# An Ecological Momentary Assessment Protocol to Measure Stress, Socialization, and Other Contributors to Smoking Behaviors Among LGBTQ+ Adolescents: Multimethod Evaluation of Feasibility, Acceptability, and Appropriateness From the Puff Break Research Study

## TL;DR

This study tested a smartphone-based method to assess stress and social factors affecting smoking in LGBTQ+ teens, finding it feasible and acceptable.

## Contribution

The study introduces and validates a tailored EMA protocol for assessing smoking behaviors in LGBTQ+ adolescents.

## Key findings

- EMA protocol showed high feasibility, acceptability, and appropriateness among LGBTQ+ adolescents.
- Participants reported increased awareness of their product use through the EMA method.
- Themes from feedback included ease of use and suggestions for improved survey timing and response options.

## Abstract

Smartphone-based ecological momentary assessment (EMA) methods highlight the impact of minority stress and socialization (eg, discrimination and social support) on smoking behaviors in lesbian, gay, bisexual, transgender, queer, and other sexual and gender minority (LGBTQ+) adults; however, studies among LGBTQ+ adolescents are limited. The Puff Break EMA protocol was developed to address this gap.

This study aims to report on the acceptability, feasibility, and appropriateness of the Puff Break EMA protocol.

We utilized a multimethod design to evaluate the acceptability, feasibility, and appropriateness of the Puff Break EMA protocol. Participants who reported tobacco/nicotine or cannabis product use within the last 30 days engaged in a 2-week EMA trial, receiving 5 daily assessments measuring tobacco, nicotine, and cannabis use, stress and socialization, and product craving. Posttrial, participants completed a 15-minute exit survey and 60-minute semistructured exit interview. The exit survey used the 12-item Weiner acceptability, appropriateness, and feasibility measures and 6-item Mobile Application Rating Scale, app-specific subscale and also included 7 open-ended responses. The exit interview focused on a review of participants’ data to help understand smoking patterns and experiences with the Puff Break EMA protocol along with questions guided by the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework to understand how a future EMA mobile intervention aimed at monitoring and reducing tobacco, nicotine, and cannabis product use could effectively be disseminated to, accessed by, and implemented with LGBTQ+ adolescents. Lastly, lessons learned were obtained through feedback and data collected throughout the study.

All 50 adolescents between the ages of 15‐19 (mean 17.82, SD 1.19) were enrolled in the study August 2023 and July 2024. Participants predominantly reported using vaporized tobacco and nicotine products (47/50, 94%), followed by cannabis products (39/50, 78%). The study sample was diverse regarding sexual orientation and gender identities with 32% (16/50) identifying as gay or lesbian, 32% (16/50) bisexual or pansexual, and 14% (7/50) transgender (neither transmasculine nor transfeminine). The median EMA response rate was 75% (~53 of 70 EMA surveys). Results indicated high feasibility (mean 4.43, SD 0.77), acceptability (mean 4.15, SD 0.83), and appropriateness (mean 4.46, SD 0.67) of the Puff Break EMA protocol. The Mobile Application Rating Scale app-specific subscale also indicated high acceptability and feasibility for the EMA method to increase knowledge, awareness, and intentions to monitor tobacco/nicotine use (mean 4.14, SD 1.01). Triangulated results from closed and open-ended survey responses identified 5 key themes related to feasibility, acceptability, and appropriateness. Participants highlighted the ease of the Puff Break EMA protocol, prompt survey reminders, and increased product use awareness. Key feedback from exit interviews included increased flexibility for survey timing, better response-option alignment, and appropriate only for populations interested in monitoring or reducing their product use.

Findings indicate that using EMA methods to understand the impact of stress and socialization experiences on smoking behaviors in LGBTQ+ adolescents is feasible, appropriate, and acceptable.