Transgender and gender expansive (TGE) adults are twice as likely to smoke cigarettes than cisgender individuals. While research suggests that, given appropriate resources and opportunities, TGE smokers are just as likely to want to quit as cisgender smokers, effective cessation interventions targeted to TGE adults have remained underdeveloped.

A new research study, published in the Journal of Medical Internet Research, and led by Andy Tan of the Annenberg School of Communication at the University of Pennsylvania aims to help fill this gap. The study identified factors that make TGE adults more or less likely to smoke, with the long-term aim of reducing tobacco use and related health disparities among TGE populations.

Tan and his colleagues utilized a community-based approach that involved participants in aspects of the research including data collection, analysis, and interpretation—thereby empowering TGE individuals to work with the team to understand factors influencing their smoking habits and help inform future interventions.

The study’s qualitative research design combined methodologies including focus group discussions and private social media groups, as well as a newer approach: digital photovoice data collection.

With the photovoice approach, participants used their phones to take photos at the moment they felt triggered to smoke, or something prevented them from doing it. This stands in contrast, Tan says, to traditional surveys during which people may be asked to recollect their experiences from a week, a month, or even a year ago. Photovoice enabled the team to glean a visually rich, connective, real-time representation of the participants’ experiences.

Participants then shared those photos in small, private Facebook groups, which Tan says many found enjoyable and affirming.

“When we designed the study, we were concerned that it would be onerous and burdensome for participants,” says Tan. “But our 47 participants who completed the study gave us positive feedback. They enjoyed being co-creators of knowledge.”

Combined with the focus group transcripts, the researchers analyzed the photos and captions to generate themes associated with smoking risk and protective factors. They identified six major themes: experience of stress, gender affirmation, health consciousness, social influences, routine behaviors, and environmental cues.

The themes were not always neatly divided into risk or protective factors. For example, being gender affirmation might give an individual the confidence not to smoke. At the same time, someone who identifies as masculine may want to pick up a cigarette as an affirmation of this identity.

“Many of these risk factors may not seem too different from experiences or stressors among cisgender smokers,” says Tan, “but among TGE adults, these stressful experiences are much more frequent.”