Smoking protective and risk factors among transgender and gender-expansive individuals (project spring): Qualitative study using digital photovoice

Background: Transgender and gender-expansive (TGE) adults are twice as likely to smoke cigarettes than cisgender individuals. There is a critical gap in research on effective and culturally sensitive approaches to reduce smoking prevalence among TGE adults. Objective: This study aims to qualitatively examine the risk and protective factors of cigarette smoking among TGE adults through real-world exemplars. Methods: We conducted a digital photovoice study among a purposeful sample of 47 TGE adults aged ≥18 years and currently smoking in the United States (March 2019-April 2020). Participants uploaded photos daily that depicted smoking risk and protective factors they experienced over 21 days on either private Facebook or Instagram groups. Next, we conducted separate focus group discussions to explore the experiences of these factors among a subset of participants from each group. We analyzed participants' photos, captions, and focus group transcripts and generated themes associated with smoking risk and protective factors. Results: We identified 6 major themes of risk and protective factors of smoking among TGE individuals: Experience of stress, gender affirmation, health consciousness, social influences, routine behaviors, and environmental cues. We describe and illustrate each theme using exemplar photos and quotes. Conclusions: The findings of this study will inform future community-engaged research to develop culturally tailored interventions to reduce smoking prevalence among TGE individuals.