Smoking and Quitting Inequalities Among Gender-Diverse Adults in Great Britain: A Population-Based Study

Smoking and Quitting Inequalities Among Gender-Diverse Adults in Great Britain: A Population-Based Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Smoking and Quitting Inequalities Among Gender-Diverse Adults in Great Britain: A Population-Based Study Sharon Cox, Lion Shahab, Sarah Jackson This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8711632/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 17 Apr, 2026 Read the published version in BMC Public Health → Version 1 posted 12 You are reading this latest preprint version Abstract Background Tobacco smoking is a leading cause of health inequalities, and smoking rates are higher among people who are gender-diverse. This study examined smoking prevalence, dependence, quit attempts, and cessation behaviours among gender-diverse adults in Great Britain, compared with adults identifying as men or women. Methods Cross-sectional data were drawn from the Smoking Toolkit Study, a nationally representative survey of adults aged 16 years and above in Great Britain, collected between October 2020 and June 2025. Gender identity was self-reported as male, female, or in another way, with the latter defined as gender-diverse. Outcomes included smoking prevalence, markers of tobacco addiction and motivation to quit, past-year quit attempts and motivations, quit success, and use of evidence-based cessation aids. Logistic and linear regression models were used to examine associations, adjusting for age and social grade and survey wave, with additional covariates included for quit success analyses. Results The analytic sample consisted of 387,629 adults, including 906 (0.2%) individuals who identified as gender-diverse. Current tobacco smoking prevalence was higher among gender-diverse adults (28.0%) than among men (18.7%; aOR = 1.38, 95% CI 1.17–1.63) and women (14.8%; aOR = 1.76, 95% CI 1.49–2.07). Among current smokers, those who were gender-diverse were more likely to smoke within 30 minutes of waking compared with men (aOR = 1.45, 95% CI 1.08–1.94) and women (aOR = 1.52, 95% CI 1.13–2.04), indicating greater tobacco addiction. Motivation to quit was lower among gender-diverse smokers compared with women (aOR = 0.61, 95% CI 0.39–0.95) and possibly men (aOR = 0.67, 95% CI 0.43–1.04). Past-year quit attempts and quit success did not differ significantly by gender identity. Conclusions Gender-diverse adults in Great Britain experience substantially higher smoking prevalence and greater tobacco addiction. While the quit attempt rate were broadly similar across groups, motivation to quit generally appeared lower among gender-diverse people who smoke. These findings highlight the need for inclusive, equity-focused tobacco control strategies that address the specific barriers faced by gender-diverse communities. Figures Figure 1 Background Tobacco smoking remains a leading cause of preventable death and disease globally 1 – 3 and is a key driver of health inequalities 1 , 4 , 5 . In Great Britain, while smoking rates have declined overall, these trends conceal persistent disparities 6 . Marginalised and minority groups—such as gender-diverse people—continue to experience disproportionately high rates of smoking 7 , 8 and as a result, higher rates of tobacco-related cancers and cardiovascular illness 8 , 9 . Gender diversity refers to an identity beyond a male and female binary. International evidence indicates that individuals who identify as gender-diverse are more likely to smoke, face greater challenges in quitting, and encounter structural and psychosocial barriers to cessation support 10 – 12 . These barriers are not confined to smoking cessation support but reflect barriers to health care and social support more generally 13 . To achieve the UK’s ambition of a smoke-free population (≤ 5% smoking prevalence) by 2030 14,15 action must be inclusive and equity-focused, addressing the specific needs of priority groups, including gender-diverse communities 16 . While some systematic reviews and commentaries on gender diversity and smoking suggest that tailored approaches are more effective, 10,12 the literature often conflates sexual orientation and gender identity, limiting the relevance and usefulness of the data for designing interventions 12 . In the UK, recent calls to improve the health of gender-diverse people have highlighted the need for public services—including tobacco control—to be inclusive and responsive 16 . However, large-scale evidence remains scarce. Many national datasets fail to include gender-diverse people within their analysis, often excluded due to small sample sizes, and over time, this leads to invisibility in research and policy. This study addresses that gap by examining smoking and quitting behaviours among gender-diverse adults in England, comparing them to those who identify as male or female. To fully assess smoking disparities between genders, here we focus on smoking prevalence, quit attempts, cessation methods, as well as markers of addiction 17 – 20 , and motivation to quit 21 . Using cross-sectional data from the Smoking Toolkit Study (STS), this study aims to examine the extent to which there are differences between gender-diverse adults and adults who identify as male and female in: The proportion who report currently smoking (a) any tobacco, (b) cigarettes, and (c) exclusively non-cigarette tobacco; Among people who currently smoke, the proportion who smoke within 30 minutes of waking, strength of urges to smoke, and cigarettes per day (as markers of tobacco addiction) and the proportion who report wanting to quit smoking in the next 3 months (as a marker of motivation); The proportion of past-year smokers who report a past-year quit attempt, and among those, factors motivating the quit attempt; The proportion of those who made a past-year quit attempt who report (a) continuous abstinence (i.e., quit success) and (b) use of evidence-based smoking cessation aids. Methods Pre-registration and ethical approval The protocol for this study was pre-registered on the Open Science Framework: https://doi.org/10.17605/OSF.IO/2V5W3 . Ethical approval is provided by the UCL Research Ethics Committee (0498/001). Participants provide informed consent to take part in the study, are treated in accordance with the Declaration of Helsinki, and all methods are carried out in accordance with relevant regulations. The data are not collected by UCL and are anonymised when received by UCL. Sample and Recruitment Data were drawn from the STS, a monthly cross-sectional survey of people (≥ 16 years) in Great Britain. The STS uses a hybrid sampling method combining random location and quota sampling, with data collected via telephone or online interviews; full details can be found elsewhere 22 , 23 . Data were weighted with the rim (marginal) technique 24 (using the R survey package) to match the analytic sample to the proportions of the English population profile on the dimensions of age, social grade, region, housing tenure, ethnicity and working status within sex. We included data from participants surveyed between October 2020, when data collection in Wales and Scotland started, and June 2025, the most recent data available at the time of analysis. Measures Explanatory variable Gender identity was assessed by self-report as male, female, and non-binary or my gender is not listed. Participants identifying as non-binary and my gender is not listed, the latter two are classified as “in another way” and here are defined as gender-diverse. Details on how this is classified by the organisation that collects the data can be found elsewhere 25 . Outcomes Smoking status was assessed by asking participants which of the following best applies to them: I smoke cigarettes (including hand-rolled) every day I smoke cigarettes (including hand-rolled), but not every day I do not smoke cigarettes at all, but I do smoke tobacco of some kind (e.g., pipe, cigar or shisha) I have stopped smoking completely in the last year I stopped smoking completely more than a year ago I have never been a smoker (i.e., smoked for a year or more) Those indicating a, b and c were considered people who currently smoke tobacco. Those who respond d were considered people who have successfully quit smoking in the last year. The following outcomes were examined: 1) Current smoking : In all adults, derived from the above question, we assessed current tobacco smoking (a-c), current cigarette smoking (a-b), exclusive non-cigarette tobacco smoking (c); 2) Smoking behaviour : In people who currently smoke: mean cigarettes per day (CPD), mean urges to smoke, the percentage who smoke within 30 minutes of waking, and the percentage who have high motivation to stop (‘really want and plan to stop within 3 months’) 17–21 ; 3) Quit attempts : In people who smoked in the past year, we assessed the percentage reporting a past-year quit attempt as measured by the question, ‘How many serious attempts to stop smoking have you made in the last 12 months? By serious attempt I mean you decided that you would try to make sure you never smoked again. Please include any attempt that you are currently making and please include any successful attempt made within the last year’. Among those reporting making one or more serious attempts to quit in the past year, the following outcome were assessed: 4) Motives for quitting : Motives for the most recent attempt to quit were assessed by the question: ‘Which of the following do you think contributed to you making the most recent attempt to quit?’ Advice from a GP/health professional TV advert for a nicotine replacement product Government TV/radio/press advert Hearing about a new stop smoking treatment A decision that smoking was too expensive Being faced with smoking restrictions I knew someone else who was stopping Seeing a health warning on a cigarette packet Being contacted by my local NHS Stop Smoking Services Health problems I had at the time A concern about future health problems Attending a local stop smoking activity or event Something said by family/friends/children A significant birthday Pregnancy Just decided to quit The coronavirus outbreak (from April 2020 on-wards) Other (please specify) However, we only include for this study; (1) Advice from a GP/health professional; (5) A decision that smoking was too expensive; (7) I knew someone else who was stopping; (10) Health problems I had at the time; (11) A concern about future health problems; (13) Something said by family/friends/children, and; (15) Pregnancy. The decision to reduce responses was based on our previous studies (e.g. Jackson 2024, 26 ) showing the most popular overall reasons for trying to stop smoking covered advice, cost, social factors, and health. 5) Quit success and methods : Among those who made a past-year quit attempt, we also present the percentage not currently smoking (i.e., quit success) and the percentage who used evidence-based cessation support (face-to-face behavioural support, prescription nicotine replacement therapy (NRT), electronic cigarettes (e-cigarettes) or prescription medication) dichotomised as yes/no. Covariates Age range was categorised as: 16–24, 25–34, 35–44, 45–54, 55–64 and 65 + years. Social grade, measured using the National Readership Survey 27 , is categorised as ‘AB’ (higher and intermediate managerial, administrative or professional managerial, administrative or professional), ‘C1’ (supervisory or clerical and junior managerial, administrative or professional), ‘C2’ (skilled manual workers), ‘D’ (semi- and unskilled manual workers) and ‘E’ (casual or lowest-grade workers, pensioners and others who depend on welfare). This was dichotomised into more advantaged (ABC1) and less advantaged (C2D1) groups. For the quit method and success, we also included alcohol use, as measured by the AUDIT-C 28 , as a continuous variable. Smoking-related covariates included in this analysis also included the number of past-year attempts and the time since the quit attempt started. In a deviation from protocol, we include a survey wave covariate to account for seasonal variation. Analyses Analyses were conducted in R (version 4.5.2). Data were weighted to represent GB population estimates (using srvyr and survey packages). We present a descriptive table for all exposure (gender: gender-diverse, male and female) and outcome variables, reporting prevalence estimates with 95% CI for each group, or means and standard deviations for continuous variables. We provide inferential statistics using logistic regression to analyse associations (presenting odds ratios, OR) adjusting for key covariates, for all except motives which deviates from our protocol, but samples sizes were not large enough. To yield the magnitude of difference between those identifying as gender-diverse to male and also females we made these comparisons for each research question. To avoid over interpreting the data (i.e., Table 2 fallacy 29 ), we only reported the fully adjusted models, including the following covariates: Age, social grade and survey wave for analyses of RQs 1 through 3 age, social grade, survey wave, strength of urges to smoke, use of evidence-based aids, alcohol use, number of past-year attempts and time since quit attempt started for RQ4 analysis Results Sample Characteristics A total of 387,629 adults were included in the analysis, comprising 188,767 men (48.7%), 197,545 women (51.0%), and 906 individuals who identified as gender-diverse (0.2%). In the total sample, 20.9% were past-year smokers, 19.2% were current tobacco smokers, and 18.4% were current cigarette smokers. Descriptive and adjusted results for smoking behaviours by gender identity are presented in Table 1 . Table 1 Smoking Characteristics and Behaviours by Gender Identity Variable Men Women Gender-diverse Adjusted Model: In Another Way vs Men (ref) Adjusted Model: In Another Way vs Women (ref) Sample Characteristics (Full Sample, N = 387,629) n = 188,767 n = 197,545 n = 906 Past-year smoking prevalence 22.1% 19.6% 29.0% OR = 1.29 (1.10–1.51) OR = 1.62 (1.38–1.90) Current tobacco smoking prevalence 18.7% (17.4–19.1) 14.8% (14.4–15.1) 28.0% (24.8–31.1) OR = 1.38 (1.17–1.63) OR = 1.76 (1.49–2.07) Current cigarette smoking prevalence 16.2% (15.8–16.5) 13.6% (13.2–13.9) 24.3% (21.3–27.3) OR = 1.36 (1.14–1.61) OR = 1.63 (1.37–1.93) Exclusive non-cigarette tobacco smoking 2.2% (2.0-2.3) 1.2% (1.1–1.3) 3.6% (2.3–4.9) OR = 1.27 (0.86–1.87) OR = 2.30 (1.55–3.41) Among Past-Year Smokers (n = 80,834) n = 41,790 n = 38,704 n = 263 Made past year quit attempt/s 33.7% (33.2–34.1) 37.4% (37.0-37.9) 32.7% (31.9–44.7) OR = 1.04 (0.80–1.13) OR = 0.88 (0.68–1.13) Continuous abstinence (quit success) 25.5% (23.7–27.2) 26.3% (24.5–28.2) 22.2% (13.9–27.8) OR = 0.99 (0.79–2.31) OR = 0.96 (0.89–1.56) Among Current Smokers (n = 74,341) Smoke within 30 minutes of waking 42.0% (40.8–43.3) 41.7% (40.3–43.0) 45.8% (38.9–52.7) OR = 1.45 (1.08–1.94) OR = 1.52 (1.13–2.04 Plan to quit in next 3 months 15.1% (14.2–16.0) 16.2% (15.2–17.2) 10.8% (6.6–15.0) OR = 0.67 (0.43–1.04) OR = 0.61 (0.39–0.95) Strength of urges (0–5 scale), M (95% CI) 1.74 (1.71–1.77) 1.87 (1.84–1.90) 2.33 (2.10–2.55) β = 0.68 (0.45–0.90) β = 0.56 (0.33–0.79) Cigarettes per day, M (95% CI) 10.8 (10.5–11.0) 9.15 (8.94–9.37) 13.7 (11.0-16.3) β = 4.58 (1.92–7.24) β = 6.47 (3.81–9.13) Cessation Aids (Among Those Who Made Attempt) (n = 3617) Use of any evidence-based aid 5.5% (4.6–6.4) 6.9% (5.9-8.0) 1.1% (-1.1-3.3) OR 0.88 (0.66- 0.97) OR 0.72 (0.68–0.93) Note: Values are percentages with 95% confidence intervals in parentheses unless otherwise specified. M = Mean. OR = Odds Ratio, β = regression coefficient. Sample sizes vary by variable due to missing data. All analyses used weighted data and excluded observations with missing values for the specific variable being analysed. Regression models used complete case analysis, excluding observations with missing data on any covariate. RQ1-3 models (current smoking prevalence) adjusted for age and social grade. RQ4 model (continuous abstinence) adjusted for age, social grade, strength of urges, evidence-based aids (prescription medication, e-cigarettes, behavioural support), alcohol use, number of past-year attempts, and time since quit attempt started. "-" indicates no regression model was conducted for this variable. Smoking Prevalence by Gender Gender-diverse adults had a higher prevalence across all measures of smoking. After adjustment for age and social grade, gender-diverse adults had significantly higher current tobacco smoking (28%) relative to men (18.7%: aOR = 1.38, 95% CI 1.17–1.63) and women (14.8%: aOR = 1.76, 95% CI 1.49–2.07). Patterns were consistent for past-year and current cigarette smoking. Exclusive non-cigarette tobacco use was relatively uncommon across all groups but was more prevalent among gender-diverse adults compared with women, with no clear difference relative to men. Markers of Addiction and Motivation Among Current Smokers Among current smokers, gender-diverse adults showed evidence of higher tobacco addiction: a greater proportion of gender-diverse smokers reported smoking within 30 minutes of waking compared with both men (aOR = 1.45, 95% CI 1.08–1.94) and women (aOR = 1.52, 95% CI 1.13–2.04). Mean strength of urges to smoke was also highest among gender-diverse smokers. Adjusted regression analyses indicated significantly stronger urges among gender-diverse smokers relative to both men (β = 0.68, 95% CI 0.45–0.90) and women (β = 0.56, 95% CI 0.33–0.79). Gender-diverse smokers also reported significantly higher cigarette consumption, smoking on average 4.6 more cigarettes per day than men and 6.5 more than women, respectively. In contrast, motivation to quit smoking was lower among gender-diverse smokers. After adjustment, the odds of planning to quit in the next 3 months were lower among gender-diverse smokers compared with women (aOR = 0.61, 95% CI 0.39–0.95, p = 0.028) and men (aOR = 0.67, 95% CI 0.43–1.04, p = 0.071), though it did not reach the significance threshold for the latter. Past-Year Quit Attempts and Motivating Factors Among past-year smokers, the proportion reporting at least one serious quit attempt in the previous 12 months was similar across gender groups; after adjusting for age and social grade, those who identified as gender-diverse did not differ from women (aOR = 0.88, 95% CI 0.68–1.13) or men (aOR = 1.04, 95% CI 0.80–1.34) Distribution of specific motivating factors also appeared broadly similar across gender identities, see Fig. 1 . Concern about future health problems was the most commonly reported motivation for a quit attempt, followed by the financial cost of smoking; however, formal regression analyses were not conducted for these outcomes due to limited sample size among gender-diverse respondents. Quit Success and Use of Evidence-Based Cessation Aids Among those who made a past-year quit attempt, continuous abstinence rates were comparable across groups. After adjustment, there was no evidence of a difference in quit success between gender-diverse adults and either men (aOR = 0.99, 95% CI 0.79–2.31) or women (aOR = 0.96, 95% CI 0.89–1.56). Among those who had made a quit attempt, use of evidence-based cessation aids was lower among gender-diverse people (1.1%) compared with both men (5.5%; aOR 0.88, 95% CI 0.66–0.97) and women (6.9%; aOR 0.72, 95% CI 0.68–0.93). Discussion Principal Findings This population-based study among adults in Great Britain highlights several smoking-related health inequalities experienced by gender-diverse individuals. After adjustment for key variables, gender-diverse adults demonstrated higher smoking prevalence, greater markers of tobacco addiction, and lower motivation to quit compared with both men and women. Our findings align with international evidence documenting elevated smoking rates among gender-diverse populations 11 . The 28% current smoking prevalence among gender-diverse adults substantially exceeds rates observed in men (18%) and women (15%), representing a nearly 80% increased odds of smoking relative to women. Further, gender-diverse individuals showed multiple indicators of heavier, more dependent smoking patterns—including higher cigarette consumption, stronger urges to smoke, and greater likelihood of smoking soon after waking. These markers suggest potentially greater difficulty in achieving cessation 17 – 21 . Notably, while quit attempt rates were similar across groups, motivation to quit was significantly lower among gender-diverse smokers. However, the fact that quit success rates did not differ significantly by gender identity is an interesting finding and perhaps should be interpreted with caution given that we found use of evidence-based aids was also lower among gender-diverse people compared with men and women. The elevated smoking prevalence and lower motivation to quit among gender-diverse adults likely reflect multiple intersecting factors. For example, minority stress theory posits that stigma, discrimination, and social marginalisation contribute to adverse health behaviours as coping mechanisms 30 . Specifically, gender-diverse individuals face persistent discrimination in healthcare, employment, and social settings, which may increase psychological distress and reliance on smoking as a stress management strategy (see Li et al., for a recent review) 31 . While these pressures explain higher smoking rates, they also plausibly explain lower motivation, unsuccessful attempts and accumulated dependence over time. Although, of course, people and their identities are simultaneously positioned across multiple categories 32 , and for some, other intersecting factors will create and maintain barriers to cessation, these are outlined in the limitations below, but sexual orientation, mental illness and stress as well as factors relating to poverty, which are common among gender-diverse people will reinforce barriers to help seeking. Implications for Policy and Practice These findings have important implications for tobacco control policy and practice in Great Britain. Achieving the UK's smoke-free 2030 target 14 will require targeted, equity-focused interventions that address the specific needs of gender-diverse communities. Current cessation services may not adequately address the barriers faced by this population. This includes avoiding gender-based assumptions, and acknowledging the specific stressors that gender-diverse people face 13 . Targeted interventions delivered in LGBTQIA+-affirming settings may be one route, and research from cancer prevention and screening studies suggests more needs to be understood on what ‘tailoring’ means and how this works in practice 33 . Other work evaluating community-based smoking cessation support is encouraging (e.g., The Last Drag) 34 but derives from the US and therefore has limited application to the UK context. At a policy level, ensuring that gender identity is routinely collected in health surveys and monitoring systems is essential for tracking disparities and evaluating intervention effectiveness. The fact that only 0.2% of our sample identified as gender-diverse—slightly below population estimates of 0.5% 35 —underscores the importance of large sample sizes to enable robust analysis of health outcomes in this community. Strengths and Limitations This study has several notable strengths. The large, nationally representative sample provides estimates of smoking behaviours across gender identities in Great Britain. The inclusion of multiple markers of tobacco addiction, motivation, and cessation behaviour provides a wider insight into smoking disparities. As noted below, there are limitations to how gender diversity is classified; nonetheless, it is important to highlight the inequalities and inequities experienced by minority groups which present with higher smoking rates. However, several limitations should be acknowledged. The cross-sectional design precludes causal inference about mechanisms underlying the observed disparities. The measure of gender diversity is analysed here as individuals who identify "in another way," which imperfect but is how the research team receives the data. Still, we appreciate that this does not capture the full spectrum of gender identities or allow for distinction between transgender, non-binary, and other gender-diverse identities. This broad categorisation may obscure important within-group variation. Sample sizes for gender-diverse adults, while sufficient for primary analyses, were limited for some secondary outcomes, particularly quit success and cessation aid use. Point estimates for these outcomes should be interpreted with appropriate caution. The collapsing of data across the study period prevented examination of temporal trends, which may be important given evolving social attitudes and policies affecting gender-diverse communities. Finally, while the study adjusted for key demographic factors, residual confounding by unmeasured variables such as sexual orientation and mental illness (which may be associated with both gender diversity and smoking) cannot be ruled out. Conclusions Gender-diverse adults in Great Britain experience a substantial and persistent smoking-related health inequity, characterised by higher smoking prevalence, greater tobacco addiction, and lower motivation to quit compared with men and women. These findings highlight the need for inclusive, equity-focused tobacco control strategies that recognise and address the specific barriers faced by gender-diverse communities. Declarations Ethics approval and consent to participate Ethical approval is provided by the UCL Research Ethics Committee (0498/001). Participants provide informed consent to take part in the study, are treated in accordance with the Declaration of Helsinki, and all methods are carried out in accordance with relevant regulations. The data are not collected by UCL and are anonymised when received by UCL. Consent for publication N/A Competing Interests SC and SJ have no competing interests. LS has received honoraria for talks, unrestricted research grants and travel expenses to attend meetings and workshops from manufactures of smoking cessation medications (Pfizer; J&J), and has acted as paid reviewer for grant awarding bodies and as a paid consultant for health care companies. Funding This work was supported by Cancer Research UK (PRCRPGNov21\100002) which provides salary support for SC and SJ. SC and LS are members of the Behavioural Research UK Leadership Hub which is supported by the Economic and Social Research Council (ES/Y001044/1). Author Contribution All authors conceptualised the study. SC led the data analyse and drafted the first version of the manuscript. LS is the grant holder and with SJ provided study oversight. All authors read and approved the final manuscript. Acknowledgements N/A Data Availability The data generated and analysed for this current study are available from the corresponding author on reasonable request. References Di Cesare M, Khang YH, Asaria P, et al. Inequalities in non-communicable diseases and effective responses. Lancet. 2013;381(9866):585–97. 10.1016/S0140-6736(12)61851-0 . Jha P, Peto R. Global Effects of Smoking, of Quitting, and of Taxing Tobacco. N Engl J Med. 2014;370(1):60–8. 10.1056/NEJMra1308383 . Jha P, Peto R, Zatonski W, Boreham J, Jarvis MJ, Lopez AD. Social inequalities in male mortality, and in male mortality from smoking: indirect estimation from national death rates in England and Wales, Poland, and North America. Lancet. 2006;368(9533):367–70. 10.1016/S0140-6736(06)68975-7 . Khan J. Making smoking obsolete: Independent review into smokefree 2030 policies. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1081366/khan-review-making-smoking-obsolete.pdf Hiscock R, Bauld L, Amos A, Fidler JA, Munafò M. Socioeconomic status and smoking: a review: Hiscock et al. Ann N Y Acad Sci. 2012;1248(1):107–23. 10.1111/j.1749-6632.2011.06202.x . Adult smoking habits in the UK. 2023. Published online October 2024. Accessed September 1, 2025. https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/healthandlifeexpectancies/bulletins/adultsmokinghabitsingreatbritain/2019#strengths-and-limitations Smoking habits of adults in the UK. 2021. Accessed April 26, 2023. https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/healthandlifeexpectancies/bulletins/adultsmokinghabitsingreatbritain/2021#adult-smoking-habits-in-the-uk-data A Socioecological Approach to Addressing Tobacco-Related Health Disparities . National Cancer Institute; 2017. Caceres BA, Brody A, Luscombe RE, et al. A Systematic Review of Cardiovascular Disease in Sexual Minorities. Am J Public Health. 2017;107(4):e13–21. 10.2105/AJPH.2016.303630 . Wolford-Clevenger C, Hill SV, Cropsey K. Correlates of Tobacco and Nicotine Use Among Transgender and Gender Diverse People: A Systematic Review Guided by the Minority Stress Model. Nicotine Tob Res. 2022;24(4):444–52. 10.1093/ntr/ntab159 . Blosnich J, Lee JGL, Horn K. A systematic review of the aetiology of tobacco disparities for sexual minorities. Tob Control. 2013;22(2):66–73. 10.1136/tobaccocontrol-2011-050181 . Dermody SS, Heffner JL, Hinds JT, et al. We are in This Together: Promoting Health Equity, Diversity, and Inclusion in Tobacco Research for Sexual and Gender Minority Populations. Nicotine Tob Res. 2020;22(12):2276–9. 10.1093/ntr/ntaa070 . Macdonald V, Verster A, Mello MB, et al. The World Health Organization’s work and recommendations for improving the health of trans and gender diverse people. J Int AIDS Soc. 2022;25(S5):e26004. 10.1002/jia2.26004 . Delivering a Smokefree 2030: The All Party Parliamentary Group on Smoking and Health recommendations for the Tobacco Control Plan 2021. Published online June 2021. Accessed October 18, 2022. https://ash.org.uk/uploads/APPGTCP2021.pdf?v=1652361624 Towards a smokefree generation: A tobacco control plan for England. Published online 2017. Accessed October 6. 2020. https://www.gov.uk/government/publications/towards-a-smoke-free-generation-tobacco-control-plan-for-england Nicotine Addiction in Britain: A Report of the Tobacco Advisory Group of the Royal College of Physicians . Royal College of Physicans; 2020. Accessed September 19, 2023. https://shop.rcplondon.ac.uk/products/nicotine-addiction-in-britain?variant=6633984645 Heatherton TF, Kozlowski LT, Frecker RC, Rickert W, Robinson J. Measuring the Heaviness of Smoking: using self-reported time to the first cigarette of the day and number of cigarettes smoked per day. Addiction. 1989;84(7):791–800. 10.1111/j.1360-0443.1989.tb03059.x . Klemperer EM, Hughes JR. Does the Magnitude of Reduction in Cigarettes Per Day Predict Smoking Cessation? A Qualitative Review. NICTOB . Published online March 5, 2015:ntv058. 10.1093/ntr/ntv058 Fidler JA, Shahab L, West R. Strength of urges to smoke as a measure of severity of cigarette dependence: comparison with the Fagerström Test for Nicotine Dependence and its components: Urges to smoke as a measure of dependence. Addiction. 2011;106(3):631–8. 10.1111/j.1360-0443.2010.03226.x . Fagerstrom K. Determinants of Tobacco Use and Renaming the FTND to the Fagerstrom Test for Cigarette Dependence. Nicotine Tob Res. 2012;14(1):75–8. 10.1093/ntr/ntr137 . Kotz D, Brown J, West R. Predictive validity of the Motivation To Stop Scale (MTSS): A single-item measure of motivation to stop smoking. Drug Alcohol Depend. 2013;128(1–2):15–9. 10.1016/j.drugalcdep.2012.07.012 . Fidler JA, Shahab L, West O, et al. The smoking toolkit study: a national study of smoking and smoking cessation in England. BMC Public Health. 2011;11(1):479. 10.1186/1471-2458-11-479 . Kock L, Shahab L, Moore G, et al. Protocol for expansion of an existing national monthly survey of smoking behaviour and alcohol use in England to Scotland and Wales: The Smoking and Alcohol Toolkit Study. Wellcome Open Res. 2021;6:67. 10.12688/wellcomeopenres.16700.1 . Sharot T. Weighting survey results. J Res Market Res Soc. 28(3):269–84. ASKING THE UK. THEIR GENDER: Inclusive Survey Design . Ipsos Mori; 2023. Accessed January 10, 2026. https://www.ipsos.com/en-uk/asking-uk-their-gender-inclusive-survey-design Jackson SE, Cox S, Buss V, Brown J. Trends in motives for trying to stop smoking: a population study in England, 2018–2023. bmjph. 2024;2(1):e000420. 10.1136/bmjph-2023-000420 . National Readership. Survey - Social Grade. Published online 2017. Bush K. The AUDIT Alcohol Consumption Questions (AUDIT-C)An Effective Brief Screening Test for Problem Drinking. Arch Intern Med. 1998;158(16):1789. 10.1001/archinte.158.16.1789 . Westreich D, Greenland S. The Table 2 Fallacy: Presenting and Interpreting Confounder and Modifier Coefficients. Am J Epidemiol. 2013;177(4):292–8. 10.1093/aje/kws412 . Tan KKH, Treharne GJ, Ellis SJ, Schmidt JM, Veale JF. Gender Minority Stress: A Critical Review. J Homosex. 2020;67(10):1471–89. 10.1080/00918369.2019.1591789 . Li M, Chau K, Calabresi K, et al. The Effect of Minority Stress Processes on Smoking for Lesbian, Gay, Bisexual, Transgender, and Queer Individuals: A Systematic Review. LGBT Health. 2024;11(8):583–605. 10.1089/lgbt.2022.0323 . Phoenix A. Interrogating intersectionality: Productive ways of theorising multiple positioning. KKF . 2006;(2–3). 10.7146/kkf.v0i2-3.28082 Drysdale K, Cama E, Botfield J, Bear B, Cerio R, Newman CE. Targeting cancer prevention and screening interventions to LGBTQ communities: A scoping review. Health Soc Care Community. 2021;29(5):1233–48. 10.1111/hsc.13257 . Williams RD, Housman JM, McDonald JD. If We Build It, Will They Come? Challenges of Adapting and Implementing a Smoking Cessation Program for the LGBTQ Community in Southcentral Texas. Health Promot Pract. 2020;21(1suppl):S118–23. 10.1177/1524839919882385 . Gender, Identity. England and Wales: Census 2021 . Office for National Statistics; 2021. https://www.ons.gov.uk/peoplepopulationandcommunity/culturalidentity/genderidentity/bulletins/genderidentityenglandandwales/census2021 Additional Declarations Competing interest reported. SC and SJ have no competing interests. LS has received honoraria for talks, unrestricted research grants and travel expenses to attend meetings and workshops from manufactures of smoking cessation medications (Pfizer; J&J), and has acted as paid reviewer for grant awarding bodies and as a paid consultant for health care companies. Cite Share Download PDF Status: Published Journal Publication published 17 Apr, 2026 Read the published version in BMC Public Health → Version 1 posted Editorial decision: Revision requested 24 Feb, 2026 Reviews received at journal 23 Feb, 2026 Reviews received at journal 09 Feb, 2026 Reviews received at journal 09 Feb, 2026 Reviewers agreed at journal 08 Feb, 2026 Reviewers agreed at journal 02 Feb, 2026 Reviewers agreed at journal 02 Feb, 2026 Reviewers invited by journal 02 Feb, 2026 Editor invited by journal 01 Feb, 2026 Editor assigned by journal 29 Jan, 2026 Submission checks completed at journal 29 Jan, 2026 First submitted to journal 27 Jan, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8711632","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":584543157,"identity":"d4f7cff7-7e8b-496e-af42-d01627d291a5","order_by":0,"name":"Sharon Cox","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAqklEQVRIiWNgGAWjYNCCCgYGPggrgVgtZxgY2EjTwthGihb5BuaHj3nnHZZnY2B++IGxLY2wFoMDbMaGM7cdNmxjYDOWYGzLIUILAw+bxMdthxOADjMDurCCGIcBtSTOAWlh/0acFoYDIFsaQFp4QLYQ47DDQL/MOJZu2MbMUyyRcI4I78u3Nz98zFNjLc/P3r7xw4eyZCIcxozMSCBCwygYBaNgFIwCIgAAOaorbXd0ChEAAAAASUVORK5CYII=","orcid":"","institution":"University College London","correspondingAuthor":true,"prefix":"","firstName":"Sharon","middleName":"","lastName":"Cox","suffix":""},{"id":584543162,"identity":"666e940f-2b2c-4190-93a7-7ed3ba4d0ab4","order_by":1,"name":"Lion Shahab","email":"","orcid":"","institution":"University College London","correspondingAuthor":false,"prefix":"","firstName":"Lion","middleName":"","lastName":"Shahab","suffix":""},{"id":584543167,"identity":"f8dfa3a6-c0b0-416d-b9b7-d50113c66e06","order_by":2,"name":"Sarah Jackson","email":"","orcid":"","institution":"University College London","correspondingAuthor":false,"prefix":"","firstName":"Sarah","middleName":"","lastName":"Jackson","suffix":""}],"badges":[],"createdAt":"2026-01-27 14:26:23","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8711632/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8711632/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12889-026-27375-4","type":"published","date":"2026-04-17T15:57:50+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":101854088,"identity":"1d7f2aa8-4ebd-40bf-b91e-4d5974958bf5","added_by":"auto","created_at":"2026-02-04 10:28:27","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":339286,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eAmong those reporting a past-year quit attempt, motives for the quit attempt by gender identity. Results show % and bar represent 95% confidence intervals.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8711632/v1/ad43a5fd12a442505de472b7.jpeg"},{"id":107351073,"identity":"878a6b50-8149-422a-beb5-2773db885dc7","added_by":"auto","created_at":"2026-04-20 16:08:57","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":777650,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8711632/v1/6a8a5234-67e1-4ef4-b318-2e302c7c0273.pdf"}],"financialInterests":"Competing interest reported. SC and SJ have no competing interests. LS has received honoraria for talks, unrestricted research grants and travel expenses to attend meetings and workshops from manufactures of smoking cessation medications (Pfizer; J\u0026J), and has acted as paid reviewer for grant awarding bodies and as a paid consultant for health care companies.","formattedTitle":"Smoking and Quitting Inequalities Among Gender-Diverse Adults in Great Britain: A Population-Based Study","fulltext":[{"header":"Background","content":"\u003cp\u003eTobacco smoking remains a leading cause of preventable death and disease globally\u003csup\u003e\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e and is a key driver of health inequalities\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e,\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e. In Great Britain, while smoking rates have declined overall, these trends conceal persistent disparities\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e. Marginalised and minority groups\u0026mdash;such as gender-diverse people\u0026mdash;continue to experience disproportionately high rates of smoking\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e,\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e and as a result, higher rates of tobacco-related cancers and cardiovascular illness\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e,\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eGender diversity refers to an identity beyond a male and female binary. International evidence indicates that individuals who identify as gender-diverse are more likely to smoke, face greater challenges in quitting, and encounter structural and psychosocial barriers to cessation support\u003csup\u003e\u003cspan additionalcitationids=\"CR11\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e. These barriers are not confined to smoking cessation support but reflect barriers to health care and social support more generally\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e. To achieve the UK\u0026rsquo;s ambition of a smoke-free population (\u0026le;\u0026thinsp;5% smoking prevalence) by 2030\u003csup\u003e14,15\u003c/sup\u003e action must be inclusive and equity-focused, addressing the specific needs of priority groups, including gender-diverse communities\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eWhile some systematic reviews and commentaries on gender diversity and smoking suggest that tailored approaches are more effective,\u003csup\u003e10,12\u003c/sup\u003e the literature often conflates sexual orientation and gender identity, limiting the relevance and usefulness of the data for designing interventions\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e. In the UK, recent calls to improve the health of gender-diverse people have highlighted the need for public services\u0026mdash;including tobacco control\u0026mdash;to be inclusive and responsive\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e. However, large-scale evidence remains scarce. Many national datasets fail to include gender-diverse people within their analysis, often excluded due to small sample sizes, and over time, this leads to invisibility in research and policy.\u003c/p\u003e \u003cp\u003eThis study addresses that gap by examining smoking and quitting behaviours among gender-diverse adults in England, comparing them to those who identify as male or female. To fully assess smoking disparities between genders, here we focus on smoking prevalence, quit attempts, cessation methods, as well as markers of addiction\u003csup\u003e\u003cspan additionalcitationids=\"CR18 CR19\" citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e, and motivation to quit\u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eUsing cross-sectional data from the Smoking Toolkit Study (STS), this study aims to examine the extent to which there are differences between gender-diverse adults and adults who identify as male and female in:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eThe proportion who report currently smoking (a) any tobacco, (b) cigarettes, and (c) exclusively non-cigarette tobacco;\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eAmong people who currently smoke, the proportion who smoke within 30 minutes of waking, strength of urges to smoke, and cigarettes per day (as markers of tobacco addiction) and the proportion who report wanting to quit smoking in the next 3 months (as a marker of motivation);\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eThe proportion of past-year smokers who report a past-year quit attempt, and among those, factors motivating the quit attempt;\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eThe proportion of those who made a past-year quit attempt who report (a) continuous abstinence (i.e., quit success) and (b) use of evidence-based smoking cessation aids.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003ePre-registration and ethical approval\u003c/h2\u003e \u003cp\u003eThe protocol for this study was pre-registered on the Open Science Framework: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.17605/OSF.IO/2V5W3\u003c/span\u003e\u003cspan address=\"10.17605/OSF.IO/2V5W3\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eEthical approval\u003c/strong\u003e \u003cp\u003e is provided by the UCL Research Ethics Committee (0498/001). Participants provide informed consent to take part in the study, are treated in accordance with the Declaration of Helsinki, and all methods are carried out in accordance with relevant regulations. The data are not collected by UCL and are anonymised when received by UCL.\u003c/p\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eSample and Recruitment\u003c/h3\u003e\n\u003cp\u003eData were drawn from the STS, a monthly cross-sectional survey of people (\u0026ge;\u0026thinsp;16 years) in Great Britain. The STS uses a hybrid sampling method combining random location and quota sampling, with data collected via telephone or online interviews; full details can be found elsewhere\u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e,\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e. Data were weighted with the rim (marginal) technique\u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e (using the R survey package) to match the analytic sample to the proportions of the English population profile on the dimensions of age, social grade, region, housing tenure, ethnicity and working status within sex.\u003c/p\u003e \u003cp\u003eWe included data from participants surveyed between October 2020, when data collection in Wales and Scotland started, and June 2025, the most recent data available at the time of analysis.\u003c/p\u003e\n\u003ch3\u003eMeasures\u003c/h3\u003e\n\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eExplanatory variable\u003c/h2\u003e \u003cp\u003eGender identity was assessed by self-report as male, female, and non-binary or my gender is not listed. Participants identifying as non-binary and my gender is not listed, the latter two are classified as \u0026ldquo;in another way\u0026rdquo; and here are defined as gender-diverse. Details on how this is classified by the organisation that collects the data can be found elsewhere\u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eOutcomes\u003c/h3\u003e\n\u003cp\u003e \u003cb\u003eSmoking status\u003c/b\u003e was assessed by asking participants which of the following best applies to them:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eI smoke cigarettes (including hand-rolled) every day\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eI smoke cigarettes (including hand-rolled), but not every day\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eI do not smoke cigarettes at all, but I do smoke tobacco of some kind (e.g., pipe, cigar or shisha)\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eI have stopped smoking completely in the last year\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eI stopped smoking completely more than a year ago\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eI have never been a smoker (i.e., smoked for a year or more)\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003eThose indicating \u003cem\u003ea, b and c\u003c/em\u003e were considered people who currently smoke tobacco. Those who respond \u003cem\u003ed\u003c/em\u003e were considered people who have successfully quit smoking in the last year.\u003c/p\u003e \u003cp\u003eThe following outcomes were examined:\u003c/p\u003e \u003cp\u003e1) \u003cb\u003eCurrent smoking\u003c/b\u003e: In all adults, derived from the above question, we assessed current tobacco smoking (a-c), current cigarette smoking (a-b), exclusive non-cigarette tobacco smoking (c);\u003c/p\u003e \u003cp\u003e2) \u003cb\u003eSmoking behaviour\u003c/b\u003e: In people who currently smoke: mean cigarettes per day (CPD), mean urges to smoke, the percentage who smoke within 30 minutes of waking, and the percentage who have high motivation to stop (\u0026lsquo;really want and plan to stop within 3 months\u0026rsquo;) \u003csup\u003e17\u0026ndash;21\u003c/sup\u003e;\u003c/p\u003e \u003cp\u003e3) \u003cb\u003eQuit attempts\u003c/b\u003e: In people who smoked in the past year, we assessed the percentage reporting a past-year quit attempt as measured by the question, \u0026lsquo;How many serious attempts to stop smoking have you made in the last 12 months? By serious attempt I mean you decided that you would try to make sure you never smoked again. Please include any attempt that you are currently making and please include any successful attempt made within the last year\u0026rsquo;.\u003c/p\u003e \u003cp\u003eAmong those reporting making one or more serious attempts to quit in the past year, the following outcome were assessed:\u003c/p\u003e \u003cp\u003e4) \u003cb\u003eMotives for quitting\u003c/b\u003e: Motives for the most recent attempt to quit were assessed by the question: \u0026lsquo;Which of the following do you think contributed to you making the most recent attempt to quit?\u0026rsquo;\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eAdvice from a GP/health professional\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eTV advert for a nicotine replacement product\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eGovernment TV/radio/press advert\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eHearing about a new stop smoking treatment\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eA decision that smoking was too expensive\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eBeing faced with smoking restrictions\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eI knew someone else who was stopping\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eSeeing a health warning on a cigarette packet\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eBeing contacted by my local NHS Stop Smoking Services\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eHealth problems I had at the time\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eA concern about future health problems\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eAttending a local stop smoking activity or event\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eSomething said by family/friends/children\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eA significant birthday\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003ePregnancy\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eJust decided to quit\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eThe coronavirus outbreak (from April 2020 on-wards)\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eOther (please specify)\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003eHowever, we only include for this study; (1) Advice from a GP/health professional; (5) A decision that smoking was too expensive; (7) I knew someone else who was stopping; (10) Health problems I had at the time; (11) A concern about future health problems; (13) Something said by family/friends/children, and; (15) Pregnancy. The decision to reduce responses was based on our previous studies (e.g. Jackson 2024,\u003csup\u003e26\u003c/sup\u003e) showing the most popular overall reasons for trying to stop smoking covered advice, cost, social factors, and health.\u003c/p\u003e \u003cp\u003e5) \u003cb\u003eQuit success and methods\u003c/b\u003e: Among those who made a past-year quit attempt, we also present the percentage not currently smoking (i.e., quit success) and the percentage who used evidence-based cessation support (face-to-face behavioural support, prescription nicotine replacement therapy (NRT), electronic cigarettes (e-cigarettes) or prescription medication) dichotomised as yes/no.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eCovariates\u003c/h2\u003e \u003cp\u003eAge range was categorised as: 16\u0026ndash;24, 25\u0026ndash;34, 35\u0026ndash;44, 45\u0026ndash;54, 55\u0026ndash;64 and 65\u0026thinsp;+\u0026thinsp;years. Social grade, measured using the National Readership Survey\u003csup\u003e\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e, is categorised as \u0026lsquo;AB\u0026rsquo; (higher and intermediate managerial, administrative or professional managerial, administrative or professional), \u0026lsquo;C1\u0026rsquo; (supervisory or clerical and junior managerial, administrative or professional), \u0026lsquo;C2\u0026rsquo; (skilled manual workers), \u0026lsquo;D\u0026rsquo; (semi- and unskilled manual workers) and \u0026lsquo;E\u0026rsquo; (casual or lowest-grade workers, pensioners and others who depend on welfare). This was dichotomised into more advantaged (ABC1) and less advantaged (C2D1) groups. For the quit method and success, we also included alcohol use, as measured by the AUDIT-C\u003csup\u003e28\u003c/sup\u003e, as a continuous variable. Smoking-related covariates included in this analysis also included the number of past-year attempts and the time since the quit attempt started. In a deviation from protocol, we include a survey wave covariate to account for seasonal variation.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eAnalyses\u003c/h3\u003e\n\u003cp\u003eAnalyses were conducted in R (version 4.5.2). Data were weighted to represent GB population estimates (using srvyr and survey packages).\u003c/p\u003e \u003cp\u003eWe present a descriptive table for all exposure (gender: gender-diverse, male and female) and outcome variables, reporting prevalence estimates with 95% CI for each group, or means and standard deviations for continuous variables. We provide inferential statistics using logistic regression to analyse associations (presenting odds ratios, OR) adjusting for key covariates, for all except motives which deviates from our protocol, but samples sizes were not large enough. To yield the magnitude of difference between those identifying as gender-diverse to male and also females we made these comparisons for each research question. To avoid over interpreting the data (i.e., Table\u0026nbsp;2 fallacy\u003csup\u003e\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e), we only reported the fully adjusted models, including the following covariates:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eAge, social grade and survey wave for analyses of RQs 1 through 3\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eage, social grade, survey wave, strength of urges to smoke, use of evidence-based aids, alcohol use, number of past-year attempts and time since quit attempt started for RQ4 analysis\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eSample Characteristics\u003c/h2\u003e \u003cp\u003eA total of 387,629 adults were included in the analysis, comprising 188,767 men (48.7%), 197,545 women (51.0%), and 906 individuals who identified as gender-diverse (0.2%). In the total sample, 20.9% were past-year smokers, 19.2% were current tobacco smokers, and 18.4% were current cigarette smokers. Descriptive and adjusted results for smoking behaviours by gender identity are presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSmoking Characteristics and Behaviours by Gender Identity\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMen\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eWomen\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eGender-diverse\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eAdjusted Model: In Another Way vs Men (ref)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAdjusted Model: In Another Way vs Women (ref)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSample Characteristics (Full Sample, N\u0026thinsp;=\u0026thinsp;387,629)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;188,767\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;197,545\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;906\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePast-year smoking prevalence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22.1%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19.6%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e29.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eOR\u0026thinsp;=\u0026thinsp;1.29 (1.10\u0026ndash;1.51)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eOR\u0026thinsp;=\u0026thinsp;1.62 (1.38\u0026ndash;1.90)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCurrent tobacco smoking prevalence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18.7% (17.4\u0026ndash;19.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14.8% (14.4\u0026ndash;15.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e28.0% (24.8\u0026ndash;31.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eOR\u0026thinsp;=\u0026thinsp;1.38 (1.17\u0026ndash;1.63)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eOR\u0026thinsp;=\u0026thinsp;1.76 (1.49\u0026ndash;2.07)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCurrent cigarette smoking prevalence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16.2% (15.8\u0026ndash;16.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13.6% (13.2\u0026ndash;13.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e24.3% (21.3\u0026ndash;27.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eOR\u0026thinsp;=\u0026thinsp;1.36 (1.14\u0026ndash;1.61)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eOR\u0026thinsp;=\u0026thinsp;1.63 (1.37\u0026ndash;1.93)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExclusive non-cigarette tobacco smoking\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.2% (2.0-2.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.2% (1.1\u0026ndash;1.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.6% (2.3\u0026ndash;4.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eOR\u0026thinsp;=\u0026thinsp;1.27 (0.86\u0026ndash;1.87)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eOR\u0026thinsp;=\u0026thinsp;2.30 (1.55\u0026ndash;3.41)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAmong Past-Year Smokers (n\u0026thinsp;=\u0026thinsp;80,834)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;41,790\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;38,704\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;263\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMade past year quit attempt/s\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e33.7% (33.2\u0026ndash;34.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e37.4% (37.0-37.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e32.7% (31.9\u0026ndash;44.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eOR\u0026thinsp;=\u0026thinsp;1.04 (0.80\u0026ndash;1.13)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eOR\u0026thinsp;=\u0026thinsp;0.88 (0.68\u0026ndash;1.13)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eContinuous abstinence (quit success)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25.5% (23.7\u0026ndash;27.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26.3% (24.5\u0026ndash;28.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e22.2% (13.9\u0026ndash;27.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eOR\u0026thinsp;=\u0026thinsp;0.99 (0.79\u0026ndash;2.31)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eOR\u0026thinsp;=\u0026thinsp;0.96 (0.89\u0026ndash;1.56)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAmong Current Smokers (n\u0026thinsp;=\u0026thinsp;74,341)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSmoke within 30 minutes of waking\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e42.0% (40.8\u0026ndash;43.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e41.7% (40.3\u0026ndash;43.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e45.8% (38.9\u0026ndash;52.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eOR\u0026thinsp;=\u0026thinsp;1.45 (1.08\u0026ndash;1.94)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eOR\u0026thinsp;=\u0026thinsp;1.52 (1.13\u0026ndash;2.04\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePlan to quit in next 3 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15.1% (14.2\u0026ndash;16.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16.2% (15.2\u0026ndash;17.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10.8% (6.6\u0026ndash;15.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eOR\u0026thinsp;=\u0026thinsp;0.67 (0.43\u0026ndash;1.04)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eOR\u0026thinsp;=\u0026thinsp;0.61 (0.39\u0026ndash;0.95)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStrength of urges (0\u0026ndash;5 scale), M (95% CI)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.74 (1.71\u0026ndash;1.77)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.87 (1.84\u0026ndash;1.90)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.33 (2.10\u0026ndash;2.55)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eβ\u0026thinsp;=\u0026thinsp;0.68 (0.45\u0026ndash;0.90)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eβ\u0026thinsp;=\u0026thinsp;0.56 (0.33\u0026ndash;0.79)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCigarettes per day, M (95% CI)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10.8 (10.5\u0026ndash;11.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9.15 (8.94\u0026ndash;9.37)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13.7 (11.0-16.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eβ\u0026thinsp;=\u0026thinsp;4.58 (1.92\u0026ndash;7.24)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eβ\u0026thinsp;=\u0026thinsp;6.47 (3.81\u0026ndash;9.13)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCessation Aids (Among Those Who Made Attempt) (n\u0026thinsp;=\u0026thinsp;3617)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUse of any evidence-based aid\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5.5% (4.6\u0026ndash;6.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.9% (5.9-8.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.1% (-1.1-3.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eOR 0.88 (0.66-\u003c/p\u003e \u003cp\u003e0.97)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eOR 0.72 (0.68\u0026ndash;0.93)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003e\u003cem\u003eNote: Values are percentages with 95% confidence intervals in parentheses unless otherwise specified. M\u0026thinsp;=\u0026thinsp;Mean. OR\u0026thinsp;=\u0026thinsp;Odds Ratio, β\u0026thinsp;=\u0026thinsp;regression coefficient. Sample sizes vary by variable due to missing data. All analyses used weighted data and excluded observations with missing values for the specific variable being analysed. Regression models used complete case analysis, excluding observations with missing data on any covariate. RQ1-3 models (current smoking prevalence) adjusted for age and social grade. RQ4 model (continuous abstinence) adjusted for age, social grade, strength of urges, evidence-based aids (prescription medication, e-cigarettes, behavioural support), alcohol use, number of past-year attempts, and time since quit attempt started. \"-\" indicates no regression model was conducted for this variable.\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eSmoking Prevalence by Gender\u003c/h2\u003e \u003cp\u003eGender-diverse adults had a higher prevalence across all measures of smoking. After adjustment for age and social grade, gender-diverse adults had significantly higher current tobacco smoking (28%) relative to men (18.7%: aOR\u0026thinsp;=\u0026thinsp;1.38, 95% CI 1.17\u0026ndash;1.63) and women (14.8%: aOR\u0026thinsp;=\u0026thinsp;1.76, 95% CI 1.49\u0026ndash;2.07). Patterns were consistent for past-year and current cigarette smoking. Exclusive non-cigarette tobacco use was relatively uncommon across all groups but was more prevalent among gender-diverse adults compared with women, with no clear difference relative to men.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eMarkers of Addiction and Motivation Among Current Smokers\u003c/h2\u003e \u003cp\u003eAmong current smokers, gender-diverse adults showed evidence of higher tobacco addiction: a greater proportion of gender-diverse smokers reported smoking within 30 minutes of waking compared with both men (aOR\u0026thinsp;=\u0026thinsp;1.45, 95% CI 1.08\u0026ndash;1.94) and women (aOR\u0026thinsp;=\u0026thinsp;1.52, 95% CI 1.13\u0026ndash;2.04).\u003c/p\u003e \u003cp\u003eMean strength of urges to smoke was also highest among gender-diverse smokers. Adjusted regression analyses indicated significantly stronger urges among gender-diverse smokers relative to both men (β\u0026thinsp;=\u0026thinsp;0.68, 95% CI 0.45\u0026ndash;0.90) and women (β\u0026thinsp;=\u0026thinsp;0.56, 95% CI 0.33\u0026ndash;0.79). Gender-diverse smokers also reported significantly higher cigarette consumption, smoking on average 4.6 more cigarettes per day than men and 6.5 more than women, respectively.\u003c/p\u003e \u003cp\u003eIn contrast, motivation to quit smoking was lower among gender-diverse smokers. After adjustment, the odds of planning to quit in the next 3 months were lower among gender-diverse smokers compared with women (aOR\u0026thinsp;=\u0026thinsp;0.61, 95% CI 0.39\u0026ndash;0.95, p\u0026thinsp;=\u0026thinsp;0.028) and men (aOR\u0026thinsp;=\u0026thinsp;0.67, 95% CI 0.43\u0026ndash;1.04, p\u0026thinsp;=\u0026thinsp;0.071), though it did not reach the significance threshold for the latter.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003ePast-Year Quit Attempts and Motivating Factors\u003c/h2\u003e \u003cp\u003eAmong past-year smokers, the proportion reporting at least one serious quit attempt in the previous 12 months was similar across gender groups; after adjusting for age and social grade, those who identified as gender-diverse did not differ from women (aOR\u0026thinsp;=\u0026thinsp;0.88, 95% CI 0.68\u0026ndash;1.13) or men (aOR\u0026thinsp;=\u0026thinsp;1.04, 95% CI 0.80\u0026ndash;1.34)\u003c/p\u003e \u003cp\u003eDistribution of specific motivating factors also appeared broadly similar across gender identities, see Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Concern about future health problems was the most commonly reported motivation for a quit attempt, followed by the financial cost of smoking; however, formal regression analyses were not conducted for these outcomes due to limited sample size among gender-diverse respondents.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eQuit Success and Use of Evidence-Based Cessation Aids\u003c/h2\u003e \u003cp\u003eAmong those who made a past-year quit attempt, continuous abstinence rates were comparable across groups. After adjustment, there was no evidence of a difference in quit success between gender-diverse adults and either men (aOR\u0026thinsp;=\u0026thinsp;0.99, 95% CI 0.79\u0026ndash;2.31) or women (aOR\u0026thinsp;=\u0026thinsp;0.96, 95% CI 0.89\u0026ndash;1.56).\u003c/p\u003e \u003cp\u003eAmong those who had made a quit attempt, use of evidence-based cessation aids was lower among gender-diverse people (1.1%) compared with both men (5.5%; aOR 0.88, 95% CI 0.66\u0026ndash;0.97) and women (6.9%; aOR 0.72, 95% CI 0.68\u0026ndash;0.93).\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003ePrincipal Findings\u003c/h2\u003e \u003cp\u003eThis population-based study among adults in Great Britain highlights several smoking-related health inequalities experienced by gender-diverse individuals. After adjustment for key variables, gender-diverse adults demonstrated higher smoking prevalence, greater markers of tobacco addiction, and lower motivation to quit compared with both men and women. Our findings align with international evidence documenting elevated smoking rates among gender-diverse populations\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThe 28% current smoking prevalence among gender-diverse adults substantially exceeds rates observed in men (18%) and women (15%), representing a nearly 80% increased odds of smoking relative to women. Further, gender-diverse individuals showed multiple indicators of heavier, more dependent smoking patterns\u0026mdash;including higher cigarette consumption, stronger urges to smoke, and greater likelihood of smoking soon after waking. These markers suggest potentially greater difficulty in achieving cessation\u003csup\u003e\u003cspan additionalcitationids=\"CR18 CR19 CR20\" citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eNotably, while quit attempt rates were similar across groups, motivation to quit was significantly lower among gender-diverse smokers. However, the fact that quit success rates did not differ significantly by gender identity is an interesting finding and perhaps should be interpreted with caution given that we found use of evidence-based aids was also lower among gender-diverse people compared with men and women.\u003c/p\u003e \u003cp\u003eThe elevated smoking prevalence and lower motivation to quit among gender-diverse adults likely reflect multiple intersecting factors. For example, minority stress theory posits that stigma, discrimination, and social marginalisation contribute to adverse health behaviours as coping mechanisms\u003csup\u003e\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u003c/sup\u003e. Specifically, gender-diverse individuals face persistent discrimination in healthcare, employment, and social settings, which may increase psychological distress and reliance on smoking as a stress management strategy (see Li et al., for a recent review)\u003csup\u003e\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u003c/sup\u003e. While these pressures explain higher smoking rates, they also plausibly explain lower motivation, unsuccessful attempts and accumulated dependence over time. Although, of course, people and their identities are simultaneously positioned across multiple categories\u003csup\u003e\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u003c/sup\u003e, and for some, other intersecting factors will create and maintain barriers to cessation, these are outlined in the limitations below, but sexual orientation, mental illness and stress as well as factors relating to poverty, which are common among gender-diverse people will reinforce barriers to help seeking.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eImplications for Policy and Practice\u003c/h2\u003e \u003cp\u003eThese findings have important implications for tobacco control policy and practice in Great Britain. Achieving the UK's smoke-free 2030 target\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e will require targeted, equity-focused interventions that address the specific needs of gender-diverse communities. Current cessation services may not adequately address the barriers faced by this population. This includes avoiding gender-based assumptions, and acknowledging the specific stressors that gender-diverse people face\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eTargeted interventions delivered in LGBTQIA+-affirming settings may be one route, and research from cancer prevention and screening studies suggests more needs to be understood on what \u0026lsquo;tailoring\u0026rsquo; means and how this works in practice\u003csup\u003e\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u003c/sup\u003e. Other work evaluating community-based smoking cessation support is encouraging (e.g., The Last Drag)\u003csup\u003e\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u003c/sup\u003e but derives from the US and therefore has limited application to the UK context.\u003c/p\u003e \u003cp\u003eAt a policy level, ensuring that gender identity is routinely collected in health surveys and monitoring systems is essential for tracking disparities and evaluating intervention effectiveness. The fact that only 0.2% of our sample identified as gender-diverse\u0026mdash;slightly below population estimates of 0.5%\u003csup\u003e35\u003c/sup\u003e \u0026mdash;underscores the importance of large sample sizes to enable robust analysis of health outcomes in this community.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eStrengths and Limitations\u003c/h2\u003e \u003cp\u003eThis study has several notable strengths. The large, nationally representative sample provides estimates of smoking behaviours across gender identities in Great Britain. The inclusion of multiple markers of tobacco addiction, motivation, and cessation behaviour provides a wider insight into smoking disparities. As noted below, there are limitations to how gender diversity is classified; nonetheless, it is important to highlight the inequalities and inequities experienced by minority groups which present with higher smoking rates.\u003c/p\u003e \u003cp\u003eHowever, several limitations should be acknowledged. The cross-sectional design precludes causal inference about mechanisms underlying the observed disparities. The measure of gender diversity is analysed here as individuals who identify \"in another way,\" which imperfect but is how the research team receives the data. Still, we appreciate that this does not capture the full spectrum of gender identities or allow for distinction between transgender, non-binary, and other gender-diverse identities. This broad categorisation may obscure important within-group variation. Sample sizes for gender-diverse adults, while sufficient for primary analyses, were limited for some secondary outcomes, particularly quit success and cessation aid use. Point estimates for these outcomes should be interpreted with appropriate caution. The collapsing of data across the study period prevented examination of temporal trends, which may be important given evolving social attitudes and policies affecting gender-diverse communities. Finally, while the study adjusted for key demographic factors, residual confounding by unmeasured variables such as sexual orientation and mental illness (which may be associated with both gender diversity and smoking) cannot be ruled out.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eGender-diverse adults in Great Britain experience a substantial and persistent smoking-related health inequity, characterised by higher smoking prevalence, greater tobacco addiction, and lower motivation to quit compared with men and women. These findings highlight the need for inclusive, equity-focused tobacco control strategies that recognise and address the specific barriers faced by gender-diverse communities.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003ch2\u003eEthics approval and consent to participate\u003c/h2\u003e \u003cp\u003e Ethical approval is provided by the UCL Research Ethics Committee (0498/001). Participants provide informed consent to take part in the study, are treated in accordance with the Declaration of Helsinki, and all methods are carried out in accordance with relevant regulations. The data are not collected by UCL and are anonymised when received by UCL.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent for publication\u003c/strong\u003e \u003cp\u003eN/A\u003c/p\u003e \u003c/p\u003e\u003cp\u003e\u003ch2\u003eCompeting Interests\u003c/h2\u003e\u003cp\u003eSC and SJ have no competing interests. LS has received honoraria for talks, unrestricted research grants and travel expenses to attend meetings and workshops from manufactures of smoking cessation medications (Pfizer; J\u0026amp;J), and has acted as paid reviewer for grant awarding bodies and as a paid consultant for health care companies.\u003c/p\u003e\u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eThis work was supported by Cancer Research UK (PRCRPGNov21\\100002) which provides salary support for SC and SJ. SC and LS are members of the Behavioural Research UK Leadership Hub which is supported by the Economic and Social Research Council (ES/Y001044/1).\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eAll authors conceptualised the study. SC led the data analyse and drafted the first version of the manuscript. LS is the grant holder and with SJ provided study oversight. All authors read and approved the final manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgements\u003c/h2\u003e \u003cp\u003eN/A\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe data generated and analysed for this current study are available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eDi Cesare M, Khang YH, Asaria P, et al. Inequalities in non-communicable diseases and effective responses. Lancet. 2013;381(9866):585\u0026ndash;97. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/S0140-6736(12)61851-0\u003c/span\u003e\u003cspan address=\"10.1016/S0140-6736(12)61851-0\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJha P, Peto R. Global Effects of Smoking, of Quitting, and of Taxing Tobacco. N Engl J Med. 2014;370(1):60\u0026ndash;8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1056/NEJMra1308383\u003c/span\u003e\u003cspan address=\"10.1056/NEJMra1308383\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJha P, Peto R, Zatonski W, Boreham J, Jarvis MJ, Lopez AD. Social inequalities in male mortality, and in male mortality from smoking: indirect estimation from national death rates in England and Wales, Poland, and North America. Lancet. 2006;368(9533):367\u0026ndash;70. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/S0140-6736(06)68975-7\u003c/span\u003e\u003cspan address=\"10.1016/S0140-6736(06)68975-7\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKhan J. Making smoking obsolete: Independent review into smokefree 2030 policies. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1081366/khan-review-making-smoking-obsolete.pdf\u003c/span\u003e\u003cspan address=\"https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1081366/khan-review-making-smoking-obsolete.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHiscock R, Bauld L, Amos A, Fidler JA, Munaf\u0026ograve; M. Socioeconomic status and smoking: a review: Hiscock et al. Ann N Y Acad Sci. 2012;1248(1):107\u0026ndash;23. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/j.1749-6632.2011.06202.x\u003c/span\u003e\u003cspan address=\"10.1111/j.1749-6632.2011.06202.x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAdult smoking habits in the UK. 2023. Published online October 2024. Accessed September 1, 2025. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/healthandlifeexpectancies/bulletins/adultsmokinghabitsingreatbritain/2019#strengths-and-limitations\u003c/span\u003e\u003cspan address=\"https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/healthandlifeexpectancies/bulletins/adultsmokinghabitsingreatbritain/2019#strengths-and-limitations\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSmoking habits of adults in the UK. 2021. Accessed April 26, 2023. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/healthandlifeexpectancies/bulletins/adultsmokinghabitsingreatbritain/2021#adult-smoking-habits-in-the-uk-data\u003c/span\u003e\u003cspan address=\"https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/healthandlifeexpectancies/bulletins/adultsmokinghabitsingreatbritain/2021#adult-smoking-habits-in-the-uk-data\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e\u003cem\u003eA Socioecological Approach to Addressing Tobacco-Related Health Disparities\u003c/em\u003e. National Cancer Institute; 2017.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCaceres BA, Brody A, Luscombe RE, et al. A Systematic Review of Cardiovascular Disease in Sexual Minorities. Am J Public Health. 2017;107(4):e13\u0026ndash;21. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.2105/AJPH.2016.303630\u003c/span\u003e\u003cspan address=\"10.2105/AJPH.2016.303630\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWolford-Clevenger C, Hill SV, Cropsey K. Correlates of Tobacco and Nicotine Use Among Transgender and Gender Diverse People: A Systematic Review Guided by the Minority Stress Model. Nicotine Tob Res. 2022;24(4):444\u0026ndash;52. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1093/ntr/ntab159\u003c/span\u003e\u003cspan address=\"10.1093/ntr/ntab159\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBlosnich J, Lee JGL, Horn K. A systematic review of the aetiology of tobacco disparities for sexual minorities. Tob Control. 2013;22(2):66\u0026ndash;73. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1136/tobaccocontrol-2011-050181\u003c/span\u003e\u003cspan address=\"10.1136/tobaccocontrol-2011-050181\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDermody SS, Heffner JL, Hinds JT, et al. We are in This Together: Promoting Health Equity, Diversity, and Inclusion in Tobacco Research for Sexual and Gender Minority Populations. Nicotine Tob Res. 2020;22(12):2276\u0026ndash;9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1093/ntr/ntaa070\u003c/span\u003e\u003cspan address=\"10.1093/ntr/ntaa070\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMacdonald V, Verster A, Mello MB, et al. The World Health Organization\u0026rsquo;s work and recommendations for improving the health of trans and gender diverse people. J Int AIDS Soc. 2022;25(S5):e26004. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1002/jia2.26004\u003c/span\u003e\u003cspan address=\"10.1002/jia2.26004\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDelivering a Smokefree 2030: The All Party Parliamentary Group on Smoking and Health recommendations for the Tobacco Control Plan 2021. Published online June 2021. Accessed October 18, 2022. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://ash.org.uk/uploads/APPGTCP2021.pdf?v=1652361624\u003c/span\u003e\u003cspan address=\"https://ash.org.uk/uploads/APPGTCP2021.pdf?v=1652361624\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTowards a smokefree generation: A tobacco control plan for England. Published online 2017. Accessed October 6. 2020. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.gov.uk/government/publications/towards-a-smoke-free-generation-tobacco-control-plan-for-england\u003c/span\u003e\u003cspan address=\"https://www.gov.uk/government/publications/towards-a-smoke-free-generation-tobacco-control-plan-for-england\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e\u003cem\u003eNicotine Addiction in Britain: A Report of the Tobacco Advisory Group of the Royal College of Physicians\u003c/em\u003e. Royal College of Physicans; 2020. Accessed September 19, 2023. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://shop.rcplondon.ac.uk/products/nicotine-addiction-in-britain?variant=6633984645\u003c/span\u003e\u003cspan address=\"https://shop.rcplondon.ac.uk/products/nicotine-addiction-in-britain?variant=6633984645\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHeatherton TF, Kozlowski LT, Frecker RC, Rickert W, Robinson J. Measuring the Heaviness of Smoking: using self-reported time to the first cigarette of the day and number of cigarettes smoked per day. Addiction. 1989;84(7):791\u0026ndash;800. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/j.1360-0443.1989.tb03059.x\u003c/span\u003e\u003cspan address=\"10.1111/j.1360-0443.1989.tb03059.x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKlemperer EM, Hughes JR. Does the Magnitude of Reduction in Cigarettes Per Day Predict Smoking Cessation? A Qualitative Review. \u003cem\u003eNICTOB\u003c/em\u003e. Published online March 5, 2015:ntv058. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1093/ntr/ntv058\u003c/span\u003e\u003cspan address=\"10.1093/ntr/ntv058\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFidler JA, Shahab L, West R. Strength of urges to smoke as a measure of severity of cigarette dependence: comparison with the Fagerstr\u0026ouml;m Test for Nicotine Dependence and its components: Urges to smoke as a measure of dependence. Addiction. 2011;106(3):631\u0026ndash;8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/j.1360-0443.2010.03226.x\u003c/span\u003e\u003cspan address=\"10.1111/j.1360-0443.2010.03226.x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFagerstrom K. Determinants of Tobacco Use and Renaming the FTND to the Fagerstrom Test for Cigarette Dependence. Nicotine Tob Res. 2012;14(1):75\u0026ndash;8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1093/ntr/ntr137\u003c/span\u003e\u003cspan address=\"10.1093/ntr/ntr137\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKotz D, Brown J, West R. Predictive validity of the Motivation To Stop Scale (MTSS): A single-item measure of motivation to stop smoking. Drug Alcohol Depend. 2013;128(1\u0026ndash;2):15\u0026ndash;9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.drugalcdep.2012.07.012\u003c/span\u003e\u003cspan address=\"10.1016/j.drugalcdep.2012.07.012\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFidler JA, Shahab L, West O, et al. The smoking toolkit study: a national study of smoking and smoking cessation in England. BMC Public Health. 2011;11(1):479. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/1471-2458-11-479\u003c/span\u003e\u003cspan address=\"10.1186/1471-2458-11-479\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKock L, Shahab L, Moore G, et al. Protocol for expansion of an existing national monthly survey of smoking behaviour and alcohol use in England to Scotland and Wales: The Smoking and Alcohol Toolkit Study. Wellcome Open Res. 2021;6:67. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.12688/wellcomeopenres.16700.1\u003c/span\u003e\u003cspan address=\"10.12688/wellcomeopenres.16700.1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSharot T. Weighting survey results. J Res Market Res Soc. 28(3):269\u0026ndash;84.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eASKING THE UK. \u003cem\u003eTHEIR GENDER: Inclusive Survey Design\u003c/em\u003e. Ipsos Mori; 2023. Accessed January 10, 2026. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.ipsos.com/en-uk/asking-uk-their-gender-inclusive-survey-design\u003c/span\u003e\u003cspan address=\"https://www.ipsos.com/en-uk/asking-uk-their-gender-inclusive-survey-design\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJackson SE, Cox S, Buss V, Brown J. Trends in motives for trying to stop smoking: a population study in England, 2018\u0026ndash;2023. bmjph. 2024;2(1):e000420. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1136/bmjph-2023-000420\u003c/span\u003e\u003cspan address=\"10.1136/bmjph-2023-000420\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNational Readership. Survey - Social Grade. Published online 2017.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBush K. The AUDIT Alcohol Consumption Questions (AUDIT-C)An Effective Brief Screening Test for Problem Drinking. Arch Intern Med. 1998;158(16):1789. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1001/archinte.158.16.1789\u003c/span\u003e\u003cspan address=\"10.1001/archinte.158.16.1789\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWestreich D, Greenland S. The Table 2 Fallacy: Presenting and Interpreting Confounder and Modifier Coefficients. Am J Epidemiol. 2013;177(4):292\u0026ndash;8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1093/aje/kws412\u003c/span\u003e\u003cspan address=\"10.1093/aje/kws412\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTan KKH, Treharne GJ, Ellis SJ, Schmidt JM, Veale JF. Gender Minority Stress: A Critical Review. J Homosex. 2020;67(10):1471\u0026ndash;89. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1080/00918369.2019.1591789\u003c/span\u003e\u003cspan address=\"10.1080/00918369.2019.1591789\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLi M, Chau K, Calabresi K, et al. The Effect of Minority Stress Processes on Smoking for Lesbian, Gay, Bisexual, Transgender, and Queer Individuals: A Systematic Review. LGBT Health. 2024;11(8):583\u0026ndash;605. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1089/lgbt.2022.0323\u003c/span\u003e\u003cspan address=\"10.1089/lgbt.2022.0323\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePhoenix A. Interrogating intersectionality: Productive ways of theorising multiple positioning. \u003cem\u003eKKF\u003c/em\u003e. 2006;(2\u0026ndash;3). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.7146/kkf.v0i2-3.28082\u003c/span\u003e\u003cspan address=\"10.7146/kkf.v0i2-3.28082\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDrysdale K, Cama E, Botfield J, Bear B, Cerio R, Newman CE. Targeting cancer prevention and screening interventions to LGBTQ communities: A scoping review. Health Soc Care Community. 2021;29(5):1233\u0026ndash;48. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/hsc.13257\u003c/span\u003e\u003cspan address=\"10.1111/hsc.13257\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWilliams RD, Housman JM, McDonald JD. If We Build It, Will They Come? Challenges of Adapting and Implementing a Smoking Cessation Program for the LGBTQ Community in Southcentral Texas. Health Promot Pract. 2020;21(1suppl):S118\u0026ndash;23. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1177/1524839919882385\u003c/span\u003e\u003cspan address=\"10.1177/1524839919882385\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGender, Identity. \u003cem\u003eEngland and Wales: Census 2021\u003c/em\u003e. Office for National Statistics; 2021. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.ons.gov.uk/peoplepopulationandcommunity/culturalidentity/genderidentity/bulletins/genderidentityenglandandwales/census2021\u003c/span\u003e\u003cspan address=\"https://www.ons.gov.uk/peoplepopulationandcommunity/culturalidentity/genderidentity/bulletins/genderidentityenglandandwales/census2021\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-8711632/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8711632/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"Background\nTobacco smoking is a leading cause of health inequalities, and smoking rates are higher among people who are gender-diverse. This study examined smoking prevalence, dependence, quit attempts, and cessation behaviours among gender-diverse adults in Great Britain, compared with adults identifying as men or women.\nMethods\nCross-sectional data were drawn from the Smoking Toolkit Study, a nationally representative survey of adults aged 16 years and above in Great Britain, collected between October 2020 and June 2025. Gender identity was self-reported as male, female, or in another way, with the latter defined as gender-diverse. Outcomes included smoking prevalence, markers of tobacco addiction and motivation to quit, past-year quit attempts and motivations, quit success, and use of evidence-based cessation aids. Logistic and linear regression models were used to examine associations, adjusting for age and social grade and survey wave, with additional covariates included for quit success analyses.\nResults\nThe analytic sample consisted of 387,629 adults, including 906 (0.2%) individuals who identified as gender-diverse. Current tobacco smoking prevalence was higher among gender-diverse adults (28.0%) than among men (18.7%; aOR = 1.38, 95% CI 1.17–1.63) and women (14.8%; aOR = 1.76, 95% CI 1.49–2.07). Among current smokers, those who were gender-diverse were more likely to smoke within 30 minutes of waking compared with men (aOR = 1.45, 95% CI 1.08–1.94) and women (aOR = 1.52, 95% CI 1.13–2.04), indicating greater tobacco addiction. Motivation to quit was lower among gender-diverse smokers compared with women (aOR = 0.61, 95% CI 0.39–0.95) and possibly men (aOR = 0.67, 95% CI 0.43–1.04). Past-year quit attempts and quit success did not differ significantly by gender identity.\nConclusions\nGender-diverse adults in Great Britain experience substantially higher smoking prevalence and greater tobacco addiction. While the quit attempt rate were broadly similar across groups, motivation to quit generally appeared lower among gender-diverse people who smoke. These findings highlight the need for inclusive, equity-focused tobacco control strategies that address the specific barriers faced by gender-diverse communities.","manuscriptTitle":"Smoking and Quitting Inequalities Among Gender-Diverse Adults in Great Britain: A Population-Based Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-04 10:28:08","doi":"10.21203/rs.3.rs-8711632/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-02-24T09:52:04+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-23T06:08:14+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-09T18:34:24+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-09T17:36:27+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"116429550975789033486539026490624248325","date":"2026-02-08T22:01:54+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"63991170274928347184160226336644777305","date":"2026-02-02T16:44:27+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"16104018148248174863631789501113931414","date":"2026-02-02T14:58:28+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-02-02T11:44:11+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-02-02T02:47:29+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-01-30T00:47:24+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-01-30T00:46:37+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2026-01-27T14:00:24+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"33673f6d-1616-4f79-9c01-6a41dedbe2b1","owner":[],"postedDate":"February 4th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-04-20T16:06:52+00:00","versionOfRecord":{"articleIdentity":"rs-8711632","link":"https://doi.org/10.1186/s12889-026-27375-4","journal":{"identity":"bmc-public-health","isVorOnly":false,"title":"BMC Public Health"},"publishedOn":"2026-04-17 15:57:50","publishedOnDateReadable":"April 17th, 2026"},"versionCreatedAt":"2026-02-04 10:28:08","video":"","vorDoi":"10.1186/s12889-026-27375-4","vorDoiUrl":"https://doi.org/10.1186/s12889-026-27375-4","workflowStages":[]},"version":"v1","identity":"rs-8711632","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8711632","identity":"rs-8711632","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}