Abstract
Objective
Transgender and gender diverse (TGD; e.g., non-binary) adults report higher cigarette smoking rates than cisgender adults. However, little is known about the prevalence and associations of current cigarette smoking among Latinx Transgender and Gender Diverse (LTGD) adults. This study examines the associations between current cigarette smoking and self-reported demographic and health characteristics (e.g., mental health diagnoses) among LTGD adults living in Puerto Rico (PR) and Florida (FL).
Methods
Using secondary data from a cross-sectional exploratory study (n = 133), binary logistic regression was conducted to evaluate associations with current cigarette smoking status (smoking vs non-smoking). The Benjamini–Hochberg procedure was applied to control the false discovery rate (FDR) using R.
Results
The mean age was 34.4 years (SD = 10.28). Almost half of participants self-identified as trans-women (45.8%), 33.6% as trans-men, and 21.1% as non-binary. More than half were born in Puerto Rico (53.5%), resided in Florida (53.5%), had an associate degree or higher (64.8%), and reported a monthly income of $0–$1000 (47.7%). Thirty-eight participants (28.6%) reported current smoking, with a median of 6 cigarettes daily (IQR: 2-10). Significant associations were observed between current smoking, country of birth, and lifetime diagnosis of depression (P < 0.05).
Conclusion
Findings highlight a high prevalence of cigarette smoking among LTGD adults and confirm associations with demographic factors and mental health. These results underscore the need to prioritize culturally adapted smoking cessation interventions for LTGD adults.
Introduction
Cigarette smoking remains a significant public health concern, with profound implications for morbidity and mortality worldwide. 1 While different efforts to address cigarette smoking (e.g., tobacco treatment programs, public health campaigns) have made notable strides in recent years, certain groups continue to face elevated cigarette smoking rates, warranting targeted interventions and research attention. Among these groups, particular attention is drawn to those with marginalized identities, such as transgender and gender diverse, and racial and ethnic groups (e.g., Latinx).2,3 In the United States (U.S.), transgender adults have significantly higher prevalence of cigarette smoking compared to cisgender adults (35.5% among transgender adults compared to 14.9% among cisgender adults). 4 A study including 770 transgender adults revealed that a high percentage incorrectly believe nicotine causes cancer (93.25%) and that lower nicotine cigarettes are less harmful (69.87%). 5 The research indicates that inaccurate harm perceptions are associated with elevated depression symptoms and lower income, suggesting a need for targeted interventions. Analysis of national data from the PATH Study revealed significant disparities between transgender and cisgender individuals who smoke menthol cigarettes, with transgender adults being less likely to perceive smoking as harmful and more likely to report depression. 6 In Latinx communities, variability in cigarette smoking prevalence has been identified based on country of birth. For instance, Puerto Rican individuals residing in the US exhibit higher rates of cigarette smoking compared to their Mexican and Dominican counterparts. 7 Furthermore, within Latinx demographics, cigarette smoking continues to be an important modifiable health risk factor contributing to illness and death. 8 These intersecting disparities underscore the importance of culturally responsive, identity-informed strategies to reduce tobacco-related harm among populations at the crossroads of gender and ethnic marginalization.
When considering the intersection of gender diverse and Latinx groups, the data becomes more limited, yet studies suggest that individuals with multiple minoritized identities (e.g., gender diverse, racial or ethnic minoritized) may encounter heightened challenges in terms of tobacco use rates. 8 Tobacco literature has documented a tendency among gender diverse groups in Latinx communities to underutilize medical care, including preventive screenings. Studies indicate that individuals with intersecting minoritized identities, such as being both Latinx and gender diverse, may face even greater challenges regarding tobacco use and accessing healthcare services. 8 The disparities in tobacco use among gender diverse groups are compounded by increased risks of chronic health conditions, such as heart disease and cancer, exacerbated by higher smoking rates.8,9 Mental health issues, including anxiety and depression, are also prevalent among gender diverse groups, contributing to substance abuse problems like chronic tobacco use. 9 Despite the urgency of the issue, there is limited research on cigarette smoking prevalence among Latinx Transgender and Gender Diverse (LTGD) adults. This study examines the prevalence and associations of current cigarette smoking among LTGD adults in Puerto Rico (PR) and Florida (FL). By understanding the unique challenges faced by this demographic, targeted interventions can be developed to address their specific needs and reduce tobacco-related disparities.
Methods
Data Collection
This study involves a secondary data analysis of a community-informed, cross-sectional survey conducted between July 2020 and April 2021 among Latino transgender women (TW) and transgender men (TM) residing in Puerto Rico (PR) and Florida (FL). The dataset used for this secondary analysis was obtained from the parent NIH-funded R21 project, with permission from the principal investigator (PI). All data were de-identified prior to analysis, and the current research team had no access to identifying information.The original dataset utilized a non-probability, community-based sampling strategy. Recruitment efforts included outreach via transgender community organizations, social media platforms, peer referrals, and direct engagement in community spaces. In the parent study, the quantitative survey aimed to recruit a total of 200 participants (100 TW and 100 TM), with the sample size determined based on exploratory aims and supported by a power analysis demonstrating sufficient power to detect small-to-moderate effects in multivariable models. For the current analysis, 128 participants met the eligibility criteria. Inclusion criteria were: (1) being 21 years of age or older (legal age of adulthood in Puerto Rico) and up to 65 years of age; (2) self-identifying as Latinx; (3) identifying with a gender identity or expression that differs from the gender socially attributed to their sex assigned at birth, including transfeminine, transmasculine, and non-binary identities; and (4) residing in Puerto Rico (PR) or Florida (FL) at the time of data collection. Participants were excluded if they were younger than 21 or older than 65, did not identify as Latinx, or did not self-identify with a transgender or gender diverse identity. Data were collected through a secure, web-based survey platform, with participants completing the survey either remotely or in person using iPads at the research offices. All participants provided informed consent prior to participation, following approval from the Ponce Health Sciences University Institutional Review Board (Protocol No. 1903009446). The survey included validated and culturally adapted measures assessing sociodemographic characteristics, cancer screening behaviors, psychosocial factors, and relevant cultural variables. This secondary analysis draws on an existing dataset to examine the prevalence of current cigarette smoking and its associations with demographic and health characteristics among Latino transgender adults.
Measures
Demographic and health characteristics were self-reported through an online survey developed by the research team available in both Spanish and English. For this secondary data analysis, demographic characteristics questions included: age (What is your age?), gender identity (You identify yourself as: Woman, Man, Trans Woman, Trans Man, Non-binary, or other, specify), sex assigned at birth (What sex were you assigned at birth? Female, Male or prefer not to respond), place of birth and residence (What country were you born in? What town or state do you currently live in?), education (What is your last year of study? I didn’t complete fourth year of high school, fourth year of high school, some college, high school, associate degree, bachelor’s degree, some grad school, master, Doctoral degree, I’d rather not respond or other, specify) and income (Approximately, how much money did you make in the last month? $0 to $100, $101 to $500, $501 to $1,000, $1001 to $1,500, $1501 to $2,000, Over $2,000, I do not know, or I’d rather not respond). The questions regarding their health characteristics included: 1) Are you using prescription hormones (e.g., estrogen or testosterone)? Yes, no or prefer not to respond (Hormone use) 2) Do you have a primary physician? Yes, no or prefer not to respond, and 3) Do you have health insurance? Yes, no or prefer not to respond. Current smoking status was ask using the following questions 1) “Do you smoke? Yes, no or prefer not to respond” and 2) If you checked “yes” in the previous section, please specify daily amount in number(s). Additionally, as part of health characteristics participants were asked about mental health history “Please indicate if you have been medically diagnosed with any of these mental health conditions, check all that apply Depression, Bipolar Disorder, Anxiety, Attention Deficit/Hyperactivity Disorder, Gender Dysphoria”. For the present analysis, only self-reported lifetime diagnosis of depression and anxiety were included. Education was recoded into three categories: High School/Didn’t complete fourth year of high school, Some College/associate degree, and Master’s/Doctoral degree. Monthly income was recoded into two categories: $0–$1000 and $1010–More than $2000. The responses “do not know” and “prefer not to answer” were coded as missing values for all questions.
Data Analysis
A total of 133 participants completed the online survey in Spanish. Five cases were excluded because of missing values on the current cigarette smoking status variable. Listwise deletion was employed to address missing data given the overall proportion of missing data was small (<5%). The total sample for the present study included 128 participants. Shapiro–Wilk test for normality was used to evaluate the distribution of age indicating that the data does not follow a normal distribution (P < .05). Descriptive analyses were conducted including absolute and relative frequencies, median (Mdn), and interquartile range (IQR) values. Logistic regression analysis was conducted to examine associations between self-reported current cigarette smoking status (smoking vs non-smoking) and demographic and health characteristics among LTGD adults. Simple logistic regressions were first performed for each independent variable to identify potential associations with smoking. Variables that were either statistically significant in the simple regressions or theoretically justified based on prior literature (e.g., income, education 2 ) were included in a multiple logistic regression model. The Benjamini–Hochberg procedure 10 was applied to adjust for multiple comparisons and control the false discovery rate (FDR). A significance threshold of P < 0.05 was used for all tests. Statistical analyses were conducted using SPSS version 29.0 and the R environment. 11
Results
Associations Between Participant Characteristics and Current Cigarette Smoking (Smoking vs Nonsmoking)
Notes: *Total sample size varies due to small amounts of missing data. Bold indicates statistical significance at P < 0.05.
Discussion
The present study explored the prevalence and associations of current cigarette smoking with demographic and health characteristics among LTGD adults in Puerto Rico and Florida. Findings revealed a current cigarette smoking rate of 29.7% in this population, a figure comparable to national estimates for transgender individuals (35.5%) 4 and significantly higher than general adult smoking prevalence rates in PR (8.7%) 12 and FL (approximately 11%). 13 These disparities highlight a pressing need for targeted public health responses tailored to LTGD communities.
The relatively young median age of the sample (33 years) underscores the importance of early prevention and cessation interventions, particularly as tobacco use remains the leading preventable cause of morbidity and mortality. Notably, smoking rates were similar across gender-diverse subgroups (TM, TW and nonbinary individuals) contrasting with prior research that has documented higher smoking rates among trans men. 14 These results suggest that within the LTGD population in PR and FL, tobacco use may be influenced more by shared sociocultural and structural factors than by gender subgroup alone.
A key finding was the association between place of birth and current smoking. LTGD adults born in PR were significantly more likely to report smoking than those born in the continental U.S. or other countries. While this association held in adjusted regression models, it should be interpreted cautiously. Potential unmeasured confounders such as acculturation, 15 experiences of stigma, 16 and migration-related stress may partially explain this relationship. Future studies should incorporate validated instruments to assess acculturation and minority stress to deepen understanding of these dynamics.
Mental health also emerged as a salient predictor. Participants with a lifetime diagnosis of depression reported significantly higher rates of smoking. This finding supports existing evidence that mental health challenges and tobacco use often co-occur, particularly among marginalized populations.17,18 In LTGD communities, the burden of intersectional stigma, related to gender identity, ethnicity, and mental health, may increase vulnerability to tobacco use as a coping mechanism.16,19 These findings highlight the need for interventions that integrate mental health support within tobacco cessation efforts, including trauma-informed care and services affirming both gender identity and cultural background.
Participants with lower income showed a descriptive tendency toward higher smoking prevalence, although this association was not statistically significant. In contrast, a lifetime diagnosis of depression was significantly associated with current cigarette smoking. These align with broader public health literature linking social disadvantage and psychological distress with increased tobacco use. However, the compounding effects of stigma, discrimination, and limited access to affirming healthcare in LTGD populations require tailored responses beyond general smoking cessation frameworks. For example, cultural values such as machismo, family rejection, and religious stigma may compound minority stress and influence smoking behaviors in ways unique to Latinx LTGD individuals.
This study makes a critical contribution to the limited literature by offering one of the first empirical estimates of smoking prevalence among LTGD adults in PR and FL. Given the lack of disaggregated data in national surveillance systems on both gender identity and ethnicity, LTGD populations often remain statistically invisible. These findings help fill that gap and support the case for more inclusive data collection, targeted funding, and public health policies that acknowledge and address the specific needs of LTGD individuals.
Nonetheless, several limitations should be noted. The study’s relatively small sample size limited statistical power and may have contributed to wide 95% confidence intervals in the logistic regression models, suggesting potential model instability and the possibility of overfitting. The relatively young mean age of participants (M = 33.4 years) may further limit the applicability of findings to older LTGD adults. Smoking behaviors were self-reported and dichotomized, precluding analysis of frequency, type of tobacco product used, or usage patterns. Mental health diagnoses were also self-reported and not verified with standardized clinical assessments, and the survey instrument lacked psychometric validation, which may further constrain interpretation.
Internal validity is supported by standardized data collection procedures and clearly defined variables, including current cigarette smoking status and lifetime depression diagnosis. Potential threats to internal validity, such as measurement error and unmeasured confounders (e.g., acculturation, minority stress), were acknowledged and addressed. External validity may be limited by the geographic focus on Puerto Rico and Florida and the specific sociodemographic characteristics of the sample, which could restrict generalizability to other LTGD populations or older age groups.
Conclusion
Despite its limitations, this study provides important insights into the elevated prevalence of cigarette smoking among LTGD adults in PR and FL and the mental health and sociodemographic factors associated with tobacco use in this population. 7 The findings affirm the need for culturally sensitive, intersectionally informed interventions that integrate smoking cessation with mental health support and address systemic barriers to care. Future research should prioritize the development of evidence-based tobacco cessation programs tailored for LTGD individuals, particularly those facing intersecting challenges related to ethnicity, economic disadvantage, and psychological distress. Addressing these issues early, especially among younger LTGD adults, could significantly reduce long-term health risks and promote greater health equity. By centering the lived experiences of LTGD individuals, public health initiatives can more effectively advance both prevention and treatment efforts in tobacco control.
Footnotes
Acknowledgments
The authors express their gratitude to the participants for generously dedicating their time and insights to this research endeavor. Additionally, we would like to extend our gratitude to Fabián Moreta-Ávila and Julián Silva-Reteguis for their invaluable collaboration in participant recruitment.
ORCID iDs
Author Contributions
Ruthmarie Hernández-Torres, PhD: Conceptualization, methodology, data curation, formal analysis, writing original draft.
Jeffrey Ramos-Santiago, PhD: Writing review and editing.
Yaritza Negrón-Vélez: Writing review and editing.
Ines Aristegui, PhD: Writing review and editing.
Francisco Cartujano-Barrera, MD: Conceptual support, writing review and editing.
Mario E. Bermonti Pérez, PhD: Data analysis and interpretation, critical review, writing review and editing.
Eliut Rivera-Segarra, PhD: Conceptual support, supervision, writing review and editing.
Alixida Ramos-Pibernus, PhD: Supervision, writing review and editing.
Funding
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Dr. Ruthmarie Hernández Torresis is supported by T32 CA009461 (MPIs: Hay/Ostroff), funded by the National Cancer Institute & National Institute on Aging and P30 CA008748 (Selwyn Vickers- MSK CCSG Core Grant). The main study was funded by NCI under award R21CA212385-01. The content is solely the authors’ responsibility and does not necessarily represent the official views of the National Institutes of Health.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.