Written evidence submitted by Action on Smoking and Health (ASH) (HSC0058)

1. Introduction

ASH is a public health charity established by the Royal College of Physicians in 1971 to advocate for policy measures to reduce the harm caused by tobacco.

ASH receives funding for its full programme of work from the British Heart Foundation and Cancer Research UK. ASH also receives project funding from the Department of Health and Social Care to support tobacco control.

We are submitting evidence to this Inquiry because the UK’s LGBT population has a disproportionately high smoking prevalence, putting the community at greater risk of smoking-related diseases and death.

Supporting LGBT smokers to quit and preventing young LGBT people from taking up smoking in the first place is key to reducing health inequities and is in line with the Tobacco Control Plan for England’s vision of a smokefree generation in which no one is left behind.

2. Smoking prevalence and characteristics

The smoking prevalence in the LGBT community is higher than in the general population. In 2014, 25.3% of people who describe themselves as gay or lesbian smoked, compared to 18.4% of people who describe themselves as heterosexual.[1] Existing data suggests that bisexual and transgender people also have a high smoking prevalence.[2] For example, a survey of the LGBT community in Northern Ireland found that trans respondents were the most likely to smoke cigarettes.[3]

The reasons why people take up smoking are multiple and complex. Some research suggests that mild poor mental health (which might include minority stress, mild anxiety and low self-esteem) could contribute to high smoking rates in LGBT communities. For example, a qualitative analysis by The Lesbian and Gay Foundation in 2014 revealed that smoking may be seen as a coping mechanism.[4] Survey respondents suggested that since growing up and coming out can be a very challenging and stressful time, smoking can be difficult to resist, and long-term harmful consequences don’t enter into decision making.[5] This is supported by 2018 insight data from a survey of 427 LGBT smokers in Greater Manchester which found that 46% of respondents smoke because it helps with stress relief, and 41% smoke because it calms them down.[6]

Further research is needed into LGBT smokers’ perceptions and experiences of smoking. In particular, the sexualization of smoking among parts of the gay and bisexual community. In a survey of nearly 1,800 gay or bisexual men, 23% identified smoking as a fetish that they are in to,[7] while 24% of the 287 women surveyed also identified smoking as a fetish.[8] This relationship to smoking is important to consider as a potential barrier to positive health messages about smoking cessation and further as a factor for stop smoking services to consider when trying to reach a broader client base and design accessible services.

Overall, this evidence suggests that LGBT people may face an increased risk of tobacco-related ill health.

3. Smoking and health

Smoking tobacco is extremely damaging to health. Tobacco kills half of people who use it and is the biggest preventable cause of death, disease and health inequalities in the UK.

The 2014 US Surgeon General report on smoking concluded that tobacco smoking causes cancer in 12 body sites and a range of non-malignant disease and disorders. Passive exposure to smoke also causes coronary heart disease and lung cancer.[9]

As well as causing disease, smoking exacerbates ill health, including respiratory diseases, diabetes, mental health conditions, HIV-AIDs, and 16 types of cancer. Some of these conditions are disproportionately experienced by some LGBT people, and quitting smoking can therefore improve patient outcomes in these circumstances. For example: 

     LGBT people are more likely to suffer from mental ill health - 49% of LGBT people worry about their mental health, compared to 37% of heterosexual people.[10] Smoking cessation is association with reduced depression, anxiety and increased positive mood, and improved quality of life.[11]

     Men who have sex with men are disproportionately affected by HIV. Of the 4363 people diagnosed with HIV in the UK in 2017 2330, 46.6%, were gay or bisexual men.[12] HIV positive smokers are more likely to develop some types of cancer[13] and are more likely to suffer from respiratory disease.[14]

It is therefore essential that LGBT people are encouraged not to take up smoking in the first place, and that those who do smoke are supported to quit. This will require professionals to improve their service accessibility, inclusivity, monitoring and collaboration.

4. Embedding tobacco dependency treatment in the NHS

The majority of smokers want to quit but require readily available support to help them do so. Embedding smoking cessation interventions in the NHS would increase LGBT access to the quit support they need, improving patient health outcomes.

For example, any smoker undergoing gender identity related surgery must be supported to address their tobacco addiction, because smoking is a significant risk factor during and after any surgical procedure. Indeed, smokers are 38% more likely to die after surgery[15] and are more likely to experience wound infection.[16]

However, it is crucial that stop smoking interventions are not only being delivered in surgical cases, but that all smokers are being routinely advised and supported to quit at every NHS contact. LGBT people access healthcare services for a variety of reasons, meaning there are multiple opportunities for clinicians to deliver Very Brief Advice and refer patients to their local stop smoking service.

Though NHS policy, NICE guidance PH48 and financial commissioning tools encourage the identification of smokers and referral for tobacco dependence treatment, this is not practically embedded in patient pathways. Typically, where treatment is available, opt-in referral to offsite local authority services is the model used, which is less effective than immediate treatment on site, or opt-out models, which when used with pregnant smokers have been shown to double quit rates.

We therefore need to ensure that all healthcare professionals are equipped to deliver Very Brief Advice around smoking cessation.

5. Improving monitoring

Unlike other protected characteristics such as physical disability, there is a lack of sexual orientation, gender identity and trans status monitoring. As a result, health systems lack accurate knowledge on the rates of LGBT people using smoking cessation services. This presents difficulties in the identification, dissection and addressing of intersectional issues, and means health practitioners are unable to target effective smoking cessation interventions. Better monitoring will provide the knowledge necessary for designing more inclusive and therefore effective services.

6. Improving service inclusivity

A 2013 study found that 20% of respondents had experienced discrimination, transphobia or homophobia, or some kind of unfair treatment based on their sexual orientation or gender identity from their GP or another member of staff at the GP practice they had accessed.[17] Indeed, a recent Stonewall survey of health and social care staff found that 24% reported hearing colleagues making negative remarks or using discriminating language about LGBT patients in the last 5 years.[18]

All health services, including stop smoking services, need to offer a more inclusive environment, empowering LGBT people to be involved in their own healthcare.

Stop smoking services offer a package of support, of which face-to-face group support with pharmacotherapy has the strongest evidence base for effectiveness.[19] Work needs to be done to ensure LGBT people do not face barriers in accessing these services, which have supported an estimated 1 million smokers to quit for good since their introduction in 2000.[20] This could be achieved through the deployment of link workers with experience of working with the LGBT community, and the further role out of schemes like ‘Pride in Practice’ to support primary care.

Quit smoking mass media campaigns could also disseminate more inclusive public health messages. For example, the Californian Department of Public Health’s Tobacco Control Program recently launched a tobacco control campaign with a special focus on reaching LGBT people.[21]

Mass advertising campaigns are known to be effective in discouraging people from starting to smoke and encouraging existing smokers to quit. The 2012 Report of the Surgeon General found that mass media campaigns “prevent the initiation of tobacco use and reduce its prevalence among youth and young adults.”[22]

7. Targeted support for LGBT smokers with multiple complex needs

A quarter of respondents to the Women and Equality select committee LGBT survey reported accessing mental health services in the last 12 months.[23] However, this is likely an underrepresentation, since we know that across the UK, a substantial proportion of people don’t access any mental health support.[24] Lesbian, gay and bisexual people are more likely to have a history of mental ill health and have more concerns about their mental health in the future.[25] People with long standing mental health problems are more than twice as likely to smoke, [26] with the average smoking rate among people with a serious mental illness (SMI) at over 40%.[27] Indeed, a third of all tobacco smoked in England is smoked by people with a mental health disorder.[28]

Moreover, evidence suggests that people in the LGBT community are significantly more likely to use illegal drugs,[29] and we know that high rates of smoking are often found among those using other substances.[30]

If some LGBT people are more likely to experience these multiple needs, they are also more likely to experience smoking, since all mental health conditions and substance misuse both increase the likelihood of smoking (see Diagram 1).

LGBT people also comprise up to 24% of the youth homelessness population,[32] and research carried out by Homeless Link suggests that as many as 77% of homeless people smoke.[33]

It is therefore important that health practitioners are aware of the ways in which these different factors interact to enforce tobacco dependency, so that they are able to make effective stop smoking interventions.

Endorsing organisations:

Submitted October 2018