Sexual orientation disparities in adolescent cigarette smoking: intersections with race/ethnicity, gender, and age

Examining tobacco use at the intersection of gender, sexual orientation, race, and ethnicity using national U.S. data of sexual and gender diverse youth

OBJECTIVES

To expand the literature documenting that tobacco use inequities persist and continue to increase for minoritized youth populations by exploring patterns of tobacco use across multiple intersections of sexual, gender, racial, and ethnic identities. Studies with this focus are needed to understand the degree to which tobacco use varies across groups who hold multiple minoritized identities.

METHODS

The current study used a novel analytical approach- Exhaustive Chi-square Automatic Interaction Detection - to examine lifetime cigarette use among a U.S.-based sample of sexual and gender diverse youth collected in 2022. Exhaustive Chi-square Automatic Interaction Detection is a data-driven, decision-tree approach that uses successive Chi-square tests to iteratively cycle through all interactions among categorical independent variables, splitting where categories differ significantly with respect to the dependent variable. Participants identified as sexual and/or gender diverse youth, resided in the U.S., and were between 13-18 years of age (N = 9,504).

RESULTS

Several important patterns emerged: The groups with the highest prevalence of cigarette experimentation included transgender boys, cisgender boys, and non-binary youth. These adolescents were likely to also hold minoritized racial and ethnic identities, and identify with plurisexual identities. Some age-related differences in patterns emerged; across grades, transgender boys and Multiracial sexually and gender diverse youth were a part of high prevalence cigarette experimentation groups.

CONCLUSIONS

The results highlight the complex patterns of cigarette use differences in heterogenous sexual and gender diverse populations, particularly across gender, sexual, and ethnoracial identities.

Gaps in smoking cessation counseling administered by healthcare providers to BIPOC gay men who smoke daily in the U.S

BACKGROUND

Black, Indigenous, and People of Color (BIPOC) racial/ethnic groups, sexual minorities (SM), and men have higher odds of smoking, less access to smoking cessation education and services, and lower smoking cessation rates than their white, heterosexual, and women counterparts. The purpose of this study is to examine the experiences of BIPOC gay men in accessing smoking cessation counseling from their healthcare providers and understand the facilitators and barriers to smoking cessation.

METHODS

This study analyzed data from BIPOC gay men who smoke daily via social media and organizational listservs throughout the United States and conducted semi-structured individual qualitative interviews. Two trained coders used thematic analysis to analyze the data.

RESULTS

Findings identified three overarching themes: 1) Sources of Information, 2) Facilitators and Barriers, and 3) Areas of Improvement for Smoking Cessation Counseling. Participants reported trusting advice from community members over healthcare providers regarding smoking cessation counseling. They also felt that the smoking cessation advice received from healthcare providers was, at times, confusing and inadequate. Identity concordance between patient and healthcare provider helped participants feel seen by their provider, which motivated them to engage in smoking cessation counseling. Finally, participants suggested improvements for smoking cessation counseling for BIPOC gay men such as integrating mental health support in smoking cessation services, accountability for patients, and providing harm reduction alternatives instead of smoking cessation only.

CONCLUSION

BIPOC gay men who smoke daily value the importance of receiving culturally adaptive and gender-affirming care from healthcare providers who share their identities when receiving smoking cessation and harm reduction counseling.

Discrimination, identity connectedness and tobacco use in a sample of sexual and gender minority young adults

INTRODUCTION

Studies show that tobacco use among sexual and gender minority (SGM) populations is disproportionately higher than heterosexual or cisgender populations. However, few studies have examined tobacco use among SGM subgroups by race/ethnicity or associations between SGM-specific discrimination and connection to SGM identity and tobacco use.

METHODS

This study analysed survey data from 11 313 SGM (gay, lesbian, bisexual, other sexual minority or gender minority) young adults in the USA and reported current cigarette, e-cigarette, other tobacco (cigar, smokeless tobacco, hookah) and polytobacco use. We used multinomial logistic regression to estimate associations between (a) SGM subgroup, race/ethnicity, SGM-specific discrimination and SGM identity connection and (b) each tobacco use outcome (vs never use of tobacco). We conducted postestimation testing to assess predicted probabilities of tobacco use against the sample average.

RESULTS

Lesbian females (particularly black lesbian females) had higher-than-average probability of polytobacco use. White bisexual and lesbian participants had higher-than-average probability of cigarette and e-cigarette use, respectively. Higher levels of discrimination were associated with polytobacco use. Higher levels of identity connectedness were protective against certain tobacco use behaviours among gender minority participants and participants with high levels of discrimination experience.

CONCLUSIONS

We found variations in tobacco use by SGM subgroups overall and by race/ethnicity. Discrimination may be a risk factor for certain tobacco use behaviours. However, SGM identity connectedness may be protective against tobacco use among gender minority individuals and individuals experiencing SGM-specific discrimination. These findings can inform targeted approaches to reach SGM subgroups at greater risk of tobacco use.

The Association of Stigma, School, and Family Factors with Patterns of Substance Use Among LGBTQ Youth

Polysubstance use is associated with myriad short- and long-term health outcomes. Although prior research has documented differences in polysubstance use between lesbian, gay, bisexual, transgender, queer/questioning, and other sexual and gender minoritized (LGBTQ +) youth and their heterosexual/cisgender counterparts, as well as between subgroups of LGBTQ + youth, it is unknown how personal, family, and school factors are associated with substance use patterns among LGBTQ + youth. Using a large, national sample of 9646 LGBTQ + youth ages 13-17, we used latent class analysis to examine patterns of alcohol, tobacco, and marijuana use and to determine whether personal, family, and school factors predict class membership. We identified five classes of substance use: polysubstance use, polysubstance experimentation, dual alcohol and cannabis, alcohol, and no use. Greater depression and LGBTQ + victimization, and an ability to be oneself at school, were associated with greater odds of membership in the polysubstance use class, while higher levels of family connection and having a Gender Sexuality Alliance (GSA) at school were associated with lower odds of membership in the polysubstance use class. Our analysis also revealed sociodemographic differences in class membership. These findings highlight potential mechanisms for intervention to reduce polysubstance use among LGBTQ + youth.

Perceived discrimination and youth vaping: The role of intersectional identities

INTRODUCTION

Electronic cigarettes (also termed e-cigarette or vapes) often contain nicotine, an addictive psychoactive substance, which can have harmful effects during adolescence. Frequent experiences of discrimination are one risk factor shown to increase susceptibility to tobacco use, especially for individuals that identify as a social minority. Applying Intersectionality Theory, this research examined the relationship between youth experiences of discrimination and vape use at the intersection of race/ethnicity and sexual orientation.

METHOD

Cross-sectional survey data from 4747 youth (ages 12-17) that participated in the 2022 Teens, Nicotine, and Tobacco Project (TNT) online survey were used to evaluate the impact of discrimination on vape use for lesbian, gay, bisexual, and/or queer/questioning (LGBQ+) youth of color.

RESULTS

Multivariable regression analyses showed that identifying as both a sexual and racial/ethnic minority was a risk factor for experiencing discrimination. Frequent discrimination and reporting discrimination due to sexual orientation was associated with a greater likelihood of ever and current vaping. Path models supported that discrimination mediated the relationship between intersectional identity and vape use. LGBQ+ youth of color reported more frequent discrimination, which was associated with a greater likelihood of ever/current vape use.

CONCLUSIONS

Intersectionality Theory aids in understanding how discrimination can exacerbate tobacco-related disparities for youth with multiple minority identities. Findings corroborate the importance of measuring discrimination in public health surveys. Effective tobacco interventions could incorporate strategies to cope with discrimination-related stress.

Dual and polytobacco use disparities at the intersection of age, sex, race and ethnicity, and income among US adults. Results from the 2018-2019 TUS-CPS

Aim

We aim to describe disparities in dual and polytobacco use at the intersection of age, sex, race and ethnicity, and income.

Methods

We used the 2018-2019 Tobacco Use Supplement to the Current Population Survey to estimate the prevalence of combinations of dual (two products) and polytobacco (three or more products) use for cigarettes, e-cigarettes, cigars, and smokeless tobacco (n = 135,268). We created five mutually exclusive categories: 1) cigarettes and e-cigarettes, 2) cigarettes and cigars, 3) cigarettes and smokeless tobacco, 4) dual/polyuse without cigarettes, and 5) polyuse with cigarettes. We estimated the dual/polyuse prevalence at the intersection of age (18-34, 35-54, 55+ years), sex (male, female), race and ethnicity (Non-Hispanic White, Non-Hispanic Black, Hispanic, and Non-Hispanic Other), and annual household income (<$50,000, $50,000-$99,999, ≥$100,000), resulting in 72 sociodemographic categories. We used a visualization tool that allowed for detailed characterization and identification of dual and polytobacco use disparities.

Results

Females were in three of the top four groups with the highest cigarette and e-cigarette dual use. Cigarette and cigar dual use was disproportionately high among low-income Non-Hispanic Black male adults aged 35-54 and 18-34. The highest prevalence of both polyuse with cigarettes and dual/polyuse without cigarettes was among low-income, Non-Hispanic White male adults aged 18-34 years.

Conclusion

We identified the population groups disproportionately using two or more tobacco products. This information is helpful for surveillance and for the implementation of tobacco control policies aimed at decreasing disparities in tobacco use.

Sexual and Gender Identity Disparities in Nicotine and Tobacco Use Susceptibility and Prevalence: Disaggregating Emerging Identities Among Adolescents From California, USA

INTRODUCTION

Prior studies report nicotine/tobacco use disparities for sexual and gender minority (SGM) youth but have insufficiently characterized SGM identity diversity.

AIMS AND METHODS

Adolescents (mean age = 15.2) from 11 high schools in Southern California completed surveys in Fall 2021. Ever use of combustible (cigarettes, cigars, hookah) and noncombustible (e-cigarettes, e-hookah, heated tobacco, smokeless/snus, oral nicotine) nicotine/tobacco (among overall sample, n = 3795) and susceptibility to future initiation of cigarettes, e-cigarettes, and flavored non-tobacco oral nicotine (among n = 3331 tobacco-naïve youth) were compared across four gender (male/masculine, female/feminine, transgender male/female, non-binary) and seven sexual (heterosexual, bisexual, pansexual, queer, questioning, gay/lesbian, asexual) identities.

RESULTS

Non-binary (vs. cisgender male) youth had greater prevalence of ever combustible (prevalence ratio [PR] = 2.86, 95% confidence intervals (CI): 1.76 to 4.66) and non-combustible (PR = 1.94, 95% CI: 1.31 to 2.86) nicotine/tobacco use, and susceptibility to future nicotine/tobacco initiation (PR range = 2.32-2.68). Transgender (vs. cisgender male) youth had greater susceptibility to nicotine/tobacco use (PR range = 1.73-1.95), but not greater tobacco use prevalence. There was greater prevalence of non-combustible nicotine/tobacco use (PR range = 1.78-1.97) and susceptibility to nicotine/tobacco initiation (PR range = 1.36-2.18) for all sexual minority (vs. heterosexual) identities, except for asexual. Bisexual (PR = 2.03, 95% CI: 1.30 to 3.16) and queer (PR = 2.87, 95% CI: 1.31 to 6.27) youth had higher ever combustible tobacco use than heterosexual youth. Questioning (vs. heterosexual) youth were more susceptible to future tobacco initiation (PR range = 1.36-2.05) but did not differ in ever use.

CONCLUSIONS

Disparities in nicotine/tobacco use and susceptibility were present with similar effect sizes across most, but not all, SGM identities. Inclusive measurement of SGM identities in research and surveillance may inform more precise tobacco control efforts to reduce disparities.

IMPLICATIONS

Among high school students from Southern California with substantial diversity in sexual and gender identities, there was greater prevalence of tobacco use and susceptibility to future tobacco initiation for most, but not all, sexual and gender minority youth, including those with emerging sexual and gender identities such as non-binary, queer and pansexual. Additionally, findings indicate that tobacco control initiatives targeting youth who are questioning their sexual identities may be particularly important for preventing tobacco use initiation. This study reinforces the importance of measuring diversity within the LGBTQ + community for tobacco use research, and highlights how inclusive measurement can inform more precise tobacco control interventions.

Prevalence of Nicotine and Tobacco Product Use by Sexual Identity, Gender Identity, and Sex Assigned at Birth Among Emerging Adult Tobacco Users in California, United States

INTRODUCTION

Sexual and gender minority (SGM) nicotine and tobacco use disparities are well-documented among youth and young adults (YYA), and despite decades of prevention efforts, these disparities stubbornly persist. To better understand tobacco use disparities and craft tailored interventions, tobacco use patterns must be assessed in a contemporary sample of YYA across lines of sexual and gender identity, sex assigned at birth, and tobacco product types.

AIMS AND METHODS

Data were from an online survey of a diverse sample of emerging adult tobacco users (ages 18-29; N = 1491) in California, United States (2020-2021). Participants were recruited from various online and in-person locations. Bivariate and adjusted models assessed differences in four nicotine and tobacco use outcomes (past 30-day use of cigarettes, e-cigarettes, other tobacco products, and multiple tobacco product types) across six groups: Cisgender heterosexual males, cisgender heterosexual females, cisgender sexual minority (SM) males, cisgender SM females, transfeminine participants, and transmasculine participants.

RESULTS

Compared to cisgender heterosexual males, both transfeminine (OR = 2.25, 95% confidence intervals (CI) = 1.29 to 4.05) and transmasculine (OR = 1.85, 95% CI = 1.32 to 2.80) participants had higher odds of using cigarettes. Few differences were noted between groups in use of e-cigarettes. Cisgender heterosexual males had higher odds of other tobacco product use, compared to most other groups (eg, cisgender SM males: OR = 0.57, 95% CI = 0.37 to 0.87). Transmasculine participants had higher odds of multiple product use, compared to cisgender heterosexual females. Among multiple product users, transfeminine participants had the highest prevalence of using all three individual product types (35.6%).

CONCLUSIONS

Results highlight the need for different tobacco control approaches across sexual and gender identities, sex assigned at birth, and nicotine and tobacco products.

IMPLICATIONS

SGM nicotine and tobacco use disparities remain entrenched, despite concerted efforts to reduce them. The SGM population is heterogeneous and different SGM subgroups may have different needs. This study assessed, among young adult nicotine and tobacco users in California, U.S. patterns of tobacco use across sexual and gender identities, sex assigned at birth, as well as specific tobacco products used-a necessity to craft tailored tobacco control measures. We found patterns of nicotine and tobacco product use across several of these characteristics, highlighting how different prevention and cessation interventions may be needed to meaningfully address SGM nicotine and tobacco use disparities.

Exploring the Potential for Smoke-Free Laws to Reduce Smoking Disparities by Sexual Orientation in the USA

BACKGROUND

We examined associations between smoke-free laws and smoking outcomes in a nationally representative sample of US adults, including exploring whether these associations differed for heterosexual and sexual minority (SM) adults.

METHODS

We constructed county-level variables representing the percent of the population covered by state-, county-, or city-level smoke-free laws in workplaces and hospitality venues. We combined this information with restricted individual-level adult data with masked county identifiers from the National Health Interview Survey (NHIS), 2013-2018. We used modified Poisson regression to explore associations between each type of smoke-free law and the prevalence ratio (PR) of current smoking, and we used linear regression to explore associations with smoking intensity (mean cigarettes per day). We assessed interactions between smoke-free laws and SM status on the additive scale to determine whether associations were different for SM and heterosexual adults.

RESULTS

In adjusted models without interaction terms, smoke-free laws in hospitality venues were associated with lower prevalence of current smoking (PR = 0.93, 95% confidence interval (CI) = 0.89, 0.98). Both types of smoke-free laws were associated with lower mean cigarettes per day (workplace law change in mean =  - 0.50, 95% CI =  - 0.89, - 0.12; hospitality law change in mean =  - 0.72, 95% CI =  - 1.14,-0.30). We did not observe any statistically significant interactions by SM status, though statistical power was limited.

CONCLUSIONS

We did not find evidence that smoke-free laws were differentially associated with smoking outcomes for heterosexual and SM adults. Additional studies are needed to further explore the potential for tobacco control policies to address the elevated risk of smoking in SM communities.

Health Inequities in Coronary Artery Bypass Grafting Literature: A Scoping Review

Although life saving, health inequities exist regarding access and patient outcomes in Coronary artery bypass grafting (CABG), especially among marginalized groups. This scoping review's goal is to outline existing literature and highlight gaps for future research. Researchers followed guidance from the Joanna Briggs Institute and PRISMA extension for scoping reviews. We conducted a search to identify articles published between 2016 and 2022 regarding CABG and inequity groups, defined by the National Institutes of Health. Fifty-seven articles were included in our final sample. Race/Ethnicity was examined in 39 incidences, Sex or Gender 29 times, Income 17 instances, Geography 10 instances, and Education Level 3 instances. Occupation Status 2 instances, and LGBTQ+ 0 times. Important disparities exist regarding CABG access and outcomes, especially involving members of the LGBTQ+, Native American, and Black communities. Further research is needed to address health disparities and their root causes for focused action and improved health of minoritized groups.

Disparities in Cigarette, E-cigarette, Cigar, and Smokeless Tobacco Use at the Intersection of Multiple Social Identities in the US Adult Population. Results From the Tobacco Use Supplement to the Current Population Survey 2018-2019 Survey

INTRODUCTION

Sociodemographic disparities in tobacco use are prevalent and persistent in the United States. Nevertheless, few studies have examined disparities in tobacco use from an intersectionality perspective. We developed a visualization tool to identify disparities in cigarette, e-cigarette, cigar, and smokeless tobacco use at the intersection of multiple social identities.

AIMS AND METHODS

We used the 2018-2019 Tobacco Use Supplement to the Current Population Survey (TUS-CPS) to estimate the prevalence of tobacco product use at the intersection of age (18-34, 35-54, ≥55 years), sex (male, female), race/ethnicity (Non-Hispanic [NH] White, NH Black, Hispanic, NH Other), and annual household income (<$50 000, $50 000-$99 999, and ≥$100 000). Estimates accounted for the complex survey design.

RESULTS

For cigarettes, the most defining characteristic was income, with the highest prevalence among low-income NH White male adults aged 35-54 years (30.7%) and low-income NH White female adults aged 35-54 years (29.7%). For e-cigarettes, the most defining characteristic was age, with adults 18-34 years old having the highest prevalence. High prevalence groups for cigars included young- and middle-aged NH Black and NH White males, while NH White males had the highest prevalence of smokeless tobacco use.

CONCLUSIONS

Our intersectionality visualization tool is helpful to uncover complex patterns of tobacco use, facilitating the identification of high-risk groups.

IMPLICATIONS

We created a visualization tool to identify disparities in cigarette, e-cigarette, cigar, and smokeless tobacco use at the intersection of age, sex, race/ethnicity, and income. Our visualization tool helps uncover complex patterns of tobacco use, facilitating the identification of high-risk population groups that would otherwise be masked. These results can be used to implement tobacco control policies targeted at factors that promote or sustain tobacco use disparities.

Age-related patterns of cocaine and methamphetamine use across the life course in the United States: Disparities by gender and sexual identity among adults

PURPOSE

Research showing substance use decreases over the life course has focused primarily on heterosexual adults. We examined how age-related patterns of cocaine and methamphetamine use vary by sexual identity and gender among a national sample.

METHODS

We included 191,954 adults aged 18-64 from the 2015-2019 National Survey on Drug Use and Health. We described the weighted prevalence of past-year cocaine and methamphetamine use and used logistic regressions to estimate relative odds of past-year cocaine and methamphetamine use by age, stratified by gender and sexual identity (heterosexual, gay/lesbian, bisexual).

RESULTS

Cocaine and methamphetamine use was highest among lesbian, gay, and bisexual (LGB) adults compared to their heterosexual counterparts. Gay/lesbian men and women and bisexual men were also more likely to use cocaine at later ages. Heterosexual adults ages 26-34 (adjusted odds ratio [aOR] = 0.73; confidence interval [CI] = 0.65-0.83) were less likely than those 21-25 to report past-year cocaine use, but there were no differences between those ages 26-34 and 21-25 among any LGB sub-group. Heterosexual (aOR = 1.62; CI = 1.28-2.04) and gay (aOR = 2.93; CI = 1.26-6.80), men ages 26-34 were more likely to report past-year methamphetamine use than their counterparts ages 21-25. There were no age-related differences in past-year methamphetamine use between bisexual men and gay/lesbian women.

CONCLUSIONS

Patterns of cocaine and methamphetamine use across the life course for LGB individuals differ from those of heterosexuals. This has implications for targeted prevention efforts to address stimulant use among minoritized populations.

Intersectionality of Sexual Orientation With Race and Ethnicity and Associations With E-Cigarette Use Status Among U.S. Youth

INTRODUCTION

Although structural discrimination against sexual and racial/ethnicity minorities is a putative risk factor for youth tobacco use, understanding health disparities in youth E-cigarette use at the intersection of sexual orientation, race, and ethnicity is still lacking. This study aims to examine the differences in E-cigarette use prevalence among U.S. youth at the intersections of sexual orientation with race and ethnicity.

METHODS

E-cigarette use status (never, experimental, or current use) was analyzed among 38,510 U.S. youth using a pooled data set from the Youth Risk Behavior Surveillance System 2015-2019. The weighted E-cigarette use status between youth at the intersections of sexual orientation with race and ethnicity was reported, stratified by sex. Multivariable multinomial regression adjusting for relevant covariates was further conducted. Data analyses were performed in April 2022.

RESULTS

After controlling for other covariates, the RRR of current E-cigarette use compared with never use between lesbian Black girls (and heterosexual Black girls) was higher than between lesbian White girls (and heterosexual White girls) (adjusted RRR=6.99; 95% CI=2.21, 22.14). The RRR of current E-cigarette use compared with never use between lesbian other race/multiracial girls (and heterosexual other race/multi-racial girls) was higher than between lesbian White girls (and heterosexual White girls) (adjusted RRR=3.60; 95% CI=1.06, 12.26).

CONCLUSIONS

This study has shown that sexual minority Black girls were more likely to currently use E-cigarettes than heterosexual Black girls. Future studies should examine the underlying reasons for current E-cigarette use among girls with intersectional identities, including race and sexual orientation.

Substance Use Behaviors Among LGBTQ+ Youth of Color: Identification of the Populations Bearing the Greatest Burden in Three Large Samples

PURPOSE

Research has identified persistent disparities in alcohol, e-cigarette, and marijuana use, by sexual orientation, gender identity, and race/ethnicity. Using an intersectionality framework, the present study analyzes three large datasets to identify intersecting social positions bearing the highest burden of substance use.

METHODS

Data from adolescents in grades 9-12 in three samples (2019 Minnesota Student Survey, 2017-2019 California Healthy Kids Survey, and 2017 National Teen Survey) were harmonized for an analysis (N = 602,470). A Chi-squared Automatic Interaction Detection analysis compared the prevalence of four types of substance use across all combinations of four social positions (six racial/ethnic identities, five sexual orientations, three gender identities, and two sexes assigned at birth). For each substance, 10 intersectional groups with the highest prevalence of use were examined.

RESULTS

In the full sample, 12%-14% of participants reported past 30-day alcohol, e-cigarette, or marijuana use and 7% reported past 30-day binge drinking. Several intersecting marginalized social positions were consistently found to bear a high burden of substance use. For example, transgender and gender diverse (TGD) Latina/x/o young people, particularly those assigned male at birth, were in the high prevalence groups for alcohol use, binge drinking, and marijuana use. Black TGD or gender-questioning youth were commonly in the high prevalence groups.

DISCUSSION

Findings suggest that support, resources, and structural changes specifically tailored to youth with multiple marginalized identities (especially TGD) may be needed. The results argue for intersectional efforts that explicitly address racial/ethnic and cultural differences, while also integrating awareness and understanding of sexual and gender diversity.

Rethinking minority stress: A social safety perspective on the health effects of stigma in sexually-diverse and gender-diverse populations

For over two decades, the minority stress model has guided research on the health of sexually-diverse individuals (those who are not exclusively heterosexual) and gender-diverse individuals (those whose gender identity/expression differs from their birth-assigned sex/gender). According to this model, the cumulative stress caused by stigma and social marginalization fosters stress-related health problems. Yet studies linking minority stress to physical health outcomes have yielded mixed results, suggesting that something is missing from our understanding of stigma and health. Social safety may be the missing piece. Social safety refers to reliable social connection, inclusion, and protection, which are core human needs that are imperiled by stigma. The absence of social safety is just as health-consequential for stigmatized individuals as the presence of minority stress, because the chronic threat-vigilance fostered by insufficient safety has negative long-term effects on cognitive, emotional, and immunological functioning, even when exposure to minority stress is low. We argue that insufficient social safety is a primary cause of stigma-related health disparities and a key target for intervention.

An Assessment of Racial and Ethnic and Sexual Identity Centrality and Smoking Behavior

Although evidence indicates that identity centrality, or identity importance, can serve as a positive coping mechanism regarding well-being, less is known if it can also buffer against health risk behaviors like cigarette smoking. This study uses an intercategorical intersectional approach using data from 1,571 Black and Latino/a sexual and gender minority adults in the Social Justice Sexuality Project to assess the relationship between sexual and racial and ethnic identity centrality and smoking patterns. Relative risk ratios from multinomial logistic regressions highlight three findings. First, there is no evidence of a significant association between identity centrality and smoking behavior nor evidence of a significant interaction effect between racial and ethnic and sexual identity centrality. Once models were adjusted for education, the association between centrality and smoking was no longer significant. Second, results indicate that education, gender identity, familial support and outness were significant predictors of smoking behaviors. Third, results suggest that there are significant differences across the intersection of race and ethnicity and sexual identity in relative risk of smoking. In addition, findings highlight elevated risk of engaging in more casual behaviors of smoking as opposed to heightened smoking behavior among both Black and Latino/a sexual minority adults.

An Identity Affirming Web App to Help Sexual and Gender Minority Youth Cope with Minority Stress: Pilot Randomized Control Trial (Preprint)

Background

Efficacious mental health interventions for sexual and gender minority youth have had limited reach, given their delivery as time-intensive, in-person sessions. Internet-based interventions may facilitate reach to sexual and gender minority youth; however, there is little research examining their efficacy.

Objective

This study aims to describe the results of a pilot randomized controlled trial of imi, a web application designed to improve mental health by supporting lesbian, gay, bisexual, transgender, queer, and other sexual and gender minority identity affirmation, coping self-efficacy, and coping skill practice.

Methods

Sexual and gender minority youth (N=270) aged 13 to 19 (mean 16.5, SD 1.5) years and living in the United States were recruited through Instagram advertisements. Approximately 78% (210/270) of the sample identified as racial or ethnic minorities. Participants were randomized in a 1:1 fashion to the full imi intervention web application (treatment; 135/270, 50%) or a resource page–only version of the imi site (control; 135/270, 50%). The imi application covered four topical areas: gender identity; lesbian, gay, bisexual, transgender, queer, and other sexual and gender minority identity; stress and coping; and internalized homophobia and transphobia. Participants explored these areas by engaging with informational resources, exercises, and peer stories at a self-guided pace. Both arms were assessed via web-based surveys at baseline and 4-week follow-up for intervention satisfaction, stress appraisals (ie, challenge, threat, and resource), coping skills (ie, instrumental support, positive reframing, and planning), and mental health symptoms among other outcomes. Main intent-to-treat analyses compared the arms at week 4, controlling for baseline values on each outcome.

Results

Survey retention was 90.4% (244/270) at week 4. Participants in the treatment arm reported greater satisfaction with the intervention than participants in the control arm (t₂₄₁=–2.98; P=.003). The treatment arm showed significantly greater improvement in challenge appraisals (ie, belief in one’s coping abilities) than the control (Cohen d=0.26; P=.008). There were no differences between the arms for threat (d=0.10; P=.37) or resource (d=0.15; P=.14) appraisals. The treatment arm showed greater increases in coping skills than the control arm (instrumental support: d=0.24, P=.005; positive reframing: d=0.27, P=.02; planning: d=0.26, P=.02). Mental health symptoms improved across both the treatment and control arms; however, there were no differences between arms. Within the treatment arm, higher engagement with imi (≥5 sessions, >10 minutes, or >10 pages) predicted greater improvement in stress appraisals (all P values <.05).

Conclusions

The results provide initial evidence that asynchronous psychosocial interventions delivered via a web application to sexual and gender minority youth can support their ability to cope with minority stress. Further research is needed to examine the long-term effects of the imi application.

Trial Registration

ClinicalTrials.gov NCT05061966; https://clinicaltrials.gov/ct2/show/NCT05061966

A population-based study of the intersection of sexual identity and race/ethnicity on physiological risk factors for CVD among U.S. adults (ages 18-59)

Objectives: Sexual minorities face significant psychosocial stressors (such as discrimination and violence) that impact their health. Several studies indicate that sexual minority women (SMW) and bisexual men may be at highest risk for cardiovascular disease (CVD), but limited research has examined physiological CVD risk or racial/ethnic differences. This study sought to examine racial/ethnic differences in physiological risk factors for CVD among sexual minority and heterosexual adults.Design: We analyzed data from the National Health and Nutrition Examination Survey (2001-2016) using sex-stratified multiple linear regression models to estimate differences in physiological CVD risk. We compared sexual minorities (gay/lesbian, bisexual, 'not sure') to heterosexual participants first without regard to race/ethnicity. Then we compared sexual minorities by race/ethnicity to White heterosexual participants.Results: The sample included 22,305 participants (ages 18-59). Lesbian women had higher body mass index (BMI) but lower total cholesterol than heterosexual women. Bisexual women had higher systolic blood pressure (SBP). Gay men had lower BMI and glycosylated hemoglobin (HbA1c) relative to heterosexual men. White and Black lesbian women and bisexual women of all races/ethnicities had higher BMI than White heterosexual women; Black bisexual women had higher SBP and HbA1c. Black sexual minority men had higher HbA1c relative to White heterosexual men. Latino 'not sure' men also had higher SBP, HbA1c, and total cholesterol than White heterosexual men.Conclusions: Given evidence of higher CVD risk in sexual minority people of color relative to White heterosexuals, there is a need for health promotion initiatives to address these disparities. Additional research that incorporates longitudinal designs and examines the influence of psychosocial stressors on CVD risk in sexual minorities is recommended. Findings have implications for clinical and policy efforts to promote the cardiovascular health of sexual minorities.

How the Expansion of the U.S. Preventive Services Task Force Lung Cancer Screening Eligibility May Improve Health Equity Among Diverse Sexual and Gender Minority Populations

This article discusses the potential implications of addressing lung cancer disparities among diverse sexual and gender minority (SGM) populations based on the recently expanded U.S. Preventive Services Task Force 2021 guidelines on lung cancer screening using low-dose computed tomography to include adults aged 50-80 years who have a 20 pack-year smoking history (one pack-year equals smoking one pack or 20 cigarettes per day for 1 year) and currently smoke or have quit within the past 15 years. Research on lung cancer screening barriers and facilitators and efforts to increase awareness and screening uptake among SGM populations are proposed.

Disparities in smoking during pregnancy by sexual orientation and race-ethnicity

The intersection between sexual orientation and race-ethnicity is emerging as an important dynamic for health. Prior research indicates that sexual orientation can have very different health implications for White, Black, and Latina individuals and that these patterns are unpredictable. Here we use U.S. data from the National Survey of Family Growth (2006-2019, n = 15,163 pregnancies) to examine how an important health indicator - smoking during pregnancy - is shaped jointly by sexual orientation and race-ethnicity. Smoking during pregnancy was more common among sexual minority women (both bisexual-identified and heterosexual-identified who expressed same-gender attraction/behavior), compared to heterosexual women. Second, the association between sexual orientation and smoking during pregnancy differed by race-ethnicity: sexual minority status was more strongly associated with smoking among Latina women, compared to White women. Finally, the subgroup with the highest rates of smoking during pregnancy was bisexual White women. These findings indicate that smoking rates among pregnant sexual minority women warrant attention (regardless of race-ethnicity), particularly as births within this group are rising. It is important to address structural factors that may create more stress for sexual minority women, since smoking is often a response to stress. These findings also highlight the role of heterogeneity: low smoking rates among pregnant Latina women mask within-group disparities.

Sexual Identity Differences in Health Behaviors and Weight Status among Urban High School Students

Although racial/ethnic disparities in childhood obesity are well documented in the United States (U.S.), fewer studies have investigated elevated body mass index (BMI) and related health behaviors among sexual minority youth (SMY; gay/lesbian, bisexual, not sure). We examined pooled data from the 2009-2017 Youth Risk Behavior Surveys, which included high school students from 12 urban U.S. school districts. We used sex-stratified logistic regression models to estimate the association of sexual identity with health behaviors and elevated BMI (reference = heterosexual participants). A total of 133,615 participants were included. Sexual minority boys were more likely to report physical inactivity than heterosexual boys. Gay and not sure boys were also less likely to consume the recommended daily intake of fruit. Bisexual girls were more likely than heterosexual girls to report watching television ≥ 3 hours on a school day and to consume sugar-sweetened beverages (AOR 1.30, 95% CI= 1.18-1.43). All SMY reported higher rates of current tobacco use than their heterosexual peers. Sexual minority girls and bisexual boys had significantly higher rates of obesity than their heterosexual counterparts. These findings can inform tailored health promotion initiatives to reduce obesity risk in SMY.

First- and Second-Hand Experiences of Enacted Stigma Among LGBTQ Youth

Research on enacted stigma, or stigma- and bias-based victimization, including bullying and harassment, among lesbian, gay, bisexual, transgender, and queer (LGBTQ) youth often focuses on one context (e.g., school) or one form (e.g., bullying or microaggressions), which limits our understanding of these experiences. We conducted qualitative go-along interviews with 66 LGBTQ adolescents (14-19 years) in urban, suburban, town, and rural locations in the United States and Canada identified through purposive and snowball sampling. Forty-six participants (70%) described at least one instance of enacted stigma. Three primary themes emerged: (1) enacted stigma occurred in many contexts; (2) enacted stigma restricted movement; and (3) second-hand accounts of enacted stigma shaped perceptions of safety. Efforts to improve well-being among LGBTQ youth must address the diverse forms and contexts of enacted stigma that youth experience, which limit freedom of movement and potential access to opportunities that encourage positive youth development. School nurses can play a critical role in reducing enacted stigma in schools and in collaboration with community partners.

Variation in diet quality across sexual orientation in a cohort of U.S. women

PURPOSE

Extensive prior research has shown that sexual minority women are more likely to have a number of cancer risk factors, thereby putting them at higher risk for cancer than heterosexual women. However, there has been little research evaluating the association between sexual orientation and diet quality.

METHOD

Data come from participants (aged 24-54 years) enrolled in Nurses' Health Study 3, an ongoing, U.S.-based cohort study (N = 15,941). We measured diet using recommendations from the Dietary Approach to Stop Hypertension (DASH) and American Health Association (AHA) 2020 Strategic Impact Goals.

RESULTS

We found limited evidence of differences across diet quality by sexual orientation. When examining predicted DASH scores, mostly heterosexual [predicted mean score (95% confidence interval), 24.0 (23.8, 24.3)] and lesbian [24.3 (23.8, 24.9)] women had healthier predicted DASH scores than the reference group of completely heterosexual women with no same-sex partners [23.6 (23.5, 23.7)]. Even though certain sexual minority women had overall healthier predict DASH scores, their consumption of certain food groups-low-fat dairy and fruit-was lower than completely heterosexual women with no same-sex partners. When measuring AHA scores, most sexual minority groups (completely heterosexual women with same-sex partners, mostly heterosexual women, and lesbian women) had higher diet quality compared to the reference group of completely heterosexual women with no same-sex partners.

CONCLUSION

Sexual minority women, particularly mostly heterosexual women and lesbian women, had healthier diet quality than completely heterosexual women with no same-sex partners. These data suggest that cancer risk factors (e.g., smoking, drinking, and inactivity) other than diet would drive higher cancer rates among sexual minority compared to heterosexual women. Nonetheless, it is critical for all women to improve their diet quality since diet quality was poor among participants of all sexual orientations.

Connected, Respected and Contributing to Their World: The Case of Sexual Minority and Non-Minority Young People in Ireland

Outcome 5 of the Irish Better Outcomes, Brighter Futures national youth policy framework (“Connected, respected, and contributing to their world”) offers a suitable way to study psychosocial determinants of adolescent health. The present study (1) provides nationally representative data on how 15- to 17-year-olds score on these indicators; (2) compares sexual minority (same- and both-gender attracted youth) with their non-minority peers. We analyzed data from 3354 young people (aged 15.78 ± 0.78 years) participating in the Health Behaviour in School-aged Children (HBSC) study in Ireland. Age and social class were associated with the indicators only to a small extent, but girls were more likely than boys to report discrimination based on gender and age. Frequency of positive answers ranged from 67% (feeling comfortable with friends) to 12% (being involved in volunteer work). Sexual minority youth were more likely to feel discriminated based on sexual orientation, age, and gender. Both-gender attracted youth were less likely than the other groups to report positive outcomes. Same-gender attracted youth were twice as likely as non-minority youth to volunteer. The results indicate the importance of a comprehensive approach to psycho-social factors in youth health, and the need for inclusivity of sexual minority (especially bisexual) youth.

Inequities in tobacco advertising exposure among young adult sexual, racial and ethnic minorities: examining intersectionality of sexual orientation with race and ethnicity

OBJECTIVE

This study examined sexual orientation differences in encoded exposure to tobacco product ads and intersections with race and ethnicity.

METHODS

We analysed data from young adults (18-24) from the US Population Assessment of Tobacco and Health Study in 2013 and 2014 (N=9110). First, we compared encoded exposure to cigarette, electronic cigarette (e-cigarette), cigar and smokeless tobacco ads between sexual minorities (lesbian/gay, bisexual and something else) versus heterosexual young adults. We then analysed encoded ad exposure across sexual orientation, racial and ethnic subgroups. Analyses controlled for demographic and tobacco use variables.

RESULTS

Bisexual women had significantly higher prevalence of encoded exposure to cigarette and cigar ads compared with heterosexual women, and significantly higher prevalence of encoded e-cigarette ad exposure compared with both heterosexual and lesbian/gay women. There were no significant differences in encoded ad exposure between lesbian versus heterosexual women and between gay or bisexual men versus heterosexual men. Compared with heterosexual white counterparts, increased encoded ad exposures were reported by heterosexual black women (cigarette and cigar ads), black heterosexual men (cigar ads) and bisexual black women (cigarette and cigar ads). Compared with heterosexual non- Hispanic counterparts, increased encoded ad exposures were reported by bisexual Hispanic women (cigarette, e-cigarette and cigar ads) and heterosexual Hispanic men (cigarettes and cigar ads).

CONCLUSION

Sexual minority women of colour and black heterosexual women and men have increased encoded exposure to certain forms of tobacco ads. Further research is needed to address the impact of tobacco ads among multiple minority individuals based on sex, sexual orientation, race and ethnicity.

Associations between tobacco use patterns and demographic characteristics of sexual minority and heterosexual youth: Results from a nationwide online survey

INTRODUCTION

Youth are at risk for tobacco use, and previous research has pointed to increased vulnerabilities associated with sexual minority identity. For example, LGB youth have increased odds for using tobacco than their heterosexual peers, and bisexual youth have higher odds of smoking than other sexual identity groups. As new tobacco products proliferate and health risks from dual/poly use grow, increased understanding of tobacco use patterns by sexual minority youth is needed.

METHODS

For 3117 youth, aged 13–18 years, who completed an online questionnaire in 2017 and identified their sexual orientation [minority (e.g. lesbian/gay, bisexual, or pansexual) vs majority (heterosexual)] and gender, we classified current tobacco use into four categories: e-cigarette only, other product only (such as cigarette, cigar, or smokeless tobacco; not an e-cigarette), dual/poly use, and no use. Analyses were conducted separately for male and female participants. Multinomial logistic regression was employed.

RESULTS

Female sexual minority youth had nearly twofold odds of dual/ poly tobacco use (OR=1.95; 95% CI: 1.12–3.40), compared to their heterosexual counterparts. For male youth, sexual minority identification was not significantly associated with dual/poly use. No significant differences were found in sexual minority and heterosexual youth e-cigarette only or other tobacco only use groups. Tobacco use patterns also significantly differed by age, race, place of residence, and parental education level.

CONCLUSIONS

Study findings reveal greater odds of dual/poly tobacco use for female sexual minority youth. Tailored tobacco prevention and cessation programs or interventions are needed for sexual minority youth most at risk of tobacco use, especially multiple product use.

We are in This Together: Promoting Health Equity, Diversity, and Inclusion in Tobacco Research for Sexual and Gender Minority Populations

INTRODUCTION

Sexual and gender minority (SGM) individuals have higher tobacco use prevalence and consequently higher burden of tobacco-caused diseases, including cancer and cardiovascular disease compared with their heterosexual or cisgender counterparts. Yet, there is a critical gap in research focused on measuring SGM tobacco-related health disparities and addressing unmet needs of SGM individuals in the context of nicotine and tobacco research.

AIMS AND METHODS

In this commentary, we summarize recommendations discussed during a pre-conference workshop focused on challenges and opportunities in conducting SGM tobacco control research at the 2019 Society for Research on Nicotine and Tobacco Annual Meeting.

RESULTS

Specifically, we recommend defining and measuring SGM identity in all nicotine and tobacco research routinely, using novel methods to engage a demographically diverse sample of the SGM population, and eliciting SGM community voices in tobacco control research.

CONCLUSIONS

Addressing these critical research gaps will enable the scientific community to generate the data to fully understand and support SGM individuals in tobacco use prevention and cessation.

IMPLICATIONS

Tobacco use and its consequences have become increasingly concentrated in disadvantaged groups, including sexual and gender minority (SGM) populations. Through concrete recommendations in this commentary, we aimed to promote health equity, diversity, and inclusion in tobacco research for SGM populations by urging the scientific community to consider expanding efforts to monitor and address tobacco-related health disparities of SGM populations within their respective research programs.

Sexual minority tobacco use disparities across adolescence and the transition to young adulthood

INTRODUCTION

Sexual minority (SM; e.g., lesbian, gay, bisexual) youth are disproportionately more likely to use tobacco than non-SM youth, yet there exist several critical gaps in knowledge. This study assessed (a) the timing of SM tobacco use disparities (e.g., during adolescence or early adulthood), (b) whether disparities generalize across different tobacco products, and (c) whether disparities differ by sex.

METHODS

Data were from a 6-year prospective cohort of diverse high school students from Southern California who were followed into early adulthood (9 waves, 2013-2019). SM (vs. non-SM) differences in past 6-month use were assessed for: any tobacco products, cigarettes, e-cigarettes, other products (e.g., hookah), and multiple products. Disparities were modeled longitudinally across adolescence (high school) and the transition to early adulthood (end of high school to post-high school). Differences were tested by sex.

RESULTS

Among females, SM disparities were evident for all outcomes during both adolescence and early adulthood; no differences were observed among males. For example, SM (vs. non-SM) females had higher odds of cigarette (aOR = 4.4 [3.0-6.5]) and e-cigarette (aOR = 1.7 [1.2-2.4]) use, averaged across adolescence. The timing of disparities varied by product. For example, cigarette use disparities emerged prior to high school and persisted through adolescence and young adulthood, while e-cigarette use disparities were present in early adolescence and young adulthood only.

CONCLUSIONS

Young SM females are at especially high risk for tobacco use, across various tobacco products, throughout adolescence and young adulthood. Interventions must consider differences in the timing of disparities by product type.

Sexual Orientation-Based Alcohol, Tobacco, and Other Drug Use Disparities: The Protective Role of School-Based Health Centers

This study investigated whether the presence of school-based health centers (SBHCs) was associated with six substance use behaviors among sexual minority youth (SMY) and their heterosexual peers. Data from the 2015 Oregon Healthy Teens Survey, including 13,608 11th graders in 137 schools (26 with SBHCs) were used in the current study. Multilevel logistic regression analyses were performed. Results revealed significant SBHC by SMY status interactions indicating a relatively lower likelihood of past 30-day alcohol use (23%), binge drinking (43%), use of e-cigarettes (22%), marijuana (44%), and unprescribed prescription drugs (28%) among SMY in SBHC schools compared with non-SMY at SBHC schools. Furthermore, SMY in SBHC schools reported lower likelihood of aforementioned substance use behaviors than SMY attending non-SBHC schools. Conversely, no differences in these outcomes were observed for non-SMY in SBHC and non-SBHC schools. Findings from this study suggest SBHCs may help to mitigate substance use disparities among marginalized populations, such as SMY.

Family Rejection and Cigarette Smoking Among Sexual and Gender Minority Adolescents in the USA

BACKGROUND

Sexual and gender minority (SGM) adolescents are more likely than their heterosexual and cisgender peers to smoke cigarettes. Family rejection has been associated with adverse health outcomes; however, few studies have examined whether SGM-specific family rejection is associated with cigarette smoking among SGM adolescents.

METHOD

A non-probability sample of 11,005 SGM adolescents (M = 15.58, SD = 1.27) completed an online cross-sectional survey. Bivariate and multivariable analyses were conducted to examine associations between SGM-specific family rejection, sociodemographic variables, and smoking.

RESULTS

Approximately 7% of the sample currently smoked cigarettes. Pansexual, asexual, trans boys, and non-binary assigned female at birth adolescents had the highest SGM family rejection scores. In multivariable regression analyses, SGM-specific family rejection was independently associated with smoking after adjusting for covariates (AOR = 1.15, 95% CI 1.04, 1.28). Family support (AOR = 0.80, 95% CI 0.73, 0.88) and experiencing violence (AOR = 1.64, 95% CI 1.49, 1.82) were also associated with smoking in multivariable models. Adolescents who identified as bisexual versus gay/lesbian (AOR = 1.50, 95% CI 1.21, 1.85) and trans boys versus cisgender girls (AOR = 2.05, 95% CI 1.13, 3.71) had an increased odds of smoking. Those who disclosed their sexual orientation identity to most (AOR = 1.95, 95% CI 1.45, 2.63) and all (AOR = 1.60, 95% CI 1.21, 2.11) of their family/parents had increased odds of smoking.

CONCLUSION

Our findings underscore the importance of attending to the role of SGM-specific family rejection and distinctions with SGM adolescents in tobacco prevention and smoking cessation efforts.

High Burden of Mental Health Problems, Substance Use, Violence, and Related Psychosocial Factors in Transgender, Non-Binary, and Gender Diverse Youth and Young Adults

Transgender and gender diverse (TGD) people are disproportionately impacted by various health issues and associated risk factors, but little is known about differences in these outcomes between gender identities within the TGD population. This study characterized the health of a diverse sample of TGD youth and young adults. Data were taken from the baseline visit of two longitudinal studies in the Chicago area, RADAR (N = 1079, M age = 20.8 years) and FAB 400 (N = 488, M age = 19.57 years), which are cohorts of young sexual and gender minorities assigned male at birth (AMAB) and assigned female at birth (AFAB), respectively. There was a combined sample of 214 TGD (128 AFAB, 86 AMAB) individuals across cohorts. We examined differences between gender identities in self-reported health and related psychosocial variables, and compared TGD youth and their cisgender sexual minority peers from their cohort of origin on all variables. Among TGD youth, we found high rates of depression and suicidality (ideation, plan, attempt), violence (trauma, victimization, childhood sexual abuse), and substance use (cigarette, alcohol, illicit drug use). With the exception of depression, transgender women and non-binary AMAB youth reported worse health outcomes than transgender men and non-binary AFAB youth. Non-binary AMAB youth reported the highest rates of certain outcomes, including traumatic experiences and suicidal ideation. TGD youth generally reported worse outcomes than cisgender sexual minority youth; these differences were less pronounced among AFAB youth. Findings point to the diversity of experiences within the TGD population and critical needs for intervention approaches to mitigate health disparities.

Are national antitobacco campaigns reaching high-risk adolescents? A cross-sectional analysis from PATH Wave 2

Smoking education and prevention campaigns have had marked success in reducing rates of tobacco use among adolescents, however, disparities in use continue to exist. It is critical to assess if adolescents at risk for tobacco use are being exposed to antitobacco campaigns. We used data from Wave 2 of the Population Assessment of Tobacco and Health Study to assess the relationship between exposure to three antitobacco campaigns and key characteristics related to higher risk of cigarette use using full-sample weights and Poisson regression models with robust variance. Adjusted models identified that exposure to antitobacco campaigns was more common among racial and sexual minority adolescents and adolescents who: reported exposure to tobacco marketing, spent more time using media and had household income greater than $25 000. While some high-risk youth are more likely to report exposure to campaigns, there are some priority groups that are not being reached by current efforts compared with non-priority groups, including youth living in households with income below the poverty line and adolescents who are susceptible to cigarette smoking. Future campaigns should consider targeting these groups specifically in order to reduce tobacco use disparities.

Differential Risk for Drug Use by Sexual Minority Status among Electronic Dance Music Party Attendees in New York City

Background: Drug use among electronic dance music (EDM) party attendees is common; however, studies are needed to examine associations between drug use and sexual orientation as this can inform prevention and harm reduction efforts in the lesbian, gay, and bisexual (LGB) community. Methods: Data were examined from a repeated cross-sectional study of 3066 young adult EDM party attendees surveyed entering nightclubs and dance festivals in New York City between 2016 and 2018. Of these participants, 277 identified as gay/lesbian, 293 identified as bisexual, and 83 identified as other sexuality. We examined how sexual orientation relates to past-year use of various 'traditional' drugs (e.g., ecstasy/MDMA/Molly) and new psychoactive substances (NPS; e.g., "bath salts") in a bivariable and multivariable manner, stratified by sex. Results: Compared to heterosexual males, gay males were at higher odds for use of ecstasy, GHB, and methamphetamine; bisexual males were at higher odds for use of LSD and unknown powders, and males identifying as "other" sexuality were at higher odds for use of mushrooms and 2C drugs. Compared to heterosexual females, lesbians were at higher odds for use of mushrooms and GHB; bisexual females were at higher odds for use of cocaine, LSD, mushrooms, and tryptamines, and females identifying as "other" sexuality were at higher odds for use of cocaine and tryptamines. Conclusions: We determined differential risk of use of different drugs among those who attend EDM parties according to sexual orientation. Findings can be used to tailor prevention messaging to specific groups within the LGB community.

Do inequalities add up? Intersectional inequalities in smoking by sexual orientation and education among U.S. adults

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Among men, inequalities in cigarette smoking are primarily driven by socio-economic inequalities.

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Among women, inequalities in cigarette smoking are primarily driven by sexual orientation inequalities.

Introduction

Inequalities in smoking by socio-economic status (SES) are well-known. A growing body of literature has demonstrated additional inequalities in smoking by sexual orientation. This study used an intersectional lens to examine smoking at the intersection of sexual orientation and education.

Methods

Data come from 28,362 adult participants in Wave 2 (2014–2015) of the Population Assessment of Tobacco and Health (PATH) Study. We used educational level (less than high school education (HS); HS or more) and sexual orientation (heterosexual; sexual minority) to form four intersectional positions.

We estimated prevalence differences in smoking corresponding to joint, referent, and excess intersectional inequalities using weighted linear binomial regression models. Results were stratified by gender and adjusted for ethnicity and age.

Results

The adjusted joint inequality represented 7.6% points (p.p.) (95% CI: 2.5, 12.8) difference in smoking between the doubly advantaged (heterosexual with HS or more) and doubly disadvantaged (sexual minority with less than HS) positions. Joint inequality was decomposed into referent SES inequality (12.5 p.p. (95% CI: 10.5, 14.4)); referent sexual orientation inequality (9.7 p.p. (95% CI: 6.8, 12.6)); and a substantial negative excess intersectional inequality (−14.6 p.p. (95% CI: −20.8, −8.3)), attributed to an unexpectedly low prevalence of smoking among doubly disadvantaged persons. Similar overall patterns were found in the stratified analyses.

Conclusions

We found that “doubly-disadvantaged” group of low-educated sexual minority adults did not have the greatest burden of smoking; whereas, low-educated heterosexual adults had the highest smoking prevalence. Our findings support tailoring cessation interventions to disadvantaged groups’ different needs.

Sexual orientation and gender identity disparities in substance use disorders during young adulthood in a United States longitudinal cohort

BACKGROUND

This study examined associations of sexual orientation and gender identity with prevalence of substance use disorders (SUDs) and co-occurring multiple SUDs in the past 12-months during young adulthood in a United States longitudinal cohort.

METHODS

Questionnaires self-administered in 2010 and 2015 assessed probable past 12-month nicotine dependence, alcohol abuse and dependence, and drug abuse and dependence among 12,428 participants of an ongoing cohort study when they were ages 20-35 years. Binary or multinomial logistic regressions using generalized estimating equations were used to estimate differences by sexual orientation and gender identity in the odds of SUDs and multiple SUDs, stratified by sex assigned at birth.

RESULTS

Compared with completely heterosexuals (CH), sexual minority (SM; i.e., mostly heterosexual, bisexual, lesbian/gay) participants were generally more likely to have a SUD, including multiple SUDs. Among participants assigned female at birth, adjusted odds ratios (AORs) for SUDs comparing SMs to CHs ranged from 1.61 to 6.97 (ps<.05); among participants assigned male at birth, AORs ranged from 1.30 to 3.08, and were statistically significant for 62% of the estimates. Apart from elevated alcohol dependence among gender minority participants assigned male at birth compared with cisgender males (AOR: 2.30; p < .05), gender identity was not associated with prevalence of SUDs.

CONCLUSIONS

Sexual and gender minority (SGM) young adults disproportionately evidence SUDs, as well as co-occurring multiple SUDs. Findings related to gender identity and bisexuals assigned male at birth should be interpreted with caution due to small sample sizes. SUD prevention and treatment efforts should focus on SGM young adults.

The association between gender roles and smoking initiation among women and adolescent girls

Smoking cigarettes is a leading global cause of preventable death and disease. Men historically smoke more than women, but the prevalence of smoking among women in low and middle-income countries is increasing at an alarming rate. Understanding the factors that influence smoking initiation among women and girls is needed to address the growing epidemic of women smokers and the looming impact on women's health worldwide. We assume that smoking initiation is embedded in socio-culturally influenced gendered context and use a social cognitive model with a gendered lens as a framework for organizing and synthesizing the research. Guided by this framework, we identified gaps in the literature and make recommendations for future research in this review paper. The results suggest that psychological and environmental determinants are rooted in fluctuating cultural influences and values, but few research studies provide a gendered analysis or systematically examine these factors in the context of gender and culture. Sex/gender is a significant construct through which women and girls experience the psychological, environmental, and other influences on smoking initiation. Much more research is needed to understand the psychological and environmental influences as well as the intersection of gender roles and other social categories on female smoking initiation.

Commentary: Educational and Clinical Training for Addressing Tobacco-Related Cancer Health Disparities

In the United States, tobacco use is a leading contributor to inequities in cancer health among individuals for many ethnic, racial, sexual minority, and other minority groups as well as individuals in lower socioeconomic groups and other underserved populations. Despite remarkable decreases in tobacco use prevalence rates in the United States over the past 50 years, the benefits of tobacco control efforts are not equitably distributed. Tobacco-related disparities include higher prevalence rates of smoking, lower rates of quitting, less robust responses to standard evidence-based treatments, substandard tobacco treatment delivery by health care providers, and an increased burden of tobacco-related cancers and other diseases. Among the multiple critical barriers to achieving progress in reducing tobacco treatment-related disparities, there are several educational barriers including a unidimensional or essentialist conceptualizations of the disparities; a tobacco treatment workforce unprepared to address the needs of tobacco users from underserved groups; and known research-to-practice gaps in understanding, assessing, and treating tobacco use among underserved groups. We propose the development of competency-based curricula that: 1) use intersectionality as an organizing framework for relevant knowledge; 2) teach interpersonal skills, such as expressing sociocultural respect, a lack of cultural superiority, and empathy as well as skills for developing other-oriented therapeutic relations; and 3) are grounded in the science of the evidence-based treatments for tobacco dependence. These curricula could be disseminated nationally in multiple venues and would represent significant progress toward addressing tobacco-related disparities.

Mental Health, Drug, and Violence Interventions for Sexual/Gender Minorities: A Systematic Review

CONTEXT

Compared with cisgender (nontransgender), heterosexual youth, sexual and gender minority youth (SGMY) experience great inequities in substance use, mental health problems, and violence victimization, thereby making them a priority population for interventions.

OBJECTIVE

To systematically review interventions and their effectiveness in preventing or reducing substance use, mental health problems, and violence victimization among SGMY.

DATA SOURCES

PubMed, PsycINFO, and Education Resources Information Center.

STUDY SELECTION

Selected studies were published from January 2000 to 2019, included randomized and nonrandomized designs with pretest and posttest data, and assessed substance use, mental health problems, or violence victimization outcomes among SGMY.

DATA EXTRACTION

Data extracted were intervention descriptions, sample details, measurements, results, and methodologic rigor.

RESULTS

With this review, we identified 9 interventions for mental health, 2 for substance use, and 1 for violence victimization. One SGMY-inclusive intervention examined coordinated mental health services. Five sexual minority-specific interventions included multiple state-level policy interventions, a therapist-administered family-based intervention, a computer-based intervention, and an online intervention. Three gender minority-specific interventions included transition-related gender-affirming care interventions. All interventions improved mental health outcomes, 2 reduced substance use, and 1 reduced bullying victimization. One study had strong methodologic quality, but the remaining studies' results must be interpreted cautiously because of suboptimal methodologic quality.

LIMITATIONS

There exists a small collection of diverse interventions for reducing substance use, mental health problems, and violence victimization among SGMY.

CONCLUSIONS

The dearth of interventions identified in this review is likely insufficient to mitigate the substantial inequities in substance use, mental health problems, and violence among SGMY.

Romantic Attraction and Substance Use in 15-Year-Old Adolescents from Eight European Countries

Sexual minority youth are at higher risk of substance use than heterosexual youth. However, most evidence in this area is from North America, and it is unclear whether the findings can be generalized to other cultures and countries. In this investigation, we used data from the 2014 Health Behaviour in School-aged Children (HBSC) study to compare substance use in same- and both-gender attracted 15-year-old adolescents from eight European countries (n = 14,545) to that of their peers who reported opposite-gender attraction or have not been romantically attracted to anyone. Both-gender attracted, and to a lesser extent, same-gender attracted adolescents were significantly more likely to smoke cigarettes, consume alcohol, get drunk and use cannabis, or be involved in multiple substance use in the last 30 days compared to their opposite-gender attracted peers. Those adolescents who have not been in love had significantly lower odds for substance use than all other youth. The pattern of results remained the same after adjusting for country, gender and family affluence. These findings are compatible with the minority stress and romantic stress theories. They suggest that sexual minority stigma (and love on its own) may contribute to higher substance use among adolescents in European countries.

Sexual and gender minority young adults' smoking characteristics: Assessing differences by sexual orientation and gender identity

INTRODUCTION

Sexual and gender minority (SGM) young adults have higher smoking prevalence than their non-SGM peers. Less is known about differences in smoking characteristics within the SGM community.

METHODS

Participants were SGM young adult smokers age 18-25 (N = 165, M age = 21.8) enrolled in a clinical trial of the Put It Out Project, a Facebook smoking cessation intervention for SGM young adults. Analyses tested differences between 1) sexual orientation groups, and 2) gender identity groups, on the following smoking characteristics: cigarettes/day, daily smoker (yes/no), social smoker (yes/no), years of smoking, number of close friends who smoke (out of 5), age of initiation, age began smoking regularly, time to first cigarette (30 min or less/>30 min), lifetime quit attempts, past-year quit attempts, and stage of change for quitting smoking (precontemplation, contemplation, preparation).

RESULTS

Participants were 56% bi/pansexual, 18% gay, 18% lesbian, 8% other (e.g., asexual, queer). The gender identity of the sample was 52% cisgender, 18% transgender, 30% gender non-binary. Lesbian women began smoking at an older age (M = 18.0, SD = 2.0) than "other" sexual orientation participants (M = 15.7, SD = 2.2), p < .05. Transgender participants smoked the most cigarettes per day (M = 11.3, SD = 6.7), followed by cisgender (M = 8.1, SD = 5.6), then non-binary (M = 5.7, SD = 3.5) participants (p < .001; pairwise comparisons p's < 0.05). No other constructs differed by sexual orientation or gender.

CONCLUSIONS

Smoking characteristics were mostly similar across subgroups of young adult SGM smokers; however, transgender individuals were heavier smokers.

Differential pathways into smoking among sexual orientation and social class groups in England: A structural equation model

PURPOSE

Previous research has shown that lesbian, gay and bisexual (LGB) populations smoke more than their heterosexual counterparts. Little is known about the pathways into smoking among LGB populations in England relative to the lower social class populations that are the focus of the current Tobacco Control Plan (TCP).

METHODS

Using the 2013/2014 waves of the Health Survey for England (HSE), we created a structural equation model to analyze pathways and interactions between sexual orientation, social class, and the number of cigarettes smoked daily. The path analysis assessed whether three intervening factors-age of initiation, mental wellbeing score, and exposure to smoke-are implicated similarly in smoking among LGB and lower social class populations, and whether interaction between sexual orientation and class is further associated with smoking.

RESULTS

Bivariate analysis showed that LGB-identified individuals and individuals in lower occupational classes smoke more cigarettes daily, respectively, than heterosexual individuals and those in professional/managerial-class populations. Path analysis showed that the number of cigarettes smoked daily was mediated by age of initiation, mental wellbeing score and weekly exposure to smoke among routine and manual workers; by mental wellbeing score and exposure to smoke among intermediate class workers, and by mental wellbeing score in the LGB population. Interactions between sexual orientation and social class were not significant.

CONCLUSIONS

The differential nature of pathways into smoking for lower social classes and LGB populations in England suggests the need for tailored prevention and cessation efforts, with programming for LGB populations focused on the distinct stressors they face.

An intersectional approach to examine sleep duration in sexual minority adults in the United States: findings from the Behavioral Risk Factor Surveillance System

OBJECTIVES

Investigate sexual identity differences in sleep duration and the multiplicative effect of sexual identity and race/ethnicity among US adults.

DESIGN

Cross-sectional.

PARTICIPANTS

The sample consisted of 267,906 participants from the Behavioral Risk Factor Surveillance System.

MEASUREMENTS

Sleep duration was categorized as very short (≤4 hours), short (5-6 hours), adequate (7-8 hours), or long (≥9 hours). Sex-stratified multinomial logistic regressions were used to examine sexual identity differences in sleep duration. We then examined sleep duration by comparing sexual minorities to (1) same-race/-ethnicity heterosexuals and (2) White participants with the same sexual identity.

RESULTS

Sexual minority women had higher odds of very short sleep compared to heterosexual women, regardless of race/ethnicity. Black gay men had higher rates of very short sleep but lower rates of long sleep relative to Black heterosexual men. Latino and Asian/Pacific Islander bisexual men reported higher rates of short sleep than their heterosexual counterparts. Black lesbian and other-race bisexual women were more likely to have very short sleep than their heterosexual peers. Black lesbian women also had higher rates of long sleep. Analyses examining racial/ethnic differences by sexual identity found that Black and Latino gay men reported higher rates of very short sleep compared to White gay men. Black bisexual women had higher rates of short sleep duration than White bisexual women.

CONCLUSIONS

More research is needed to understand how to promote sleep health among sexual minorities, particularly racial/ethnic minorities, and the impact of inadequate sleep duration on health outcomes in this population.

Sexual and Gender Minority College Students and Tobacco Use in Texas

Introduction

Most research regarding sexual and gender minority (SGM) populations is limited to examination of cigarette or general tobacco use or does not examine heterogeneity across SGM groups other than lesbian or gay and bisexual individuals. This study examined differences in the odds of current use and age of initiation of five tobacco/nicotine products among three groups of SGM young adults who self-identified as (1) gay or lesbian, (2) bisexual, and (3) queer, transgender, or "other," compared to their heterosexual peers.

Methods

Participants were 4252 college students aged 18-29 years from 24 colleges in Texas who completed an online tobacco use survey. Multilevel logistic regression models were used to examine the odds of SGM participants currently using each tobacco product. Multilevel linear regression models were used to examine the association of current product users' SGM status with self-reported age of each product's initiation. All models were adjusted for sociodemographic factors and accounted for students clustered within each college.

Results

At least one SGM group had significantly greater odds of currently using every tobacco product type compared to heterosexual participants, except hookah. There were few differences across groups in age of initiation. However, queer, transgender, and "other-" identified participants initiated e-cigarettes 1.34 years younger than heterosexual participants, and bisexual participants initiated smokeless tobacco 3.66 years younger than heterosexual participants.

Conclusions

Findings highlight some significant tobacco use disparities among SGM young adults compared to their heterosexual peers. Longitudinal studies with larger group sizes will identify prospective predictors of sustained SGM-related tobacco use disparities.

Implications

This study extends the current literature by including the sexual and gender minority identity options of queer, transgender, and "other," highlighting disparities in tobacco use between young adults in these subgroups compared to their heterosexual peers, particularly in noncigarette tobacco product use. Findings underscore the need for the Food and Drug Association and other health agencies to tailor health communication efforts specific to sexual and gender minority populations pertaining to the risks and harms surrounding tobacco product use.

What drives us apart? Decomposing intersectional inequalities in cigarette smoking by education and sexual orientation among U.S. adults

Background

Socio-economic and sexual orientation inequalities in cigarette smoking are well-documented; however, there is a lack of research examining the social processes driving these complex inequalities. Using an intersectional framework, the current study examines key processes contributing to inequalities in smoking between four intersectional groups by education and sexual orientation.

Methods

The sample (28,362 adults) was obtained from Wave 2 (2014–2015) of the Population Assessment of Tobacco and Health (PATH) Study. Four intersectional positions were created by education (high- and low-education) and sexual orientation (heterosexual or lesbian, gay, bisexual, or queer/questioning (LGBQ). The joint inequality, the referent socio-economic inequality, and the referent sexual orientation inequality in smoking were decomposed by demographic, material, tobacco marketing-related, and psychosocial factors using non-linear Oaxaca decomposition.

Results

Material conditions made the largest contribution to the joint inequality (9.8 percentage points (p.p.), 140.9%), referent socio-economic inequality (10.01 p.p., 128.4%), and referent sexual orientation inequality (4.91 p.p., 59.8%), driven by annual household income. Psychosocial factors made the second largest contributions to the joint inequality (2.12 p.p., 30.3%), referent socio-economic inequality (2.23 p.p., 28.9%), and referent sexual orientation inequality (1.68 p.p., 20.5%). Referent sexual orientation inequality was also explained by marital status (20.3%) and targeted tobacco marketing (11.3%).

Conclusion

The study highlights the pervasive role of material conditions in inequalities in cigarette smoking across multiple dimensions of advantage and disadvantage. This points to the importance of addressing material disadvantage to reduce combined socioeconomic and sexual orientation inequalities in cigarette smoking.

Sexual Identity and Behavior Among U.S. High School Students, 2005-2015

Sexual orientation is a multidimensional construct which is increasingly recognized as an important demographic characteristic in population health research. For this study, weighted Youth Risk Behavior Survey data were pooled across 47 jurisdictions biennially from 2005 to 2015, resulting in a national sample of 98 jurisdiction-years (344,815 students). Respondents were a median of 15.5 years, 49.9% male, and 48.8% White. Sexual identity and behavior trends from 2005 to 2015 were assessed with logistic regression analysis. Overall, 13.9% of females and 7.0% of males identified as lesbian, gay, bisexual (LGB), or not sure, while 9.1% of females and 4.2% of males indicated both same-and-different-sex behavior or same-sex behavior. In total, 17.0% of female and 8.5% of male youth reported non-heterosexual (LGB or not sure) sexual identity, same-sex sexual behavior, or both. LGB youth were approximately twice as likely as other youth to report lifetime sexual behavior. White and Asian youth were less likely to report non-heterosexual identity and/or have engaged in same-sex sexual behaviors than youth of other races/ethnicities. Prevalence of non-heterosexual identities increased over time for both sexes, but only female youth reported significantly more same-sex behavior over time. This is the first study to simultaneously assess adolescent sexual identity and behavior over time within a national dataset. These findings are critical for understanding the sexual health needs of adolescents and for informing sexual health policy and practice.

Cigarette Smoking Among Youth at the Intersection of Sexual Orientation and Gender Identity

Purpose: The purpose of this study was to identify subgroups of sexual and gender minority (SGM) youth who are most vulnerable to tobacco use. Methods: We analyzed data from a national nonprobability sample of 11,192 SGM youth (ages 13-17). Age of cigarette initiation and current use were modeled using Cox proportional hazard and binomial regression. Sexual and gender identities were explanatory variables and the models were adjusted for ethnoracial identity and age. Results: Approximately 7% of the sample reported current smoking. Cisgender and transgender boys had higher odds of current smoking compared with cisgender and transgender girls (adjusted odds ratio [AOR] = 1.86; 95% confidence interval [CI]: 1.56-2.21). Pansexual-identified youth had higher odds of smoking (AOR = 1.33; 95% CI: 1.05-1.70) compared with gay/lesbian youth independent of gender identity. Pansexual-identified cisgender boys had the highest smoking prevalence (21.6%). Predicted probabilities were higher among transgender boys across all sexual identities, except asexual. The hazard of smoking at a younger age was greater for transgender boys compared with cisgender boys (adjusted hazard ratio [AHR] = 1.67; 95% CI: 1.43-1.94) as well as for bisexual (AHR = 1.12; 95% CI: 1.01-1.24) and pansexual (AHR = 1.17; 95% CI: 1.03-1.33) youth compared with those who identified as gay or lesbian. Conclusions: These findings suggest that transgender boys may be at higher risk for early and current cigarette use regardless of their sexual identity, whereas smoking varied more widely for youth across different sexual identities. The findings suggest that specific subgroups of SGM youth require focused attention in tobacco control research and practice.

Racial/Ethnic Differences in Mental Health, Substance Use, and Bullying Victimization Among Self-Identified Bisexual High School-Aged Youth

Purpose: Sexual minority youth are at increased risk for mental health problems and substance use, and accumulating evidence indicates that bisexual youth are at greatest risk. However, bisexual youth are not a homogenous group and scholars have called for greater attention to the intersections of multiple marginalized identities. As such, we examined racial/ethnic differences in mental health (sadness/hopelessness and suicidal ideation), substance use (cigarette use, binge drinking, marijuana use, and other illicit drug use), and bullying (in-person and electronic) among self-identified bisexual high school-aged youth (overall and by sex). Method: Data from the local versions of the Youth Risk Behavior Survey were pooled across jurisdictions and years (2011-2015), resulting in an analytic sample of 18,515 bisexual youth who were racially/ethnically diverse. Results: Black and Hispanic bisexual youth were less likely to report in-person and electronic bullying than White bisexual youth. In addition, Black bisexual youth were less likely to report sadness/hopelessness and suicidal ideation than White, Hispanic, and Other race/ethnicity bisexual youth. Black bisexual female youth were also less likely to report cigarette use, binge drinking, and other illicit drug use than White bisexual female youth. In contrast to most of our findings, Black bisexual youth were more likely to report marijuana use than White bisexual youth. Most of the significant racial/ethnic differences in mental health and substance use remained significant after controlling for bullying. Conclusion: These findings highlight the heterogeneity of bisexual youth and the need to consider multiple marginalized identities to understand the health disparities affecting this diverse population.

Latent Classes of Polysubstance Use Among Adolescents in the United States: Intersections of Sexual Identity with Sex, Age, and Race/Ethnicity

PURPOSE

We aimed to estimate latent classes of concurrent polysubstance use and test for sexual orientation differences in latent class memberships with representative data from adolescents living in 19 U.S. states. We also tested whether sex, race/ethnicity, and age moderated the sexual identity differences in polysubstance use class memberships.

METHODS

We analyzed data from 119,437 adolescents from 19 states who participated in the 2015 Youth Risk Behavior Survey. Latent class analysis characterized polysubstance use patterns based on self-reported frequency of lifetime and past-month use of alcohol (including heavy episodic drinking), tobacco (cigarettes, cigars, and smokeless tobacco), and marijuana. Multinomial logistic regression models tested differences in latent class memberships by sexual identity. Interaction terms tested whether sex, race/ethnicity, and age moderated the sexual identity differences in polysubstance use class memberships.

RESULTS

A six-class model of polysubstance use fit the data best and included nonusers (61.5%), experimental users (12.2%), marijuana-alcohol users (14.8%), tobacco-alcohol users (3.8%), medium-frequency three-substance users (3.6%), and high-frequency three-substance users (4.1%). Gay/lesbian- and bisexual-identified adolescents had significantly higher odds than heterosexual-identified adolescents of being in all of the user classes compared with the nonuser class. These sexual identity differences in latent polysubstance use class memberships were generally larger for females than for males, varied occasionally by race/ethnicity, and were sometimes larger for younger ages.

CONCLUSION

Compared with their heterosexual peers, gay/lesbian and bisexual adolescents-especially females-are at heightened risk of engaging in multiple types of polysubstance use. Designing, implementing, and evaluating interventions will likely reduce these sexual orientation disparities.