Adolescent and young adult tobacco and nicotine use continues to be a major public health concern. The 2024 National Youth Tobacco Survey found that 8.1% of all middle and high school youths surveyed reported current use of tobacco products, with 2.8% of students reporting combustible cigarette use, while 5.9% of middle school students and 7.8% of high school students reported current e-cigarette use [1]. While rates of e-cigarette use declined from the previous year, demonstrating the success of public health efforts and policy regulations to prevent or reduce use among youth (eg, warning labels, and drug and tobacco policies to regulate sales and access) [2,3], 38.4% of the students using e-cigarettes reported frequent use (at least 20 out of 30 days) and 26.3% reported daily use [4]. Similar studies, such as Monitoring the Future, also highlight that, in 2024, 9% of 8th graders, 12.7% of 10th graders, and 19.5% of 12th graders reported using any nicotine products [5]. Adolescent and young adult users of e-cigarettes have an elevated likelihood of initiating combustible cigarette use [6,7] and using e-cigarettes in conjunction with other tobacco products (cigars, and smokeless tobacco) [8-10], thus increasing their risk for nicotine dependence.

Early prevention of tobacco use in all forms is paramount. It is particularly imperative to target research and prevention efforts toward subpopulations who are at elevated risk for both smoking and tobacco-related disease and negative consequences, such as lesbian, gay, bisexual, transgender, queer, and other sexual and gender minority (LGBTQ+) adolescents [11,12]. Starting in adolescence, LGBTQ+ populations are at substantially elevated risk for combustible tobacco and e-cigarette use compared to heterosexual and cisgender populations [13,14]. Data from the California Healthy Kids Survey (CHKS) shows that middle and high school LGBTQ+ students report a 1% to 2% higher prevalence of past 30-day current use of combustible cigarettes relative to their heterosexual peers, and high school transgender students report a 6% to 7% higher prevalence of past 30-day current use of combustible cigarettes relative to their cisgender peers [15]. Similarly, middle and high school LGBTQ+ students report a 2% to 5% higher prevalence of past 30-day current use of e-cigarettes relative to their heterosexual peers, and high school transgender students report a 7% higher prevalence of past 30-day current use of e-cigarettes relative to their cisgender peers [15]. Furthermore, an analysis of CHKS data revealed that transgender middle and high school students of color had up to 6.0 greater odds of using e-cigarettes or vape products in the last 30 days relative to their cisgender peers of the same race and ethnicity [16]. Similar studies using nationally representative and longitudinal cohort data also highlight increased prevalence and odds of tobacco and nicotine use among LGBTQ+ adolescents relative to their heterosexual and cisgender peers [17,18]. While the overall prevalence of combustible cigarettes and e-cigarette use is decreasing among LGBTQ+ adolescents, addressing nicotine and tobacco dependence and addiction is still an important health priority [19].

Beyond typical risk factors for smoking in adolescence (eg, mood, craving, risk perceptions and expectancies, exposure to tobacco-related media, and being around peers who smoke) [20-22], sexual orientation and gender disparities in smoking may be further elevated due to daily minority stress and LGBTQ+-specific socialization experiences. Minority stress theory [23-25] posits that LGBTQ+ populations experience excess stress due to exposure to various forms of prejudice, discrimination, and internalized stigma, which results in adverse mental and physical health (eg, anxiety and depression) and maladaptive coping behaviors (eg, smoking and vaping). Elevated rates of smoking have been associated with high degrees of sexuality- and gender-based mistreatment. In their analysis of CHKS data, Coulter et al [26] found that sexual and gender minority middle and high school students reported substantially higher rates of sexuality- and gender-based harassment than their heterosexual and cisgender peers. The combined effect of sexuality- and gender-based harassment led to significantly higher tobacco and e-cigarette use compared to when each type of harassment was evaluated separately [26].

In addition to stress-related factors, LGBTQ+ individuals may be more likely to smoke due to socialization factors, such as perceived norms that promote tobacco use [27,28]. For instance, a review by Simons-Morton and Farhat [27] found that peer group homogeneity (eg, adolescents with friends who smoke are more likely to smoke themselves), peer influence (eg, best friends who smoke), and crowd affiliation (eg, group membership) predict adolescent smoking behaviors. In a similar light, research by Garcia et al [29] found that adolescents were 7 times more likely to have ever used an e-cigarette if their close friends also used e-cigarettes. Furthermore, studies by Hinds et al [28] indicated that sexual minority young adults are more accepting of cigarette-related norms compared to their heterosexual peers [28,29]. These findings allude to the need to explore how peer group norms may influence tobacco and nicotine product use among LGBTQ+ adolescents.

The contributions of minority stress processes and socialization factors on LGBTQ+ youth smoking have been primarily studied via retrospective surveys [28,30], limiting understanding of the real-time impacts of minority stress and socialization effects on smoking behaviors during the developmental period when sexual orientation and gender disparities in smoking emerge. Minority stress experiences [31,32] and exposure to peer norms [27-29] that influence smoking are common daily events. These events shape contemporaneous and future smoking, requiring methods that enable intensive time-series analyses to examine the contributions of these factors to LGBTQ+ adolescent smoking behaviors. Therefore, a deeper understanding of these real-time impacts is crucial for developing effective interventions.

Ecological momentary assessment (EMA) is a moment-to-moment data collection method that can detect real-time relationships between experiences with exposures, such as stress, sociocontextual cues, psychological states, and changes in behavioral outcomes [33], such as tobacco, nicotine, and cannabis product use. EMA research has examined the contributions of minority stress and socialization factors to smoking among LGBTQ+ adult populations [34-36]. For example, Livingston et al [32] found that for every unit increase in stress, there was a 3-fold increase in reports of smoking among LGBTQ+ young adults in the same observation period. EMA research by Nguyen et al [34] also identified sociocontextual and environmental influences (eg, being around other smokers and socializing in bars) as unique risk factors for smoking. However, the study was constrained to only the adult LGBTQ+ population. Identifying age-appropriate sociocontextual and environmental risk (and protective) factors for LGBTQ+ adolescents warrants additional research.

EMA methodologies have been used to measure exposure to tobacco-related media among adolescent students with high rates of retention and participation, demonstrating their potential acceptability and feasibility among this adolescent population [21]. Furthermore, EMA can be adapted for dynamic interventions (eg, just-in-time adaptive interventions [JITAIs]), enabling researchers to both measure substance use behavior and quickly implement interventions in response to triggers for behavior [37]. With limited EMA studies on tobacco and nicotine use among LGBTQ+ adolescents, significant gaps remain in understanding specifically how minority stress and socialization factors jointly contribute to these behaviors at the individual level in real time among LGBTQ+ youth. Delineating such processes could contribute to the development of secondary prevention approaches to reduce current tobacco, nicotine, and cannabis use and promote positive health behaviors (eg, salubrious coping strategies) in response to underlying behavioral determinants.

The Puff Break Research Study, further referred to as Puff Break, is a 2-phase EMA pilot designed to characterize the momentary associations among general stress, minority stress, socialization, and other evidence-based predictors of tobacco, nicotine, and cannabis product use (eg, mood, craving) among LGBTQ+ adolescents aged 14 to 19 years. In phase 1, Puff Break aimed to use key informant interviews with subject matter experts and LGBTQ+ adolescent interview data to adapt an existing adult EMA protocol to validly and reliably measure minority stress exposure, smoking socialization, and smoking and vaping behavior among LGBTQ+ adolescents. In phase 2, via the adapted EMA protocol, we will assess the acceptability and feasibility of real-time measurement of minority stress; smoking socialization; and tobacco, nicotine, and cannabis product use behaviors in a sample of 50 LGBTQ+ identified adolescents (aged 14-19) who reported combustible cigarette or e-cigarette use. This paper describes the phase 2 protocol.

All study procedures were reviewed and approved by the San Diego State University Human Research Protection Program’s Institutional Review Board (HS-2022-0101).

Puff Break used Tango gift cards to remunerate participants, as Tango gift cards offer a wide variety of redeemable merchants and branded gift cards. Participants received US $25 for completing the baseline survey and US $25 for completing the exit survey and interview. Remuneration during the EMA trial was commensurate with the completion rate of the assessment, in which participants received an additional US $50 for a <50% survey completion rate, US $100 for ≥50% and ≤80%, or an additional US $125 for >80%. The total remuneration a participant could receive ranged from US $100 to US $175. The remuneration schedule is consistent with previous EMA research of similar duration with adolescent samples [38,39]. Participants who attended a meeting in person were given an additional US $40 for transportation reimbursement. Thus, participants who attended both the onboarding and exit meetings in person received an additional US $80.

Phase 1 of the project included the development of the EMA protocol, adapted from other existing protocols for measuring antecedents and correlates of smoking behaviors among LGBTQ+ young adults [32,34,36] and other existing protocols for measuring antecedents and correlates of smoking behaviors among LGBTQ+ young adults. To ensure the acceptability, feasibility, and appropriateness of phase 2 of the Puff Break protocol, we first established a participatory planning group, consisting of 5 leaders within the local county health department and nonprofit organizations focused on serving LGBTQ+ youth, to consult on their expertise related to the goals of the project. In addition, we conducted semistructured interviews with 7 key informant subject matter experts and 10 LGBTQ+ adolescents, 90% (9/10) of whom reported tobacco, nicotine, and cannabis use. Insights from these interviews led to iterative adaptations (eg, measurement selection, preferences for response formats, momentary sampling response schedule, and flexibility of scheduling due to work or school conflicts), contributing to the development of the phase 2 protocol described in this paper.

The phase 2 protocol was programmed into the mobile EMA (mEMA) software ilumivu [40]. Figure 1 [34,41-45] displays the domains of the final adapted EMA protocol used to assess stress, socialization, and other pertinent factors in relation to tobacco or nicotine product use among LGBTQ+ adolescents. A detailed list of measures included in the EMA protocol is provided in Multimedia Appendix 1 [41,46-56] and Multimedia Appendix 2 [34,41-43,46,55,57-61]. Both in-person and remote protocols to train participants on EMA procedures and complete onboarding and exit assessments were developed to make the study as accessible as possible for participants. Unless otherwise noted, study components were identical for the in-person and remote versions of Puff Break.

The following inclusion criteria were set based on previous EMA studies on youth smoking behavior [22,65]: (1) individuals who reported current tobacco, nicotine, or cannabis product use (ie, any use in the past 30 days); (2) individuals who were aged between 14 to 19 years old; (3) individuals who self-identified as LGBTQ+; and (4) individuals who had daily access to a personal smartphone. The screener survey collected respondents’ contact and demographic information (age, residence, race, ethnicity, sex, gender identity, and sexual orientation). The survey also included 13 questions assessing the past month and daily product use. Participants were first asked if they had used any of the following products within the past 30 days: combustible cigarette, cigar, cigarillo, bidi, hookah, e-cigarette, chewing tobacco, snus, snuff, nicotine lozenges, nicotine patches, nicotine gum, cannabis, and other. If they responded yes to using any of the products, additional follow-up questions were asked, adapted from the Population Assessment of Tobacco and Health study, Wave 7 [41]. However, a more detailed assessment of recent product use was captured for those who enrolled in the study at the onboarding meeting (refer to Timeline Follow Back Assessment section). Finally, participants were asked to choose a potential date for onboarding into the study, provided they met the eligibility criteria. Participants who reported using combustible or vaporized products at least 5 times per day on a typical day were prioritized for enrollment, but this level of use was not an eligibility requirement.

The overall study components included an in-person or remote onboarding meeting, a 2-week EMA trial, and an in-person or remote exit meeting (Figure 2). Except when noted, in-person and remote protocols were identical.

Puff Break is an EMA protocol developed through an iterative process incorporating existing EMA protocols, key informant insights, and perspectives from LGBTQ+ adolescents and community members. This protocol aimed to measure a range of factors influencing tobacco, nicotine, and cannabis use behaviors among LGBTQ+ youth on a momentary basis. Participants were onboarded into the study in person or remotely and completed the Puff Break protocol using flexible momentary sampling schedules. The brief Puff Break assessments were bolstered by an in-depth baseline assessment, an exit survey, and an exit interview, all of which provide the research team with additional opportunities to contextualize and validate EMA data. The quantitative and qualitative data collected from Puff Break have great potential to inform the development of JITAIs to reduce tobacco, nicotine, and cannabis use among LGBTQ+ youth.

There are some inherent limitations in the design of the Puff Break protocol. First, the small sample size may limit our ability to detect individual-level tailoring variables (eg, sexual orientation or gender-specific patterns in response) that could be meaningful for JITAI development. Second, while EMA assessments can generate numerous observations per participant, capturing time, state, and context factors that contribute to real-time and lagged tobacco, nicotine, and cannabis use, the brevity of EMA, by design, may overlook key exposures or modifying factors of product use. To account for these potential limitations, Puff Break used exit interviews to carefully review snapshots of each participant’s response data that enabled participants to further contextualize factors that influenced their tobacco, nicotine, and cannabis use.

If Puff Break is deemed acceptable and feasible by LGBTQ+ youth participants and is able to support identification of robust exposures linked to tobacco, nicotine, and cannabis use, this protocol has great potential to serve as the basis for the development of a JITAI to reduce tobacco, nicotine, and cannabis use. With such results, we will seek funding to adapt Puff Break from an observational tool into an ecological momentary intervention. However, if analyses indicate that Puff Break did not measure robust exposures linked to tobacco, nicotine, and cannabis use among LGBTQ+ youth nor generate enough substantive information to inform JITAI development, we will further adapt the Puff Break protocol until sufficient evidence is collected.