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