Reporting of Tobacco Use and Health Outcomes among Transgender and Gender-expansive People in Gender

Hinds JT, Wein PY, Stern E, Cioffi L, Cuddleston K, Gordon T, Delbourgo Patton C, Weinberger AH.
Reporting of Tobacco Use and Health Outcomes among Transgender and Gender-expansive People in Gender-affirming Hormone Therapy Research: 1980-2024
Nicotine Tob Res. 2025 Oct 22;27(11):1891-1902. doi: 10.1093/ntr/ntaf158. PMID: 40795336.

Purpose: Transgender/gender-expansive (TGE) people, who use tobacco at high rates, are frequently advised not to use tobacco during gender-affirming hormone therapy (GAHT) due to the increased risk of negative health events. However, there is no summary of studies reporting the risk of negative health events for TGE people with versus without tobacco use during GAHT. This systematic review assesses what is known about tobacco use and health outcomes in studies of TGE people pursuing GAHT.

Methods: Searches were conducted in PubMed, Embase, PsycInfo, Google Scholar, and Mednar. The protocol was registered in Prospero (CRD42023416390).

Results: One hundred and seven studies published from 1980 to 2024 mentioned tobacco and GAHT for TGE patients. Most studies focused on adults (80.4%). Patient samples were feminine/transfeminine (29.9%), masculine/transmasculine (26.2%), or "both"/combinations (43.0%). Most studies (96.3%) reported smoking prevalence, ranging from 4.2% to 73.0%. Forty-three studies (40.2%) explored patient outcomes as they related to GAHT and tobacco use, but significantly increased risk of adverse health events for TGE people receiving GAHT with tobacco use relative to no tobacco use was found in only five studies (4.7%). Tobacco cessation was not mentioned in 79.4% of studies, and no studies reported offering cessation assistance.

Conclusion: Identifying whether TGE people pursuing GAHT experience unique or exacerbated outcomes based on whether and what type of tobacco they use is critical for TGE-focused clinicians and researchers. This systematic review found few studies that identified empirical associations between tobacco use and GAHT-related health outcomes. Accurate tobacco assessment is essential to discern associations with GAHT-related outcomes.

Implications: There are tobacco disparities for transgender and gender expansive (TGE) individuals and a growing demand for gender affirming hormone treatment (GAHT). This was the first systematic review of existing literature exploring the association between tobacco use and GAHT among TGE people. Results highlight the need for accurate tobacco use assessment and follow-up for patients pursuing GAHT in future studies exploring the association between tobacco use and GAHT-related outcomes. All healthcare professionals have TGE patients and should be aware of the risks between GAHT and tobacco, assess and record tobacco use accurately, and offer cessation assistance.