1998.
Main outcome measures
This study analyses trends for whether or not movies depicted smoking, and among movies with smoking, counts for character smoking scenes and average smoking scene duration.
Results
There was no detectable trend for any measure prior to the MSA. In 1999, 79% of movies contained smoking, and movies with smoking contained 8 scenes of character smoking, with the average duration of a character smoking scene being 81 s. After the MSA, there were significant negative post-MSA changes (p<0.05) for linear trends in proportion of movies with any smoking (which declined to 41% by 2011) and, in movies with smoking, counts of character smoking scenes (which declined to 4 by 2011). Between 1999 and 2000, there was an immediate and dramatic drop in average length of a character smoking scene, which decreased to 19 s, and remained there for the duration of the study. The probability that the drop of −62.5 (95% CI −55.1 to −70.0) seconds was due to chance was p<10−16.
Conclusions
This study's correlational data suggest that restricting payments for tobacco product placement coincided with profound changes in the duration of smoking depictions in movies.
doi:10.1136/tobaccocontrol-2015-052400
PMCID: PMC4965330  PMID: 26822189
Media; Tobacco industry; Public policy
8.  Smoking Cessation Awareness and Utilization Among Lesbian, Gay, Bisexual, and Transgender Adults: An Analysis of the 2009–2010 National Adult Tobacco Survey 
Nicotine & Tobacco Research  2015;18(4):496-500.
Introduction:
Each year, there are more than 480 000 deaths in the United States attributed to smoking. Lesbian, gay, bisexual and transgender (LGBT) adults are a vulnerable population that smokes at higher rates than heterosexuals.
Methods:
We used data collected from the National Adult Tobacco Survey 2009–2010, a large, nationally representative study using a randomized, national sample of US landline and cellular telephone listings, (N = 118 590). We compared LGBT adults to their heterosexual counterparts with regard to exposure to advertisements promoting smoking cessation, and awareness and use of tobacco treatment services, including quitlines, smoking cessation classes, health professional counseling, nicotine replacement therapy, and medications.
Results:
Fewer GBT men, compared to heterosexual men, were aware of the quitline. However, LGBT individuals have similar exposure to tobacco cessation advertising, as well as similar awareness of and use of evidence based cessation methods as compared to heterosexual peers.
Conclusions:
The similarly of awareness and use of cessation support indicates a need for LGBT-specific efforts to reduce smoking disparities. Potential interventions would include: improving awareness of, access to and acceptability of current cessation methods for LGBT patients, developing tailored cessation interventions, and denormalizing smoking in LGBT community spaces.
doi:10.1093/ntr/ntv103
PMCID: PMC4854493  PMID: 26014455
9.  Social Branding to Decrease Lesbian, Gay, Bisexual, and Transgender Young Adult Smoking 
Nicotine & Tobacco Research  2015;17(8):983-989.
Introduction:
Lesbian, gay, bisexual, and transgender (LGBT) individuals are more likely to smoke than the general population. This study evaluated a Social Branding intervention, CRUSH, which included an aspirational brand, social events, and targeted media to discourage smoking among LGBT young adults in Las Vegas, NV.
Methods:
Cross-sectional surveys (N = 2,395) were collected in Las Vegas LGBT bars at 2 time points 1 year apart. Multivariate logistic regressions examined associations between campaign exposure, message understanding, and current (past 30 days) smoking, controlling for demographics.
Results:
LGBT individuals were significantly more likely to report current (past 30 day) smoking than heterosexual/straight, gender-conforming participants. Overall, 53% of respondents reported exposure to CRUSH; of those exposed, 60% liked the campaign, 60.3% reported they would attend a CRUSH event on a night when they usually went somewhere else, and 86.3% correctly identified that the campaign was about “partying fresh and smokefree.” Current smoking was reported by 47% of respondents at Time 1 and 39.6% at Time 2. There were significant interactions between time and campaign exposure and campaign exposure and understanding the message. Among those who understood the CRUSH smokefree message, the highest level of campaign exposure was significantly associated with 37%–48% lower odds for current smoking.
Conclusions:
While longitudinal studies would better assess the impact of this intervention, CRUSH shows promise to reduce tobacco use among LGBT bar patrons.
doi:10.1093/ntr/ntu265
PMCID: PMC4580542  PMID: 26180223
10.  A PILOT STUDY TO ASSESS TOBACCO USE AMONG SEXUAL MINORITIES IN HOUSTON, TEXAS 
Background and Objectives
To assess tobacco use among lesbian, gay, bisexual, and transgender (LGBT) individuals from the 2014 Houston Pride Parade and Festival in Houston, Texas (TX).
Methods
Cross-sectional study using convenience sample of LGBT individuals (n=99) examining tobacco use, sexual orientation, and other socio-demographic factors through survey participation.
Results
Findings showed a high prevalence of tobacco and electronic cigarettes use. White LGBT individuals had greater odds of using any type of tobacco product.
Discussion and Conclusions
Despite a high smoking prevalence among the surveyed LGBT individuals, this study sample did not identify tobacco use as a health issue.
Scientific Significance
Supports the need for further investigation on tobacco-related disparities among LGBT individuals in Houston, TX.
doi:10.1111/ajad.12244
PMCID: PMC4516602  PMID: 26009978
11.  Effect of Exposure to Smoking in Movies on Young Adult Smoking in New Zealand 
PLoS ONE  2016;11(3):e0148692.
Onscreen Smoking Is a Form of Tobacco Marketing
Tobacco advertising has been prohibited in New Zealand since 1990, and the government has set a goal of becoming a smokefree nation by 2025. However, tobacco marketing persists indirectly through smoking in motion pictures, and there is strong evidence that exposure to onscreen smoking causes young people to start smoking. We investigated the relationship between exposure to smoking in movies and youth smoking initiation among New Zealand young adults. Data from an online survey of 419 smokers and non-smokers aged 18 to 25 were used to estimate respondents’ exposure to smoking occurrences in 50 randomly-selected movies from the 423 US top box office movies released between 2008 and 2012. Analyses involved calculating movie smoking exposure (MSE) for each respondent, using logistic regression to analyse the relationship between MSE and current smoking behaviour, and estimating the attributable fraction due to smoking in movies.
Effect of Smoking in Movies on New Zealand Youth
Exposure to smoking occurrences in movies was associated with current smoking status. After allowing for the influence of family, friends and co-workers, age and rebelliousness, respondents’ likelihood of smoking increased by 11% for every 100-incident increase in exposure to smoking incidents, (aOR1.11; p< .05). The estimated attributable fraction due to smoking in movies was 54%; this risk could be substantially reduced by eliminating smoking from movies currently rated as appropriate for youth. We conclude that exposure to smoking in movies remains a potent risk factor associated with smoking among young adults, even in a progressive tobacco control setting such as New Zealand. Harmonising the age of legal tobacco purchase (18) with the age at which it is legal to view smoking in movies would support New Zealand’s smokefree 2025 goal.
doi:10.1371/journal.pone.0148692
PMCID: PMC4784919  PMID: 26960189
12.  The effects of educational curricula and training on LGBT-specific health issues for healthcare students and professionals: a mixed-method systematic review 
Abstract
Introduction: Poor access of lesbian, gay, bisexual and transgender (LGBT) people to healthcare providers with clinical and cultural competency contributes to health inequalities between heterosexual/cisgender and LGBT people. This systematic review assesses the effect of educational curricula and training for healthcare students and professionals on LGBT healthcare issues.
Methods: Systematic review; the search terms, strategy and process as well as eligibility criteria were predefined and registered prospectively on PROSPERO. A systematic search of electronic databases was undertaken. Screening for eligible studies and data extraction were done in duplicate. All the eligible studies were assessed for risk of bias. The outcome of interest was a change in participants’ knowledge, attitude and or practice.
Results: Out of 1171 papers identified, 16 publications reporting 15 studies were included in the review. Three were non-randomized controlled studies and 12 had a pre/post-design; two had qualitative components. Bias was reported in the selection of participants and confounding. Risk reported was moderate/mild. Most studies were from the USA, the topics revolved around key terms and terminology, stigma and discrimination, sexuality and sexual dysfunction, sexual history taking, LGBT-specific health and health disparities. Time allotted for training ranged from 1 to 42 hours, the involvement of LGBT people was minimal. The only intervention in sub-Saharan Africa focused exclusively on men who have sex with men. All the studies reported statistically significant improvement in knowledge, attitude and/or practice post-training. Two main themes were identified from the qualitative studies: the process of changing values and attitudes to be more LGBT inclusive, and the constraints to the application of new values in practice.
Conclusions: Training of healthcare providers will provide information and improve skills of healthcare providers which may lead to improved quality of healthcare for LGBT people. This review reports short-term improvement in knowledge, attitudes and practice of healthcare students and professionals with regards to sexual and LGBT-specific healthcare. However, a unified conceptual model for training in-terms of duration, content and training methodology was lacking.
doi:10.7448/IAS.20.1.21624
PMCID: PMC5577719  PMID: 28782330
systematic review; LGBT health; education; healthcare students; healthcare professionals
13.  Teaching lesbian, gay, bisexual and transgender health in a South African health sciences faculty: addressing the gap 
BMC Medical Education  2013;13:174.
Background
People who identity as lesbian, gay, bisexual and transgender (LGBT) have specific health needs. Sexual orientation and gender identity are social determinants of health, as homophobia and heteronormativity persist as prejudices in society. LGBT patients often experience discrimination and prejudice in health care settings. While recent South African policies recognise the need for providing LGBT specific health care, no curricula for teaching about LGBT health related issues exist in South African health sciences faculties. This study aimed to determine the extent to which LGBT health related content is taught in the University of Cape Town’s medical curriculum.
Methods
A curriculum mapping exercise was conducted through an online survey of all academic staff at the UCT health sciences faculty, determining LGBT health related content, pedagogical methodology and assessment.
Results
127 academics, across 31 divisions and research units in the Faculty of Health Sciences, responded to the survey, of which 93 completed the questionnaire. Ten taught some content related to LGBT health in the MBChB curriculum. No LGBT health related content was taught in the allied health sciences curricula. The MBChB curriculum provided no opportunity for students to challenge their own attitudes towards LGBT patients, and key LGBT health topics such as safer sex, mental health, substance abuse and adolescent health were not addressed.
Conclusion
At present, UCTs health sciences curricula do not adequately address LGBT specific health issues. Where LGBT health related content is taught in the MBChB curriculum, it is largely discretionary, unsystematic and not incorporated into the overarching structure. Coordinated initiatives to integrate LGBT health related content into all health sciences curricula should be supported, and follow an approach that challenges students to develop professional attitudes and behaviour concerning care for patients from LGBT backgrounds, as well as providing them with specific LGBT health knowledge. Educating health professions students on the health needs of LGBT people is essential to improving this population’s health by providing competent and non-judgmental care.
doi:10.1186/1472-6920-13-174
PMCID: PMC3877956  PMID: 24373219
LGBT health; Health professions education; Heteronormativity; Homophobia; South Africa
14.  Social Support, Self-Rated Health, and Lesbian, Gay, Bisexual, and Transgender Identity Disclosure to Cancer Care Providers 
Oncology nursing forum  2015;42(1):44-51.
Purpose/Objectives
To describe factors related to diagnosis, identity disclosure, and social support among lesbian, gay, bisexual, and transgender (LGBT) patients with cancer, and to explore associations between these factors and self-rated health.
Design
Cross-sectional self-report survey design using descriptive and exploratory multivariate statistical approaches.
Setting
Online, Internet-based.
Sample
291 LGBT patients (89% Caucasian; 50% gay, 36% lesbian, 7% bisexual, 3% transgender) with mixed cancers.
Methods
Participants completed a researcher-designed online survey assessing experiences of cancer diagnosis among LGBT patients at a single time point.
Main Research Variables
Demographics, which provider(s) delivered the patients’ cancer diagnoses, to whom patients had disclosed their LGBT identity, how they disclosed, who was on their social support team at the time of diagnosis, and current self-rated health.
Findings
79% of participants reported disclosing their identities to more than one cancer care provider. Participants most commonly introduced the topic of LGBT identity themselves, sometimes as a way to correct heterosexual assumptions (34%). Friends were the most common members of LGBT patients’ support teams (79%). Four disclosure and support factors were consistently associated with better self-rated health.
Conclusions
Disclosure of LGBT identity is a common experience in the context of cancer care, and disclosure and support factors are associated with better self-reported health among LGBT patients.
Implications for Nursing
Creating safe environments for LGBT patients to disclose could improve cancer care delivery to this underserved population. Nurses and other providers should acknowledge and include diverse support team members in LGBT patients’ care.
doi:10.1188/15.ONF.44-51
PMCID: PMC4360905  PMID: 25542320
cancer; sexual orientation; health disparities; social support
15.  Medical students’ perception of lesbian, gay, bisexual, and transgender (LGBT) discrimination in their learning environment and their self-reported comfort level for caring for LGBT patients: a survey study 
Medical Education Online  2017;22(1):1368850.
ABSTRACT
Background: Historically, medical students who are lesbian, gay, bisexual or transgendered (LGBT) report higher rates of social stress, depression, and anxiety, while LGBT patients have reported discrimination and poorer access to healthcare.
Objective: The objectives of this study were: (1) to assess if medical students have perceived discrimination in their learning environment and; (2) to determine self-reported comfort level for caring for LGBT patients.
Design: Medical students at the University of Ottawa (N = 671) were contacted via email and invited to complete a confidential web-based survey.
Results: Response rate was 15.4% (103/671). This included 66 cis-gender heterosexuals (64.1%) and 37 LGBT students (35.9%). Anti-LGBT discrimination had been witnessed by 14.6% and heterosexism by 31.1% of respondents. Anti-LGBT discrimination most often originated from fellow medical students. Respondents who self-identified as LGBT were more likely to have perceived heterosexism (favoring opposite-sex relationships) (OR = 8.2, p < 0.001) or anti-LGBT discrimination (OR = 6.6, p = 0.002). While half of LGBT students shared their status with all classmates (51.4%), they were more likely to conceal this from staff physicians (OR = 27.2, p = 0.002). Almost half of medical students (41.7%) reported anti-LGBT jokes, rumors, and/or bullying by fellow medical students and/or other members of the healthcare team. Still, most respondents indicated that they felt comfortable with and capable of providing medical care to LGBT patients (≥83.5%), and were interested in further education around LGBT health issues (84.5%).
Conclusion: Anti-LGBT discrimination and heterosexism are noted by medical students, indicating a suboptimal learning environment for LGBT students. Nonetheless, students report a high level of comfort and confidence providing health care to LGBT patients.
doi:10.1080/10872981.2017.1368850
PMCID: PMC5653936  PMID: 28853327
Undergraduate medical education; LGBT (lesbian; gay; bisexual; or transgender) persons; social discrimination; cultural competence; healthcare disparities
16.  From adversary to target market: the ACT-UP boycott of Philip Morris 
Tobacco Control  2003;12(2):203-207.
Background: In 1990, the AIDS Coalition to Unleash Power (ACT-UP) sparked a year long boycott of Philip Morris's Marlboro cigarettes and Miller beer. The boycott protested the company's support of Senator Jesse Helms (R-North Carolina), a leading opponent of AIDS funding and civil rights for lesbian, gay, bisexual and transgender (LGBT) people. ACT-UP demanded that Philip Morris sever its ties with Helms and acknowledge its responsibility to the LGBT community and to people with AIDS.
Objective: To assess the impact of the boycott on the LGBT community, the tobacco industry, and the tobacco control movement; and to determine what lessons tobacco control advocates can extract from this case.
Data sources: Internal tobacco industry documents and newspaper archives.
Methods: Search of tobacco industry documents websites using "boycott", "ACT-UP", "gay", and other terms.
Results: Philip Morris used the boycott to its own advantage. It exploited differences within the community and settled the boycott by pledging large donations to combat AIDS. Through corporate philanthropy, Philip Morris gained entrée to the LGBT market without appearing gay friendly. Many LGBT organisations, thirsty for recognition and funding from mainstream corporations, welcomed Philip Morris's overtures without considering the health hazards of tobacco.
Conclusions: Unless the goal of a boycott is to convince the tobacco industry to abandon tobacco altogether, such actions invite the industry to expand its marketing under the guise of philanthropy. Tobacco control advocates should be clear about goals and acceptable settlement terms before participating in a boycott of a tobacco company.
doi:10.1136/tc.12.2.203
PMCID: PMC1747705  PMID: 12773732
17.  Acceptability and Preliminary Efficacy of a Lesbian, Gay, Bisexual, and Transgender-Affirmative Mental Health Practice Training in a Highly Stigmatizing National Context 
LGBT Health  2017;4(5):360-370.
Abstract
Purpose: Lesbian, gay, bisexual, and transgender (LGBT) individuals in Romania encounter pervasive stigma and discrimination and there is a high need for LGBT-competent mental health professionals (MHPs). We tested the impact of a pilot LGBT-affirmative training for MHPs in Romania on these professionals' LGBT-relevant attitudes, knowledge, and perception of clinical skills.
Methods: We conducted a 2-day training for MHPs in Bucharest. Fifty-four attended and 33 provided training evaluation data at baseline and follow-up.
Results: The majority of trainees were female (90%) and heterosexual (73%) with a mean age of 36.4 (SD = 7.7). From baseline to follow-up, trainees demonstrated a significant increase in perceived LGBT-relevant clinical skills (P < 0.001) and perceived knowledge (P < 0.05). LGBT-affirmative practice attitudes (P < 0.05) and comfort in addressing the mental health of LGBT individuals (P < 0.01) increased significantly, and homonegative and transnegative attitudes decreased significantly (P < 0.01). Negative attitudes toward LGBT individuals were low at both baseline and follow-up. The majority of trainees reported being highly interested in the training (84%), which they reported had prepared them to interact with and care for LGBT individuals (74%).
Conclusion: This pilot training appeared to be effective in increasing perceived LGBT competence among participating MHPs. This type of training model needs to be tested further in a randomized controlled trial with longer follow-up periods to assess intervention durability and implementation of clinical skills. Future trainings can be incorporated into existing curricula. National accreditation bodies might consider encouraging such training as part of standard educational requirements.
doi:10.1089/lgbt.2016.0194
PMCID: PMC5661855  PMID: 28891750
homophobia; intervention; LGBT; mental health; training
18.  Is tobacco a gay issue? Interviews with leaders of the lesbian, gay, bisexual and transgender community 
Culture, health & sexuality  2008;10(2):143-157.
This study examined the extent of tobacco industry funding of lesbian, gay, bisexual and transgender (LGBT) organisations and whether leaders of these organisations thought tobacco was a priority health issue for their community. We interviewed leaders of 74 LGBT organisations and publications in the USA, reflecting a wide variety of groups. Twenty-two percent said they had accepted tobacco industry funding and few (24%) identified tobacco as a priority issue. Most leaders did not perceive tobacco as an issue relevant to LGBT identity. They saw smoking as a personal choice and individual right rather than as a health crisis fuelled by industry activities. As such, they were reluctant to judge a legal industry, fearing it might lead to having to evaluate other potential funders. They saw tobacco control as divisive, potentially alienating their peers who smoke. The minority who embraced tobacco control saw the industry as culpable and viewed their own roles as protecting the community from all harms, not just those specific to the gay community. Lesbian, gay, bisexual and transgender tobacco-control advocates should reframe smoking as an unhealthy response to the stresses of homophobia to persuade leaders that tobacco control is central to LGBT health.
doi:10.1080/13691050701656284
PMCID: PMC2789682  PMID: 18247208
LGBT; community health; tobacco control; tobacco industry; licit and illicit substances
19.  Scrambling for access: availability, accessibility, acceptability and quality of healthcare for lesbian, gay, bisexual and transgender people in South Africa 
Background
Sexual orientation and gender identity are social determinants of health for people identifying as lesbian, gay, bisexual and transgender (LGBT), and health disparities among sexual and gender minority populations are increasingly well understood. Although the South African constitution guarantees sexual and gender minority people the right to non-discrimination and the right to access to healthcare, homo- and transphobia in society abound. Little is known about LGBT people’s healthcare experiences in South Africa, but anecdotal evidence suggests significant barriers to accessing care. Using the framework of the UN International Covenant on Economic, Social and Cultural Rights General Comment 14, this study analyses the experiences of LGBT health service users using South African public sector healthcare, including access to HIV counselling, testing and treatment.
Methods
A qualitative study comprised of 16 semi-structured interviews and two focus group discussions with LGBT health service users, and 14 individual interviews with representatives of LGBT organisations. Data were thematically analysed within the framework of the UN International Covenant on Economic, Social and Cultural Rights General Comment 14, focusing on availability, accessibility, acceptability and quality of care.
Results
All interviewees reported experiences of discrimination by healthcare providers based on their sexual orientation and/or gender identity. Participants recounted violations of all four elements of the UN General Comment 14: 1) Availability: Lack of public health facilities and services, both for general and LGBT-specific concerns; 2) Accessibility: Healthcare providers' refusal to provide care to LGBT patients; 3) Acceptability: Articulation of moral judgment and disapproval of LGBT patients’ identity, and forced subjection of patients to religious practices; 4) Quality: Lack of knowledge about LGBT identities and health needs, leading to poor-quality care. Participants had delayed or avoided seeking healthcare in the past, and none had sought out accountability or complaint mechanisms within the health system.
Conclusion
Sexual orientation and gender identity are important categories of analysis for health equity, and lead to disparities in all four dimensions of healthcare access as defined by General Comment 14. Discriminatory and prejudicial attitudes by healthcare providers, combined with a lack of competency and knowledge are key reasons for these disparities in South Africa.
doi:10.1186/s12914-017-0124-4
PMCID: PMC5450393
Lesbian, gay, bisexual and transgender; Sexual orientation; Gender identity; Right to health; Access to healthcare; Discrimination; General Comment 14; South Africa
20.  “It’s for us –newcomers, LGBTQ persons, and HIV-positive persons. You feel free to be”: a qualitative study exploring social support group participation among African and Caribbean lesbian, gay, bisexual and transgender newcomers and refugees in Toronto, Canada 
Background
Stigma and discrimination harm the wellbeing of lesbian, gay, bisexual and transgender (LGBT) people and contribute to migration from contexts of sexual persecution and criminalization. Yet LGBT newcomers and refugees often face marginalization and struggles meeting the social determinants of health (SDOH) following immigration to countries such as Canada. Social isolation is a key social determinant of health that may play a significant role in shaping health disparities among LGBT newcomers and refugees. Social support may moderate the effect of stressors on mental health, reduce social isolation, and build social networks. Scant research, however, has examined social support groups targeting LGBT newcomers and refugees. The purpose of this qualitative study was to explore experiences of social support group participation among LGBT African and Caribbean newcomers and refugees in an urban Canadian city.
Methods
We conducted 3 focus groups with a venue-based sample of LGBT African and Caribbean newcomers and refugees (n = 29) who attended social support groups at an ethno-specific AIDS Service Organization. Focus groups followed a semi-structured interview guide and were analyzed using narrative thematic techniques.
Results
Participant narratives highlighted immigration stressors, social isolation, mental health issues, and challenges meeting the SDOH. Findings reveal multi-level benefits of social support group participation at intrapersonal (self-acceptance, improved mental health), interpersonal (reduced isolation, friendships), community (reciprocity, reduced stigma and discrimination), and structural (housing, employment, immigration, health care) levels.
Conclusions
Findings suggest that social support groups tailored for LGBT African and Caribbean newcomers and refugees can address social isolation, community resilience, and enhance resource access. Health care providers can provide support groups, culturally and LGBT competent health services, and resource access to promote LGBT newcomers and refugees’ health and wellbeing.
doi:10.1186/s12914-016-0092-0
PMCID: PMC4930565  PMID: 27369374
Social support; LGBT; Refugee; Newcomer; Social determinants of health; SDOH; Mental health; Sexual and gender minorities
21.  A Qualitative Study of the Barriers to and Facilitators of Smoking Cessation Among Lesbian, Gay, Bisexual, and Transgender Smokers Who Are Interested in Quitting 
LGBT Health  2017;4(1):24-33.
Abstract
Purpose: Lesbian, gay, bisexual, and transgender (LGBT) individuals are significantly more likely to smoke compared with their heterosexual and cisgender counterparts. The purpose of this study was to explore barriers to and facilitators of smoking cessation readiness among LGBT smokers.
Methods: This descriptive study used a qualitative approach. Four 90-minute focus groups (eligibility criteria: age ≥21, self-identify as LGBT, current smoker, interest in quitting smoking) were conducted. Participants also completed a brief survey that measured additional demographic characteristics and smoking behaviors. Topics explored included quit experiences, attitudes and beliefs, barriers to and facilitators of cessation, and cultural factors related to smoking behaviors. Established qualitative methods were used to conduct the focus groups and data analysis.
Results: The mean age of participants (N = 31) was 37.1 years with the majority identifying as male (58.1%). The sample group was racially diverse: 32% were African American, 39% were White, and 29% were more than one race. Interest in quitting was high (M = 9.0, range 0–10). Barriers to smoking cessation fell under the broad themes of individual-level factors, cultural factors, psychosocial factors, and access to treatment. Facilitators of smoking cessation included stage of readiness, health concerns, social stigma, a shift in social norms, financial costs, and improving dating prospects.
Conclusions: Interest in smoking cessation was high in this sample of LGBT smokers and influenced by a range of facilitators. Nevertheless, several general and culturally specific barriers to smoking cessation readiness were identified. The study results have implications for future research and the development of outreach, prevention, and treatment programs.
doi:10.1089/lgbt.2016.0059
PMCID: PMC5395032  PMID: 28068208
barriers and facilitators to smoking cessation; cultural factors; lesbian; gay; bisexual; and transgender (LGBT); smoking
22.  Intention to quit smoking among lesbian, gay, bisexual, and transgender smokers 
Nicotine & Tobacco Research  2009;11(11):1312-1320.
Introduction:
Smoking is highly prevalent among lesbian, gay men, bisexual, and transgender (LGBT) persons and contributes to health disparities. Guided by the theory of planned behavior (TPB), we identified beliefs related to attitudes, perceived behavioral control, and subjective norms, as well as LGBT-specific variables, to explain variance in intention to quit smoking in the next 6 months in LGBT smokers.
Methods:
Individual interviews (n = 19) identified beliefs about quitting smoking and LGBT-salient variables and aided in survey development. Surveys were sent to a random sample from an LGBT community center's mailing list and center attendees, with a 25.4% response rate. Bivariate and multivariate analyses were conducted with the final sample of 101 smokers.
Results:
No sociodemographic or LGBT-specific variables beyond the TPB constructs were related to intention to quit smoking. A multivariate TPB model explained 33.9% of the variance in quitting intention. More positive attitudes and specific beliefs that cessation would make smokers feel more like their ideal selves and improve health and longevity were related to greater intention to quit (p values < .05). Subjective norm and perceived behavioral control were marginally significant, with perceived approval of partners and others and beliefs that life goal achievement would make it easier to quit positively related to intention. Depression and stress levels were high.
Discussion:
This is among the first studies to examine theoretically grounded variables related to intention to quit smoking in LGBT smokers. We identified specific behavioral, normative, and control beliefs that can serve as intervention targets to reduce smoking in the LGBT community.
doi:10.1093/ntr/ntp140
PMCID: PMC2762930  PMID: 19778994
23.  Outness, Stigma, and Primary Health Care Utilization among Rural LGBT Populations 
PLoS ONE  2016;11(1):e0146139.
Background
Prior studies have noted significant health disadvantages experienced by LGBT (lesbian, gay, bisexual, and transgender) populations in the US. While several studies have identified that fears or experiences of stigma and disclosure of sexual orientation and/or gender identity to health care providers are significant barriers to health care utilization for LGBT people, these studies have concentrated almost exclusively on urban samples. Little is known about the impact of stigma specifically for rural LGBT populations, who may have less access to quality, LGBT-sensitive care than LGBT people in urban centers.
Methodology
LBGT individuals residing in rural areas of the United States were recruited online to participate in a survey examining the relationship between stigma, disclosure and “outness,” and utilization of primary care services. Data were collected and analyzed regarding LGBT individuals’ demographics, health care access, health risk factors, health status, outness to social contacts and primary care provider, and anticipated, internalized, and enacted stigmas.
Results
Higher scores on stigma scales were associated with lower utilization of health services for the transgender & non-binary group, while higher levels of disclosure of sexual orientation were associated with greater utilization of health services for cisgender men.
Conclusions
The results demonstrate the role of stigma in shaping access to primary health care among rural LGBT people and point to the need for interventions focused towards decreasing stigma in health care settings or increasing patients’ disclosure of orientation or gender identity to providers. Such interventions have the potential to increase utilization of primary and preventive health care services by LGBT people in rural areas.
doi:10.1371/journal.pone.0146139
PMCID: PMC4701471  PMID: 26731405
24.  Trends in Tobacco and Alcohol Brand Placements in Popular US Movies, 1996 Through 2009 
JAMA pediatrics  2013;167(7):634-639.
Importance
Tobacco and alcohol use in movies could be influenced by product placement agreements. Tobacco brand placement was limited by the Master Settlement Agreement (MSA) after 1998, while alcohol is subject to self-regulation only.
Objective
To examine recent trends for tobacco and alcohol use in movies. We expected that the MSA would be associated with declines in tobacco but not alcohol brand placement (hypothesis formulated after data collection).
Design
Content analysis.
Setting
Top 100 box-office hits released in the United States from 1996 through 2009 (N = 1400).
Intervention
The MSA, an agreement signed in 1998 between the state attorneys general and tobacco companies, ended payments for tobacco brand placements in movies.
Main Outcomes and Measures
Trend for tobacco and alcohol brand counts and seconds of screen time for the pre-MSA period from 1996 through 1999 compared with the post-MSA period from 2000 through 2009.
Results
Altogether, the 1400 movies contained 500 tobacco and 2433 alcohol brand appearances. After implementation of the MSA, tobacco brand appearances dropped exponentially by 7.0% (95% CI, 5.4%–8.7%) each year, then held at a level of 22 per year after 2006. The MSA also heralded a drop in tobacco screen time for youth- and adult-rated movies (42.3% [95% CI, 24.1%–60.2%] and 85.4% [56.1%–100.0%], respectively). In contrast, there was little change in alcohol brand appearances or alcohol screen time overall. In addition, alcohol brand appearances in youth-rated movies trended upward during the period from 80 to 145 per year, an increase of 5.2 (95% CI, 2.4–7.9) appearances per year.
Conclusions and Relevance
Tobacco brands in movies declined after implementation of externally enforced constraints on the practice, coinciding also with a decline in tobacco screen time and suggesting that enforced limits on tobacco brand placement also limited onscreen depictions of smoking. Alcohol brand placement, subject only to industry self-regulation, was found increasingly in movies rated for youth as young as 13 years, despite the industry’s intent to avoid marketing to underage persons.
doi:10.1001/jamapediatrics.2013.393
PMCID: PMC3779902  PMID: 23712747
25.  A Longitudinal Examination of Risk and Protective Factors for Cigarette Smoking among Lesbian, Gay, Bisexual and Transgender Youth 
Purpose
Investigate change across development in two smoking outcomes (smoking status and rate), describe demographic differences in smoking, and longitudinally examine the effects of psychosocial variables on smoking (psychological distress, victimization, and social support) in lesbian, gay, bisexual and transgender (LGBT) youth.
Methods
Participants were 248 ethnically-diverse LGBT youth (ages 16–20 at baseline) from a longitudinal cohort study with six waves over 3.5 years. Baseline questionnaires included demographic variables and a measure of impulsivity, and longitudinal questionnaires included measures of cigarette smoking (status and average number of cigarettes smoked daily), LGBT-based victimization, psychological distress, and perceived social support. Analyses were conducted with Hierarchical Linear Modeling.
Results
Males had higher odds of smoking and smoking rate than females, but females’ smoking rate increased more rapidly over time. Psychological distress was associated with higher odds of smoking and smoking rate at the same wave, and it predicted smoking rate at the subsequent wave. LGBT victimization was associated with higher odds of smoking at the same wave and predicted smoking rate at the subsequent wave. Finally, significant other support predicted higher odds of smoking and smoking rate at the subsequent wave, but family support was negatively correlated with smoking rate at the same wave.
Conclusions
There are several viable avenues for development of smoking prevention interventions for LGBT youth. In order to optimize efficacy of prevention strategies, we must consider experiences with victimization, the impact of psychological distress, and optimizing support from families and romantic partners.
doi:10.1016/j.jadohealth.2013.10.208
PMCID: PMC3999176  PMID: 24388111
LGBT youth; smoking; psychological distress; victimization; family support; romantic support

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