Research Article
Tobacco Use and Sexual Orientation in a National Cross-sectional Study: Age, Race/Ethnicity, and Sexual Identity–Attraction Differences

https://doi.org/10.1016/j.amepre.2018.03.009Get rights and content

Introduction

The purpose of this study is to determine the past-year prevalence estimates of any nicotine/tobacco use, cigarette smoking, and DSM-5 tobacco use disorder based on sexual identity among U.S. adults, and to examine potential variations in these estimates by age, race/ethnicity, and sexual identity–attraction concordance/discordance.

Methods

The 2012–2013 National Epidemiologic Survey on Alcohol and Related Conditions collected data via in-person interviews with a cross-sectional nationally representative sample of non-institutionalized adults (response rate=60.1%) and analyses for the present study were conducted in 2017.

Results

Any past-year nicotine/tobacco use, cigarette smoking, and DSM-5 tobacco use disorder were most prevalent among sexual minority–identified adults compared with heterosexual-identified adults, with notable variations based on sex, age, race/ethnicity, and sexual identity–attraction discordance. Elevated rates of any nicotine/tobacco use, cigarette smoking, and DSM-5 tobacco use disorder among sexual minorities were most prevalent among younger lesbian women and gay men, and all age groups of bisexual men and women. The odds of any nicotine/tobacco use, cigarette smoking, and DSM-5 tobacco use disorder were significantly greater among sexual identity–attraction discordant women and significantly lower among sexual identity–attraction discordant men.

Conclusions

These findings provide valuable new information about sexual minority subgroups, such as self-identified bisexual older adults and sexual identity–attraction discordant women, that appear to be at higher risk for adverse smoking-related health consequences as a result of their elevated rates of cigarette smoking. Additional attention is warranted to examine these high-risk subpopulations prospectively and, if the results are replicated with larger samples, this information can be used to target smoking-cessation and lung cancer screening efforts.

Introduction

Despite national progress in reducing tobacco use, which remains the leading preventable cause of death, disparities in smoking are evident in a number of population groups in the U.S. and elsewhere. There is evidence that some smoking-cessation programs may increase socioeconomic inequalities in smoking.1 High-quality research has unequivocally shown that sexual minorities (i.e., people who identify as lesbian, gay, or bisexual; report same-sex attraction; or engage in same-sex sexual behaviors) are at substantially higher risk for tobacco use than their heterosexual counterparts.2, 3, 4, 5, 6, 7, 8, 9, 10 However, risks vary across sexual minority subgroups. For example, bisexual women are at higher risk of smoking than lesbian women.11, 12 Additionally, there are differences in risk for cigarette smoking and other substance use behaviors based on age, race/ethnicity, and how sexual orientation is defined (i.e., based on attraction, behavior, or identity).2, 3, 11, 12, 13, 14, 15, 16, 17, 18, 19 These findings emphasize the need to better understand variations in risk within and across sexual orientation dimensions.20, 21

Findings based on sexual identity often vary from those on sexual attraction or behaviors. For example, one study found that bisexual-identified men were at heightened risk of cigarette smoking, but no such differences were found based on the sex of sexual partners or those to whom the men were attracted.12 These findings are consistent with other work14, 16, 17 that concluded sexual identity should be considered within the context of other sexual orientation dimensions when examining substance use behaviors.

Discordance between domains of sexual orientation (i.e., a mismatch between self-reported sexual identity and sexual attraction or behavior) may play a role in substance use risk.14, 17, 22, 23 Consistent with prior research and the minority stress model, sexual minority identification may expose an individual to discrimination, tobacco-friendly community norms, and targeted tobacco marketing.24, 25 Alternatively, sexual minorities who conceal their sexual minority identity may limit their exposure to discrimination, but experience cognitive dissonance, leading to stress and increased risk of substance use.17, 24, 26 Although limited, research findings suggest that discordant sexual orientation dimensions increase risk of hazardous drinking and other substance use. This research has focused primarily on sexual minority women; less is known about sexual orientation discordance for sexual minority men or the implications of discordance on health.14, 17, 22, 23

Studies that examine the role of sexual orientation discordance and substance use have relied heavily on samples of predominantly heterosexual-identified women, assessed lifetime sexual orientation as opposed to current orientation, combined sexual orientation dimensions (e.g., sexual attraction and behavior), and often excluded cigarette smoking and high-risk tobacco use, such as DSM-5 tobacco use disorder (TUD). This is problematic, given that bisexual men and women appear to have the highest rates of cigarette smoking and TUD.5, 7, 27 In addition, past national surveys indicate sexual identity–attraction discordance is more prevalent than sexual identity–behavior discordance.28, 29 More research is needed to understand variations in tobacco use disparities across sexual orientation dimensions, including sexual identity–attraction discordance.

Age and race appear to be important moderators of the associations between sexual orientation and alcohol, tobacco, and other substance use (e.g., white sexual minorities at greater risk for cigarette smoking).12, 15, 19, 21 However, no nationally representative study has examined tobacco use in relation to age, race/ethnicity, and sexual identity–attraction discordance. Investigations that consider such differences are a next logical step in understanding tobacco use disparities among sexual minorities. Such information can be used to enhance screening, diagnosis, prevention, and treatment efforts.27 Building on previous research, the authors hypothesize that cigarette smoking, any nicotine/tobacco use (i.e., cigarette smoking, cigars, pipe, chewing tobacco, or e-cigarettes/e-liquid), and DSM-5 TUD are more prevalent among sexual minorities than heterosexual adults. This study also explores variations in cigarette smoking, any nicotine/tobacco use, and DSM-5 TUD by age, race/ethnicity, and sexual identity–attraction concordance/discordance.

Section snippets

Study Sample

Data are from the 2012–2013 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC-III), the primary source of information regarding DSM-5 TUD among the general civilian non-institutionalized population of individuals aged ≥18 years in the U.S. The NESARC-III included the National Institute on Alcohol Abuse and Alcoholism Alcohol Use Disorder and Associated Disabilities Interview Schedule-5 (AUDADIS-5), a fully structured diagnostic interview conducted in households. In-person

Results

As illustrated in Table 1, there were notable sexual identity differences in nicotine/tobacco use, cigarette smoking, and DSM-5 TUD for the total sample. For example, 35.3% of lesbian women and 44.9% of bisexual women reported past-year cigarette smoking compared with 20.2% of heterosexual women (p<0.05). Similarly, 35.7% of gay men and 45.2% of bisexual men reported past-year cigarette smoking compared with 26.0% of heterosexual men (p<0.05). This study found similar differences in past-year

Discussion

These findings provide new evidence about tobacco use disparities among sexual minorities. Although studies that combine lesbian, gay, and bisexual adults in analyses are helpful for identifying potential health disparities, they do not fully account for possible within-group differences among sexual minoritities. Findings that bisexual men are at higher risk than gay or heterosexual men for past-year nicotine/tobacco use point to higher risk for smoking-related adverse health consequences in

Conclusions

Significantly higher rates of cigarette smoking, other nicotine/tobacco use, and DSM-5 TUD were found among sexual minorities, sexual identity–attraction discordant women, and sexual identity–attraction concordant men. Moreover, young and middle adult lesbian women and gay men were at higher risk than their age-matched heterosexual counterparts; by contrast, bisexual men and women of all ages were at higher risk. These findings represent valuable new information that can help identify sexual

Acknowledgments

The development of this article was supported by research grants L40DA042452, R01CA203809, R01CA212517, R01DA031160, and R01DA036541 from the National Cancer Institute and National Institute on Drug Abuse, NIH. This manuscript was prepared using a limited access dataset obtained from the National Institute on Alcohol Abuse and Alcoholism. The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or

References (38)

  • J.G. Lee et al.

    Tobacco use among sexual minorities in the USA, 1987 to May 2007: a systematic review

    Tob Control

    (2009)
  • J.G. Lee et al.

    Up in smoke: vanishing evidence of tobacco disparities in the Institute of Medicine’s report on sexual and gender minority health

    Am J Public Health

    (2012)
  • Medley G, Lipari RN, Bose J, Cribb DS, Kroutil LA, McHenry G. Sexual orientation and estimates of adult substance use...
  • S.E. McCabe et al.

    Assessment of difference in dimensions of sexual orientation: implications for substance use research in a college-age population

    J Stud Alcohol

    (2005)
  • D.D. Matthews et al.

    A profile of North Carolina lesbian, gay, and bisexual health disparities, 2011

    Am J Public Health

    (2014)
  • S.T. Russell et al.

    Adolescent same-sex romantic attractions and relationships: implications for substance use and abuse

    Am J Public Health

    (2002)
  • L. Drabble et al.

    Reports of alcohol consumption and alcohol-related problems among homosexual, bisexual, and heterosexual respondents: results from the 2000 National Alcohol Survey

    J Stud Alcohol

    (2005)
  • A.K. Matthews et al.

    A longitudinal study of the correlates of persistent smoking among sexual minority women

    Nicotine Tob Res

    (2014)
  • S.E. McCabe et al.

    Sexual orientation, substance use behaviors, and substance dependence in the United States

    Addiction

    (2009)
  • Cited by (0)

    View full text