Measuring Stress, Socialization, and Smoking Behaviors Among Lesbian, Gay, Bisexual, Transgender, Queer, and Other Sexual and Gender Minority Adolescents (the Puff Break Research Study): Protocol for a Ecological Momentary Assessment Study.

backgroundAdolescent tobacco and nicotine use is a major public health concern, with lesbian, gay, bisexual, transgender, queer, and other sexual and gender minority (LGBTQ+) adolescents showing disproportionately high use compared to their heterosexual and cisgender peers. Research suggests factors such as socialization, stress, mood, and craving exacerbate tobacco and nicotine use. However, there is a dearth of knowledge of how these factors influence tobacco, nicotine, and cannabis use among LGBTQ+ adolescents in general and particularly on a momentary basis.

objectiveThis study aims to use ecological momentary assessment (EMA) to assess real-time predictors of tobacco, nicotine, and cannabis product use among LGBTQ+ adolescents.

methodsThe Puff Break protocol was adapted from existing EMA protocols, key informant recommendations, LGBTQ+ adolescent perspectives, and insights from community members. Recruitment occurred through multiple channels, with high recruitment results via social media. Eligible participants were aged 14 to 19 years; self-identified as LGBTQ+; and used tobacco, nicotine, or cannabis products at least once in the past 30 days. The EMA pilot began with a 1.5-hour in-person or remote meeting where participants completed a timeline follow-back assessment for tobacco and nicotine use, salivary cotinine assessment, baseline survey, and EMA protocol training. Then, participants completed a 2-week EMA trial during which they received 1- to 2-minute surveys 5 times a day. Within a week of completing the EMA trial, participants concluded with an exit survey and exit interview.

resultsFunded in July 2022, the Puff Break study conducted EMA data collection between August 2023 and November 2024, recruiting a sample of 50 participants. Analyses evaluating the feasibility and acceptability of the Puff Break EMA protocol will be completed by July 2025. Multilevel modeling techniques to estimate both contemporaneous and lagged associations among stress, socialization, and craving (exposures) and smoking (outcomes-combustible cigarette, smokeless product, e-cigarette, and cannabis use) are expected to be completed by November 2025. Finally, qualitative thematic analyses to identify robust tailoring variables, intervention options, and decision rules to support future just-in-time-adaptive intervention development are expected to be completed by May 2026.

conclusionsPuff Break is an innovative EMA protocol developed to capture factors influencing tobacco, nicotine, and cannabis use among LGBTQ+ youth. Despite some inherent limitations to the EMA design, the Puff Break protocol has the potential to inform the development of a just-in-time-adaptive intervention to reduce tobacco, nicotine, and cannabis use among LGBTQ+ adolescents. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/71927.