Vaping disparities and minority stress among transgender adolescents: A case-based analysis

Jordan, a 16-year-old Black transgender male presented to a community health clinic with a persistent cough, chest discomfort, and worsening symptoms of anxiety and depression. He began vaping at the age of 14 after being able to secure vaping product samples at a Pride event he learned about through a Facebook marketing campaign. Jordan used these products to cope with stress resulting from bullying and harassment at school after coming out with his change in gender identity.

While his nicotine use was initially intermittent, over time his consumption increased, progressing to higher doses and more frequent use. In addition, he has begun vaping tetrahydrocannabinol (THC) products. Although Jordan attempted to quit, he has struggled due to the stress relief he associates with vaping.

Jordan reported daily vaping with nicotine concentrations averaging 20 mg/ml, particularly during periods of heightened stress or gender dysphoria. Additionally, he admitted to occasional marijuana and alcohol use concomitantly. A review of systems was positive for persistent dry cough, shortness of breath and mild pleuritic chest pain. His symptoms worsened with physical activity such as walking prolonged distances or climbing stairs. Additionally, it was becoming increasingly difficult for him to participate in his routine group fitness classes at the local recreational center due to these symptoms. Upon assessment, Jordan was noted to be anxious and fidgety but did not appear to be in any acute distress. Physical examination revealed bilateral wheezing and reduced breath sounds, while mental health assessments indicated moderate to severe anxiety and depressive symptoms.

Pulmonary function tests revealed diminished lung capacity, and a chest X-ray demonstrated bilateral infiltrates. Mental health evaluations suggested that his vaping behavior was exacerbating his preexisting anxiety and depression, which were rooted in experiences of harassment and minority stress. In addition, Jordan was diagnosed with nicotine dependence and chronic bronchitis.

The foundation for treatment strategies begins with tailored patient education to the intended population of interest. Research shows that transgender individuals are disproportionately exposed to e-cigarette advertising, which may increase the likelihood of use and reduce the effectiveness of generic anti-vaping messages.^[10] Some marketing research has demonstrated that the transgender community does not respond well to anti-tobacco campaigns unless it is targeted specifically toward community values including individuality, autonomy, and community relationship pride. However, educational messages targeting the harm caused by vaping products were found to be more beneficial in reducing use than strategies directed at wellness and pride-themed messages.^[11] This emphasizes the importance of providing transparent messages about the health risks associated with vaping while respecting the values of transgender individuals and presenting information in a relatable and sensitive manner.

Jordan’s treatment plan addressed both his physical and mental health needs through an integrated, patient-centered approach:

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Yoga, walking, and stretching designed to enhance respiratory health, reduce anxiety, and gently rebuild cardiovascular endurance—essential after prolonged vaping-related lung impairment.^[18]

Guidance from a dietitian helped replenish weight and energy levels with culturally appropriate, calorie-dense, nutrient-rich foods—addressing issues related to appetite suppression and stress-induced weight loss.

Grounding exercises, guided imagery, and mindful breathing served as tools for managing cravings, dysphoria, and emotional turbulence—techniques that complement CBT and support relapse prevention.^[19]

Structured sleep and self-care routines were encouraged to stabilize circadian rhythms and promote emotional resilience, essential during cessation and identity-related stress.

It is estimated up to 35.5% of transgender populations are smokers which is 15% higher than their cisgender counterparts.^[20] In addition to higher rates of combustible cigarette use, transgender individuals report disproportionately higher rates of e-cigarette use (Sandhu et al, 2023). Although there is little scholarly inquiry into vaping in the transgender community, it is known that the highest rate increase in adolescent transgender vaping was 11% to 21% from 2017-2018. This disparity among transgender youth stems from unique stressors such as gender dysphoria, discrimination, and minority stress.^[8] As exemplified in Jordan’s case, these interconnected psychological and social mechanisms significantly increase the risk for e-cigarette use as both a coping mechanism and a social activity.

Studies show that transgender adolescents are 2.5 times more likely than cisgender peers to vape, with higher rates of concurrent substance use, including alcohol and marijuana.^[21] In addition, there are several other risk factors consistent with Jordan’s case that are attributed to increased use of vaping products including visual nonconformity, disclosing gender identity to social network, and discrimination/harassment.^[3] These findings highlight the need for targeted interventions addressing the specific vulnerabilities of this population.

Vaping poses significant health risks, including respiratory dysfunction, cardiovascular complications, and increased likelihood of nicotine dependence. A recent 5-year longitudinal study found that exclusive e-cigarette use was associated with a 2.1-fold increased risk of physician-diagnosed COPD and a 1.3-fold increased risk of hypertension, reinforcing the serious long-term health consequences of vaping—even in the absence of combustible tobacco use.^[22] Complementing these findings, quantitative lung imaging has demonstrated that even nicotine-free vaping can result in immediate reductions in pulmonary oxygenation, ventilation abnormalities, and airway inflammation, patterns distinct from those seen with traditional smoking.^[23] These physiological impacts are especially concerning for vulnerable populations, including transgender individuals, who already face elevated rates of anxiety, depression, and chronic stress that may compound the health consequences of nicotine addiction.

Due to persistent exposure to structural stigma and discrimination, transgender individuals often experience elevated rates of depression, anxiety, and suicidality, which may increase their use of substances like e-cigarettes as maladaptive coping strategies.^{[14, 15]} Importantly, nicotine dependence itself can worsen mental health, contributing to a feedback loop of psychological distress, heightened emotional reactivity, and decreased life satisfaction. When combined with existing barriers to healthcare and limited access to affirming mental health support, these factors further increase the risk for poor health outcomes among transgender individuals.^{[17, 24]} Nicotine addiction is known to impact mental health and can contribute to stress, potentially exacerbating underlying conditions.^[25] As a result, transgender individuals are disproportionately affected due to preexisting health disparities ultimately contributing to poorer health outcomes.^[24]

Recent trends in evidence from the literature suggest transgender populations encounter healthcare access problems through both interpersonal and structural barriers. Healthcare providers must routinely screen transgender patients for use of vaping products and provide tailored cessation support. This includes the need to target psychological distress in cessation methods.^[24] Integrated care models, combining mental health and substance use interventions, have shown effectiveness. Providers should also employ evidence-based strategies such as cognitive behavioral therapy (CBT) and motivational interviewing while advocating for culturally competent cessation resources.^[17] CBT can help patients identify distorted thinking patterns contributing to emotional distress and maladaptive behaviors.

Best approaches to education strategies have demonstrated effectiveness when incorporating transgender community values rather than relying solely on wellness or Pride-themed messaging. When it comes to visual messaging, images of female couples have been shown to be more effective in conveying the risks associated with vaping than the use of cartoons or similar drawings.^[11] Additionally, e-cigarette aerosol exposure has been linked to increased airway inflammation, respiratory symptoms, and higher incidence of asthma in adolescents and young adults, highlighting the importance of screening and prevention counseling in this population.^[18]

In 2016, the U.S. Food and Drug Administration included vaping products in extended tobacco rule regulations, but this action did not include oversight of product marketing. As such, vaping products are often marketed as a safe alternative with continued targeting of transgender populations for use. Notably, prevention measures often focus on the general population, rather than transgender individuals, missing the mark for messages which best resonate with this special population.^[20]

Policies limiting targeted marketing of vaping products to LGBTQ+ populations and promoting non-discrimination protections can reduce stressors associated with substance use. Public health campaigns and school-based initiatives should focus on educating transgender youth about the risks of vaping and fostering supportive environments.^[26] There is a demonstrable amount of evidence that creating welcoming or safe spaces for encouraging acceptance of transgender youth is quite beneficial in both prevention and treatment.^[17] In addition, future studies should re-examine how to tailor and reframe wellness and pride messaging to see benefits similar to that of harmful effects marketing.^[11]

Variability in vaping device design and the relative lack of standardization in liquid nicotine concentrations contribute to significant inconsistencies in nicotine flux, with levels often surpassing those of combustible cigarettes.^[27] For example, Soule et al. (2023b) reported that popular disposable vapes had a mean predicted nicotine yield of 4.98 mg per 10 puffs—more than double that of a typical cigarette. To provide a standardized reference point, prior studies estimate that a typical cigarette delivers 1–2 mg of nicotine systemically, while many disposable vaping devices yield 3–5 mg of nicotine per 10 puffs—often exceeding cigarette nicotine exposure.^{[27, 28]} These data underscore the need for targeted education and regulatory strategies that specifically address the potency and risks of vaping products marketed to transgender populations.