Abstract

Introduction:

National surveillance data are needed for the lesbian, gay, bisexual, and transgender population, a group which has been shown to have unique health needs.

Methods:

This study uses data from Legacy’s Young Adult Cohort Study, a nationally representative sample collected in the summer of 2011 to examine patterns of tobacco use by sexual identity.

Results:

Homosexual and bisexual past 30-day cigarette use (35% and 27%, respectively) was higher than heterosexual past 30-day cigarette use (18%; p = .004). The prevalence of any current tobacco use among heterosexuals was 22% compared with 35% in homosexuals and 31% in bisexuals (p = .04). Prevalence of dual use was 30% among heterosexuals, 43% among homosexuals, and 35% among bisexuals. High school education (OR = 4.27), current alcohol use (OR = 12.64), and current other drug use (OR = 9.67) were significant predictors of current cigarette use among lesbian, gay, and bisexual respondents. Strong predictors of other tobacco product use were Black race (OR = 6.95), current alcohol use (OR = 11.70), and current other drug use (OR = 7.42).

Conclusions:

Prevalence estimates for tobacco use were higher among young adults who self-identify as sexual minorities compared with those who identify as heterosexuals. Tobacco use is strongly associated with alcohol and other drug use in this population. This study highlights the significant disparities in tobacco use behaviors among sexual minority populations and the critical need to conduct surveillance among these groups.

INTRODUCTION

Cigarette smoking continues to be the leading cause of preventable death and disease, taking 443,000 lives each year in the United States alone (Centers for Disease Control and Prevention, 2008; Danaei et al., 2009; Mokdad, Marks, Stroup, & Gerberding, 2005). To monitor trends in tobacco use across demographic groups, national population-based surveillance surveys reveal that tobacco use continues to be higher among individuals with low income and education, the uninsured, and among some racial and ethnic minority groups (Schiller, Lucas, Ward, & Peregoy, 2012). However, national surveillance data are currently limited for the lesbian, gay, bisexual, and transgender (LGBT) population, a group which has been shown to have unique health needs (Institute of Medicine, 2011).

Sexual orientation is an all-inclusive term comprising three domains: attraction (who a person is romantically or sexually attracted to), behavior (with whom a person engages in sexual behavior), and identity (which community a person identifies with) (Blosnich, Lee, & Horn, 2013; Lee, Griffin, & Melvin, 2009). The Institute of Medicine identifies three major challenges to collecting health data on sexual minorities: first, operationalizing and measuring sexual minorities (i.e., identifying the appropriate metric or metrics from the sexual orientation domains listed above); second, the willingness of respondents to disclose their sexual minority status; and third, collecting quality samples from this relatively small population (Institute of Medicine, 2011). This study operationalizes sexual orientation as sexual identity per previously published studies (VanKim, Padilla, Lee, & Goldstein, 2010).

As of 2012, no major federally funded health survey thoroughly asked about sexual orientation (Brown, 2011). Due to the lack of data, some researchers have estimated sexual minority status as having an “unmarried partner” of the same sex in the same household using the National Health Interview Survey (NHIS) or the U.S. Census (Heck & Jacobson, 2006; Mayer et al., 2008). However, this measure excludes those without a current partner or those with a current partner not living in the household; without asking respondents about their sexual attraction, identity, or behavior, it is difficult to accurately account for the sexual minority population across time. The 2009–2010 National Adult Tobacco Survey (NATS) includes measures on sexual orientation and provides national estimates of tobacco use among the LGBT population (Engstrom & Mariolis, 2010). A recent analysis of NATS data found that 32.8% of LGBT American adults aged 18 or older smoke cigarettes compared with 19.5% of their heterosexual/straight counterparts (King, Dube, & Tynan, 2012).

Surveillance at the local and state levels also point to high smoking prevalence among sexual minority adults (Lee et al., 2009; Stall, Greenwood, Acree, Paul, & Coates, 1999) and a greater likelihood of smoking compared with heterosexuals (Blosnich, Jarrett, & Horn, 2011; Burgard, Cochran, & Mays, 2005; Conron, Mimiaga, & Landers, 2010; Lee et al., 2009; McKirnan, Tolou-Shams, Turner, Dyslin, & Hope, 2006; Pizacani, Rohde, Bushore, & Al, 2009; Tang et al., 2004; Trocki, Drabble, & Midanik, 2009). Recent state population-based health surveys in California (Gruskin, Greenwood, Matevia, Pollack, & Bye, 2007), Arizona (Arizona Department of Health Services, 2006), New Mexico (VanKim & Padilla, 2010), Oregon, Washington (Dilley et al., 2005; Pizacani et al., 2009), Illinois, and Massachusetts (American Lung Association, 2010) have added sexual orientation items, and these studies confirm this disparity in cigarette use among sexual minority adults beyond studies with small convenience samples.

Understanding the tobacco use patterns of sexual minority youth is also crucial when examining health behaviors across the life course. Sexual orientation items added to the Youth Risk Behavior Surveillance Surveys in Massachusetts, Delaware, Maine, Rhode Island, Vermont, and some major U.S. cities show that the median current smoking rate among heterosexual high school students is 13.6% compared with nearly 31% for lesbian, gay, and bisexual (LGB) students. Current smokeless tobacco use and current cigar use are also higher for sexual minority youth (Centers for Disease Control and Prevention, 2011a). For adolescents, some longitudinal research demonstrates that teen substance use, including tobacco use, not only starts earlier among sexual minority youth (Corliss et al., 2013) but that it escalates more intensely into emerging adulthood than it does for “100% heterosexual” youth (Gregor, Zvolensky, Bernstein, Marshall, & Yartz, 2007). A few studies did not find differences in tobacco use among certain subgroups of sexual minorities (Bowen et al., 2004; McCabe, Boyd, Hughes, & D’Arcy, 2003). However, findings may be attributed to poor statistical power due to small sample sizes (Gruskin, Greenwood, Matevia, Pollack, & Bye, 2007).

It remains unclear as to why sexual minorities generally smoke cigarettes at much higher rates than their heterosexual peers. A recent systematic review identified two broad domains that may influence these differences: first, risk factors that are unique to sexual minority populations, and second, risks for smoking that are common in the overall population but which are elevated in the sexual minority community (Blosnich et al., 2013). Risk factors unique to LGB populations include actual and perceived social stigma and discrimination, identity within the sexual minority community, reactions to “coming out,” and the cultural role of bars in some sexual minority populations (American Lung Association, 2010; Blosnich et al., 2013). Other risk factors common in the overall population but elevated in the sexual minority community include younger age, educational attainment, alcohol use, other drug use, and depression (Blosnich et al., 2013).

The 31st Surgeon General’s report on tobacco initiation and use among young people released in 2012 demonstrates that understanding tobacco use patterns among young adults is crucial to make significant progress in tobacco control (U.S. Department of Health and Human Services, 2012). In 2011, 1 in 3 young adults under age 26 smoked cigarettes and adults between ages 18 and 25 used all forms of tobacco at the highest rates (Substance Abuse and Mental Health Services Administration, 2012). Ninety-nine percent of daily smokers report that they tried their first cigarette by age 26 (U.S. Department of Health and Human Services, 2012). Additionally, the tobacco industry has historically targeted the LGBT community (Dilley, Spigner, Boysun, Dent, & Pizacani, 2008; Stevens, Carlson, & Hinman, 2004; Washington, 2002) and young adults continue to be a prime audience for tobacco marketing, particularly after the Master Settlement Agreement banned advertising to youth (Biener & Albers, 2004; Hafez & Ling, 2005; Hendlin, Anderson, & Glantz, 2010).

The goal of this study is to fill a critical research gap by: (a) estimating tobacco use among sexual minority young adults compared with heterosexual young adults in a population-based nationally representative sample, (b) assessing unique predictors of any tobacco use among sexual minority young adults compared with heterosexual young adults, and (c) assessing predictors of cigarette use and other tobacco products among sexual minority young adults.

METHODS

Respondents

This study uses the Legacy Young Adult Cohort, a nationally representative longitudinal sample of young adults aged 18–34 (N = 4,215). The detailed methods of this sample have been described elsewhere (Rath, Villanti, Abrams, & Vallone, 2012). Briefly, the cohort is drawn from the Knowledge Networks’ KnowledgePanel®. The KnowledgePanel® is recruited via address-based sampling, a probability-based random sampling method which provides statistically valid representation of the U.S. population, including cell phone-only households, Blacks, Latinos, and younger adults. This study uses data from the baseline survey that was fielded during the summer of 2011. Poststratification adjustments were used to offset any nonresponse or noncoverage bias by weighting the data. Observations were deleted for those respondents where data were missing on the item, which assessed ever tobacco use (N = 14). This study was approved by the Independent Investigational Review Board, Inc.

Measures

Sexual identity was assessed using the following item (VanKim et al., 2010): “Do you consider yourself to be (mark only one)”: Response choices were adapted to include “transgender” as follows: “heterosexual or straight,” “homosexual or gay/lesbian,” “bisexual,” “transgender,” “other,” “don’t know/not sure.” Additional analyses were conducted to compare only those identifying as “homosexual or gay/lesbian” and “bisexual” (LGB), consistent with previous studies in the adolescent population (Russell, Driscoll, & Truong, 2002; Udry & Chantala, 2002). Participants who refused to respond to the sexual identity item were counted as missing. Sexual identity, rather than behavior or attraction, was chosen following personal communication with J. G. Lee to be consistent with forthcoming national measures (J. G. Lee, personal communication, May 6, 2011; Miller & Ryan, 2011; Senseman, 2008).

Demographic factors include age, gender, race/ ethnicity, educational attainment, current employment status, and self-described financial situation. Self-rated health status was assessed using the following item: “Would you say that your health in general is excellent, very good, good, fair or poor?” (Centers for Disease Control and Prevention, 2011b). Major depressive disorder was assessed using the Patient Health Questionnaire-2 (PHQ-2), a two-item depression screener (Kroenke, Spitzer, & Williams, 2003). Generalized anxiety disorder was assessed using the Generalized Anxiety Disorder-2 (GAD-2) (Kroenke, Spitzer, & Williams, 2007). Sensation seeking was measured using the eight-item Brief Sensation Seeking Scale (Hoyle, Stephenson, Palmgreen, Lorch, & Donohew, 2002). Current alcohol, marijuana, and other drug use were assessed using the following question: “How often, if ever, do you currently use the following products?” with response choices “every day,” “some days,” and “not at all.” Other drug use was described as use of “cocaine, heroin, ecstasy, meth, etc.” Participants who responded that they used these products “every day” or “some days” were classified as current users.

Tobacco use was assessed with measures of ever tobacco use and past 30-day use in the full sample. Response categories for both questions included cigarettes, cigars, pipe (with tobacco), little cigars/cigarillos/bidis (like Black & Milds, Swisher Sweets, Phillies Blunt, or Captain Black), e-cigarettes (like BLU or NJOY), chewing tobacco (like Levi Garrett, Red Man, or Beech-Nut), dip/snuff (like Skoal or Copenhagen), snus (like Camel Snus), dissolvable tobacco products (like Ariva, Stonewall, Camel Orbs, Sticks, or Strips), and hookah/shisha (hookah tobacco). Ever use also captured consumption of nicotine replacement products (like gum, patches, lozenges). Participants were asked to recall their age at tobacco product initiation and at progression to regular use, defined as monthly use. Given the rising prevalence of hookah use, participants were also asked whether they had ever visited a hookah bar or restaurant. Current menthol cigarette use was assessed using self-report, with participants entering their typical brand and identifying the brand as menthol or non-menthol.

Current use of cigarettes was assessed using the item: “Do you now smoke cigarettes every day, some days, or not at all?” (National Cancer Institute, 2006). The item: “Do you now use other tobacco products (not including cigarettes) every day, some days, or not at all?” assessed current other tobacco product use. Any current tobacco use was defined as being a current user of either cigarettes or other tobacco products. Dual use categories include current users of “cigarettes only,” “cigarettes and other tobacco products,” and “other tobacco products only.” Respondents who reported no current tobacco product use, including those who never used a product were classified as “neither.” Unlike adult surveys of tobacco use, participants did not have to meet a 100-cigarette threshold to be considered a current user.

Data analysis

All analyses were performed using Stata IC 11.0 (StataCorp, 2009), and data were weighted to produce nationally representative prevalence estimates. Bivariate analyses were conducted to describe the distribution of sociodemographic variables by sexual identity, estimate the prevalence of ever use and past 30-day use for all tobacco products, visiting a hookah bar/restaurant, initiation after age 18, becoming a regular tobacco user after age 18, current menthol cigarette use, and current dual use of tobacco products. Differences in prevalence estimates were assessed using p values from the design-based F statistic. P values for differences in means were determined using the lincom command. Multivariable logistic regression models were used to calculate the adjusted odds ratios (ORs) for any current tobacco use stratified by sexual identity (heterosexual vs. LGB) using the “subpop” command, controlling for sociodemographics, self-rated health, major depressive disorder, generalized anxiety disorder, sensation seeking, and other substance use (i.e., alcohol, marijuana, and other drugs). Models were developed to evaluate the presence of interaction between LGB and education, alcohol, and other drug use. Multivariable models were also developed to examine predictors of current use of cigarettes or other tobacco products among LGB participants.

RESULTS

Of the 4,159 young adults aged 18–34 in this study, 2.9% self-identified as homosexual, 3.3% as bisexual, 0.3% as transgender, 1.2% as other, 2.3% as questioning (“don’t know/not sure”), and 90% self-identified as heterosexual; 42 respondents (1%) were missing data on sexual identity. Table 1 highlights the significant differences in demographics between these groups. Compared with heterosexual respondents, homosexual respondents were more likely to be male (71.3% vs. 49.9%), and bisexual respondents were more likely to be female (78.7% vs. 50.1%). Transgender, other, and questioning respondents were less likely to be White. Those who responded “other” or “don’t know/not sure” were more likely to be Hispanic compared with heterosexuals and were also significantly more likely to be of lower education than heterosexuals. Respondents who were unsure of their sexual identity were also significantly less likely to work full-time, to report not meeting basic expenses, and more likely to report symptoms consistent with major depressive disorder compared with heterosexuals. The prevalence of major depressive disorder was also higher among LGB respondents compared with heterosexual respondents (22.9% vs. 14.6%, p = .02), whereas the prevalence of generalized anxiety disorder was marginally higher in LGB respondents compared with heterosexuals (22.1% vs. 15.8%, p = .07). Mean sensation seeking was significantly higher in the bisexual group compared with the heterosexual group (25.42 vs. 22.87) and this was reflected in greater alcohol use (79.0% vs. 52.9%), marijuana use (37.7% vs. 11.5%), and other drug use (10.3% vs. 2.2%) among bisexuals. Other drug use was also significantly higher among homosexual respondents compared with the heterosexual respondents (8.4% vs. 2.2%). Respondents unsure of their sexual orientation were significantly less likely to be current tobacco product users compared with heterosexuals (8.8% vs. 22.2%), and homosexuals were significantly less likely than their straight counterparts to use other tobacco products only (0.5% vs. 3.8%).

Table 1.

Demographics by Sexual Identity Using Poststratification Weights for the Full Sample (unweighted n = 4,159)

 Full sample (%) Heterosexual or straight (%) Homosexual or gay/lesbian (%) Bisexual (%) Transgender (%) Other (%) Don’t know/not sure (%) p value 
Overall – 90.0 2.9 3.3 0.3 1.2 2.3 – 
Age 
    18–24 years 41.8 42.0 29.0 51.3 81.6 35.6 33.6 .042 
    25–34 years 58.2 58.0 71.0 48.7 18.4 64.5 66.4 
Gender 
    Male 49.8 49.9 71.3 21.3 67.7 61.8 52.9 <.001 
    Female 50.2 50.1 28.8 78.7 32.3 38.2 47.1 
Race/ethnicity 
    White, non-Hispanic 60.3 61.8 53.8 68.1 47.4 22.3 22.4 <.001 
    Black, non-Hispanic 13.5 13.5 22.8 12.3 0.0 9.1 9.3 
    Other, non-Hispanic 7.4 7.3 11.3 5.0 13.3 4.1 11.6 
    Hispanic 18.8 17.5 12.0 14.6 39.3 64.6 56.7 
Education 
    Less than high school 12.4 11.7 4.3 16.1 12.0 37.9 28.5 <.001 
    High school 21.1 21.0 20.1 15.8 16.8 25.2 31.4 
    Some college or greater 66.5 67.3 75.6 68.1 71.2 37.0 40.1 
Current employment status 
    Work full-time 46.6 47.7 50.6 35.3 2.1 38.1 26.7 .028 
    Work part-time 21.6 20.9 23.3 31.1 25.3 23.8 35.0 
    Don’t currently work for pay 31.7 31.5 26.1 33.7 72.6 38.1 38.4 
Financial situation 
    Don’t meet basic expenses 9.1 8.4 14.3 12.6 0.0 15.2 23.8 .032 
    Just meet basic expenses 32.2 31.9 32.6 36.8 79.0 32.5 33.8 
    Meet needs with a little left 35.3 35.8 30.8 38.3 8.5 27.6 25.3 
    Live comfortably 23.4 24.0 22.4 12.3 12.5 24.8 17.1 
Self-reported health 
    Excellent 18.3 18.5 20.9 8.4 18.8 22.4 18.5 .095 
    Very good 39.2 40.2 33.8 34.9 39.7 27.3 17.9 
    Good 32.8 32.1 31.2 40.0 39.5 35.4 51.0 
    Fair 8.4 8.0 12.9 13.7 2.1 9.8 12.4 
    Poor 1.4 1.3 1.2 3.1 0.0 5.1 0.2 
Current tobacco use 
    No tobacco use 77.4 77.8 65.2 68.9 66.8 80.2 91.2 .045 
    Cigarette use only 12.0 11.8 19.0 16.9 33.2 8.1 4.7 
    Cigarette and other tobacco product use 6.9 6.7 15.4 11.0 0.0 3.5 3.9 
    Other tobacco product use only 3.6 3.8 0.5 3.1 0.0 8.3 0.2 
Major depressive disorder (PHQ-2) 15.5 14.6 22.3 23.4 4.3 17.7 32.7 .005 
Generalized anxiety disorder (GAD-2) 16.2 15.8 22.0 22.3 0.0 10.6 20.2 .305 
Sensation seeking (mean) 22.97 22.87 24.50 25.42 23.67 22.35 21.72  
Current alcohol use 53.7 52.9 66.7 79.0 85.3 44.5 32.8 <.001 
Current marijuana use 12.3 11.5 11.8 37.7 0.0 15.1 5.6 <.001 
Current other drug use 2.8 2.2 8.4 10.3 0.0 3.8 4.5 <.001 
 Full sample (%) Heterosexual or straight (%) Homosexual or gay/lesbian (%) Bisexual (%) Transgender (%) Other (%) Don’t know/not sure (%) p value 
Overall – 90.0 2.9 3.3 0.3 1.2 2.3 – 
Age 
    18–24 years 41.8 42.0 29.0 51.3 81.6 35.6 33.6 .042 
    25–34 years 58.2 58.0 71.0 48.7 18.4 64.5 66.4 
Gender 
    Male 49.8 49.9 71.3 21.3 67.7 61.8 52.9 <.001 
    Female 50.2 50.1 28.8 78.7 32.3 38.2 47.1 
Race/ethnicity 
    White, non-Hispanic 60.3 61.8 53.8 68.1 47.4 22.3 22.4 <.001 
    Black, non-Hispanic 13.5 13.5 22.8 12.3 0.0 9.1 9.3 
    Other, non-Hispanic 7.4 7.3 11.3 5.0 13.3 4.1 11.6 
    Hispanic 18.8 17.5 12.0 14.6 39.3 64.6 56.7 
Education 
    Less than high school 12.4 11.7 4.3 16.1 12.0 37.9 28.5 <.001 
    High school 21.1 21.0 20.1 15.8 16.8 25.2 31.4 
    Some college or greater 66.5 67.3 75.6 68.1 71.2 37.0 40.1 
Current employment status 
    Work full-time 46.6 47.7 50.6 35.3 2.1 38.1 26.7 .028 
    Work part-time 21.6 20.9 23.3 31.1 25.3 23.8 35.0 
    Don’t currently work for pay 31.7 31.5 26.1 33.7 72.6 38.1 38.4 
Financial situation 
    Don’t meet basic expenses 9.1 8.4 14.3 12.6 0.0 15.2 23.8 .032 
    Just meet basic expenses 32.2 31.9 32.6 36.8 79.0 32.5 33.8 
    Meet needs with a little left 35.3 35.8 30.8 38.3 8.5 27.6 25.3 
    Live comfortably 23.4 24.0 22.4 12.3 12.5 24.8 17.1 
Self-reported health 
    Excellent 18.3 18.5 20.9 8.4 18.8 22.4 18.5 .095 
    Very good 39.2 40.2 33.8 34.9 39.7 27.3 17.9 
    Good 32.8 32.1 31.2 40.0 39.5 35.4 51.0 
    Fair 8.4 8.0 12.9 13.7 2.1 9.8 12.4 
    Poor 1.4 1.3 1.2 3.1 0.0 5.1 0.2 
Current tobacco use 
    No tobacco use 77.4 77.8 65.2 68.9 66.8 80.2 91.2 .045 
    Cigarette use only 12.0 11.8 19.0 16.9 33.2 8.1 4.7 
    Cigarette and other tobacco product use 6.9 6.7 15.4 11.0 0.0 3.5 3.9 
    Other tobacco product use only 3.6 3.8 0.5 3.1 0.0 8.3 0.2 
Major depressive disorder (PHQ-2) 15.5 14.6 22.3 23.4 4.3 17.7 32.7 .005 
Generalized anxiety disorder (GAD-2) 16.2 15.8 22.0 22.3 0.0 10.6 20.2 .305 
Sensation seeking (mean) 22.97 22.87 24.50 25.42 23.67 22.35 21.72  
Current alcohol use 53.7 52.9 66.7 79.0 85.3 44.5 32.8 <.001 
Current marijuana use 12.3 11.5 11.8 37.7 0.0 15.1 5.6 <.001 
Current other drug use 2.8 2.2 8.4 10.3 0.0 3.8 4.5 <.001 

Note. p < .05 are noted in boldface.

Missing observations (n): current employment status (15); financial situation (21); self-reported health (11); major depressive disorder (70); generalized anxiety disorder (94); current alcohol use (27); current marijuana use (41); current other drug use (32); current tobacco use (2).

Table 2 presents ever use and past 30-day use of tobacco products by sexual identity. Ever use of pipes (with tobacco), chewing tobacco, dip/snuff, snus, and nicotine products (e.g., gum, patches, lozenges) was similar between heterosexual and LGB respondents. Ever use of cigarettes and hookah was significantly higher among the LGB respondents compared with those who identified as heterosexual. Additionally, homosexuals reported marginally higher ever cigar use (46% vs. 31%, p = .05) and dissolvable product use (4% vs. 0%, p = .001) compared with heterosexuals. Bisexuals reported significantly higher ever little cigar/cigarillo/bidi use (41% vs. 26%, p = .03). Past 30-day use was similar between groups for all tobacco products except cigarettes; consistent with patterns of ever use, LGB respondents reported a significantly higher prevalence of cigarette use in the past 30-days compared with heterosexuals (p = .004). Past 30-day cigarette use was 88% higher among homosexuals and 49% higher among bisexuals compared with heterosexual respondents.

Table 2.

Prevalence of Tobacco Product by Ever-Use and Past 30-Day Use, Using Poststratification Weights for the Full Sample

 n Heterosexual Homosexual Bisexual p value 
Prevalence (95% CI) Prevalence (95% CI) Prevalence (95% CI) 
Ever-use (n = 4,033)      
Cigarettes  51.1 (48.8–53.4) 73.5 (60.5–83.4) 69.8 (57.8–79.6) <.001 
Cigars  30.7 (28.6–32.9) 45.6 (31.9–60.1) 37.0 (26.4–49.1) .050 
Pipe (with tobacco)  9.6 (8.3–11.1) 11.6 (5.5–22.6) 6.1 (2.5–14.0) .518 
Little cigars/cigarillos/bidis (like Black & Milds, Swisher Sweets, Phillies Blunt, or Captain Black)  25.8 (23.9–27.9) 30.1 (19.2–44.0) 41.1 (29.8–53.5) .025 
E-cigarettes (like BLU or NJOY)  5.5 (4.5–6.8) 5.5 (2.2–13.0) 12.4 (6.3–23.1) .047 
Chewing tobacco (like Levi Garrett, Red Man, or Beech-Nut)  7.7 (6.4–9.1) 5.9 (1.9–16.5) 4.4 (1.3–14.1) .593 
Dip/snuff (like Skoal or Copenhagen)  10.3 (8.9–11.9) 12.2 (5.5–24.6) 5.9 (2.2–14.8) .483 
Snus (like Camel Snus)  5.8 (4.8–7.1) 8.3 (2.9–21.4) 7.3 (3.0–16.8) .709 
Dissolvable tobacco products (like Ariva, Stonewall, Camel Orbs, Sticks or Strips)  0.5 (0.3–0.9) 3.9 (1.0–14.3) 0.2 (0.0–1.4) .001 
Hookah/shisha (hookah tobacco)  16.8 (15.2–18.6) 29.7 (18.7–43.8) 34.7 (23.8–47.6) <.001 
Nicotine products (like gum, patches, lozenges)a  6.4 (5.3–7.8) 6.6 (2.1–18.6) 11.5 (6.0–20.9) .300 
Past 30-day use 
Cigarettes 4,029 18.5 (16.6–20.5) 34.8 (22.7–49.3) 27.5 (17.9–39.7) .004 
Cigars 3,978 3.3 (2.5–4.3) 6.9 (2.5–17.5) 2.1 (0.9–4.8) .153 
Pipe (with tobacco) 3,968 0.8 (0.4–1.6) 2.3 (0.4–11.0) 0.5 (0.1–1.9) .262 
Little cigars/cigarillos/bidis (like Black & Milds, Swisher Sweets, Phillies Blunt, or Captain Black) 3,975 2.7 (2.0–3.7) 7.6 (2.5–20.8) 3.4 (1.8–6.7) .077 
E-cigarettes (like BLU or NJOY) 3,967 1.3 (0.8–2.0) – 1.7 (0.6–5.3) .539 
Chewing tobacco (like Levi Garrett, Red Man, or Beech-Nut) 3,966 0.9 (0.5–1.7) 0.5 (0.1–3.5) 0.2 (0.0–1.4) .374 
Dip/snuff (like Skoal or Copenhagen) 3,968 2.1 (1.4–3.1) – 0.3 (0.1–1.4) .227 
Snus (like Camel Snus) 3,965 0.9 (0.5–1.4) – 1.5 (0.4–5.2) .560 
Dissolvable tobacco products (like Ariva, Stonewall, Camel Orbs, Sticks or Strips) 3,964 0.2 (0.1–0.7) – 0.2 (0.0–1.4) .818 
Hookah/shisha (hookah tobacco) 3,971 1.2 (0.8–2.0) 2.1 (0.3–11.5) 2.3 (1.0–5.2) .479 
 n Heterosexual Homosexual Bisexual p value 
Prevalence (95% CI) Prevalence (95% CI) Prevalence (95% CI) 
Ever-use (n = 4,033)      
Cigarettes  51.1 (48.8–53.4) 73.5 (60.5–83.4) 69.8 (57.8–79.6) <.001 
Cigars  30.7 (28.6–32.9) 45.6 (31.9–60.1) 37.0 (26.4–49.1) .050 
Pipe (with tobacco)  9.6 (8.3–11.1) 11.6 (5.5–22.6) 6.1 (2.5–14.0) .518 
Little cigars/cigarillos/bidis (like Black & Milds, Swisher Sweets, Phillies Blunt, or Captain Black)  25.8 (23.9–27.9) 30.1 (19.2–44.0) 41.1 (29.8–53.5) .025 
E-cigarettes (like BLU or NJOY)  5.5 (4.5–6.8) 5.5 (2.2–13.0) 12.4 (6.3–23.1) .047 
Chewing tobacco (like Levi Garrett, Red Man, or Beech-Nut)  7.7 (6.4–9.1) 5.9 (1.9–16.5) 4.4 (1.3–14.1) .593 
Dip/snuff (like Skoal or Copenhagen)  10.3 (8.9–11.9) 12.2 (5.5–24.6) 5.9 (2.2–14.8) .483 
Snus (like Camel Snus)  5.8 (4.8–7.1) 8.3 (2.9–21.4) 7.3 (3.0–16.8) .709 
Dissolvable tobacco products (like Ariva, Stonewall, Camel Orbs, Sticks or Strips)  0.5 (0.3–0.9) 3.9 (1.0–14.3) 0.2 (0.0–1.4) .001 
Hookah/shisha (hookah tobacco)  16.8 (15.2–18.6) 29.7 (18.7–43.8) 34.7 (23.8–47.6) <.001 
Nicotine products (like gum, patches, lozenges)a  6.4 (5.3–7.8) 6.6 (2.1–18.6) 11.5 (6.0–20.9) .300 
Past 30-day use 
Cigarettes 4,029 18.5 (16.6–20.5) 34.8 (22.7–49.3) 27.5 (17.9–39.7) .004 
Cigars 3,978 3.3 (2.5–4.3) 6.9 (2.5–17.5) 2.1 (0.9–4.8) .153 
Pipe (with tobacco) 3,968 0.8 (0.4–1.6) 2.3 (0.4–11.0) 0.5 (0.1–1.9) .262 
Little cigars/cigarillos/bidis (like Black & Milds, Swisher Sweets, Phillies Blunt, or Captain Black) 3,975 2.7 (2.0–3.7) 7.6 (2.5–20.8) 3.4 (1.8–6.7) .077 
E-cigarettes (like BLU or NJOY) 3,967 1.3 (0.8–2.0) – 1.7 (0.6–5.3) .539 
Chewing tobacco (like Levi Garrett, Red Man, or Beech-Nut) 3,966 0.9 (0.5–1.7) 0.5 (0.1–3.5) 0.2 (0.0–1.4) .374 
Dip/snuff (like Skoal or Copenhagen) 3,968 2.1 (1.4–3.1) – 0.3 (0.1–1.4) .227 
Snus (like Camel Snus) 3,965 0.9 (0.5–1.4) – 1.5 (0.4–5.2) .560 
Dissolvable tobacco products (like Ariva, Stonewall, Camel Orbs, Sticks or Strips) 3,964 0.2 (0.1–0.7) – 0.2 (0.0–1.4) .818 
Hookah/shisha (hookah tobacco) 3,971 1.2 (0.8–2.0) 2.1 (0.3–11.5) 2.3 (1.0–5.2) .479 

Note. CI = confidence interval.

aPast 30-day use not assessed in baseline survey.

p < .05 are noted in boldface.

A greater proportion of homosexuals (39%) and bisexuals (43%) reported having visited a hookah bar/restaurant compared with heterosexual respondents (23%, p < .001), and homosexual respondents were significantly more likely to report initiation after age 18 (53% vs. 31%, p = .01). There were no statistically significant differences among the three groups in terms of either becoming a regular user after age 18 or menthol cigarette use.

The prevalence of any current tobacco use among heterosexuals was 22% compared with 35% in homosexuals and 31% in bisexuals (p = .04). Current cigarette use was 7 percentage points higher among homosexual compared with heterosexual respondents, dual use of cigarettes and other tobacco products was 8 percentage points higher, and other tobacco product use only was 4 percentage points lower among homosexual compared with heterosexual respondents. This represents a 30% prevalence of dual use in heterosexuals and 44% prevalence of dual use in respondents identifying as homosexual. Similarly, cigarette-only use was 5 percentage points higher, dual use 4 percentage points higher and other tobacco product only use 1 percentage point lower in bisexuals compared with their heterosexual counterparts. This corresponds to a 35% prevalence of dual use among bisexual respondents.

Multivariable regression of sociodemographic, health, and other substance use variables indicated different predictors of any current tobacco use among LGB compared with heterosexual respondents, controlling for all other variables in the model. Among heterosexual respondents, being 25–34 years of age, having a high school education or less, reporting lower socioeconomic status, having generalized anxiety disorder, greater sensation seeking, and current use of alcohol and marijuana were associated with a higher odds of any current tobacco use (Table 3). Hispanics were less likely to report any tobacco use by 45% in the heterosexual group. In the LGB group, high school education, alcohol use, and other drug use were positively associated with any tobacco use. There were no associations between age, race/ethnicity, socioeconomic status, generalized anxiety disorder, or sensation seeking, or marijuana use and any tobacco use in the LGB population compared with the heterosexual population and while both reported an increased odds of any tobacco use among current alcohol users, alcohol use appeared to be a stronger predictor in the LGB group (OR = 12.08, 95% CI: 3.10–47.16) compared with the heterosexual group (OR = 2.28, 95% CI: 1.69–3.06), but this was not a significant difference when tested as an interaction term in a full model.

Table 3.

Multivariable Logistic Regression of Predictors for Any Tobacco Use Among Heterosexual and LGB Participants Using Poststratification Weights for the Full Sample

 Heterosexual (n = 3,599) LGB (n = 245) 
OR (95% CI) OR (95% CI) 
Age 
    18–24 years Ref. Ref. 
    25–34 years 1.34 (1.00–1.79)* 0.96 (0.42–2.16) 
Gender 
    Male Ref. Ref. 
    Female 0.80 (0.62–1.04) 0.79 (0.34–1.81) 
Race/ethnicity 
    White, non-Hispanic Ref. Ref. 
    Black, non-Hispanic 0.88 (0.57–1.37) 1.16 (0.32–4.21) 
    Other, non-Hispanic 0.72 (0.37–1.40) 1.23 (0.25–6.03) 
    Hispanic 0.55 (0.37–0.82)* 1.69 (0.52–5.50) 
Education 
    Less than high school 3.23 (2.04–5.14)** 4.41 (0.70–27.58) 
    High school 2.91 (2.08–4.08)** 6.36 (2.19–18.44)** 
    Some college or greater Ref. Ref. 
Current employment status 
    Work full-time Ref. Ref. 
    Work part-time 1.03 (0.73–1.46) 0.92 (0.34–2.48) 
    Don’t currently work for pay 0.90 (0.64–1.26) 1.09 (0.35–3.35) 
Financial situation 
    Don’t meet basic expenses 2.04 (1.21–3.44)* 2.75 (0.66–11.38) 
    Just meet basic expenses 1.65 (1.20–2.27)* 1.72 (0.65–4.60) 
    Meet needs with a little left Ref. Ref. 
    Live comfortably 0.79 (0.54–1.16) 0.77 (0.24–2.51) 
Self-reported health 1.13 (0.97–1.33) 1.20 (0.72–2.00) 
Major depressive disorder (PHQ-2) 0.74 (0.48–1.16) 0.47 (0.13–1.79) 
Generalized anxiety disorder (GAD-2) 1.86 (1.25–2.75)* 1.53 (0.53–4.44) 
Sensation seeking (mean) 1.05 (1.02–1.08)** 1.04 (0.97–1.12) 
Current alcohol use 2.28 (1.69–3.06)** 12.08 (3.10–47.16)** 
Current marijuana use 2.97 (1.97–4.50)** 0.58 (0.20–1.64) 
Current other drug use 1.82 (0.70–4.71) 6.59 (1.68–25.82)* 
 Heterosexual (n = 3,599) LGB (n = 245) 
OR (95% CI) OR (95% CI) 
Age 
    18–24 years Ref. Ref. 
    25–34 years 1.34 (1.00–1.79)* 0.96 (0.42–2.16) 
Gender 
    Male Ref. Ref. 
    Female 0.80 (0.62–1.04) 0.79 (0.34–1.81) 
Race/ethnicity 
    White, non-Hispanic Ref. Ref. 
    Black, non-Hispanic 0.88 (0.57–1.37) 1.16 (0.32–4.21) 
    Other, non-Hispanic 0.72 (0.37–1.40) 1.23 (0.25–6.03) 
    Hispanic 0.55 (0.37–0.82)* 1.69 (0.52–5.50) 
Education 
    Less than high school 3.23 (2.04–5.14)** 4.41 (0.70–27.58) 
    High school 2.91 (2.08–4.08)** 6.36 (2.19–18.44)** 
    Some college or greater Ref. Ref. 
Current employment status 
    Work full-time Ref. Ref. 
    Work part-time 1.03 (0.73–1.46) 0.92 (0.34–2.48) 
    Don’t currently work for pay 0.90 (0.64–1.26) 1.09 (0.35–3.35) 
Financial situation 
    Don’t meet basic expenses 2.04 (1.21–3.44)* 2.75 (0.66–11.38) 
    Just meet basic expenses 1.65 (1.20–2.27)* 1.72 (0.65–4.60) 
    Meet needs with a little left Ref. Ref. 
    Live comfortably 0.79 (0.54–1.16) 0.77 (0.24–2.51) 
Self-reported health 1.13 (0.97–1.33) 1.20 (0.72–2.00) 
Major depressive disorder (PHQ-2) 0.74 (0.48–1.16) 0.47 (0.13–1.79) 
Generalized anxiety disorder (GAD-2) 1.86 (1.25–2.75)* 1.53 (0.53–4.44) 
Sensation seeking (mean) 1.05 (1.02–1.08)** 1.04 (0.97–1.12) 
Current alcohol use 2.28 (1.69–3.06)** 12.08 (3.10–47.16)** 
Current marijuana use 2.97 (1.97–4.50)** 0.58 (0.20–1.64) 
Current other drug use 1.82 (0.70–4.71) 6.59 (1.68–25.82)* 

Note. OR = odds ratio; CI = confidence interval; LGB = lesbian, gay, and bisexual.

*p < .05, **p < .01.

Table 4 examines correlates of current cigarette use or other tobacco product use in the LGB population, controlling for all other sociodemographic, health, and other substance use variables in the model. High school education (OR = 4.27, 95% CI: 1.51–12.12), current alcohol use (OR = 12.65, 95% CI: 2.99–53.54), and current other drug use (OR = 9.67; 95% CI: 2.22–42.09) were significantly associated with current cigarette use among homosexual and bisexual respondents. Strong correlates of other tobacco product use were Black race (OR = 6.95, 95% CI: 1.59–30.36), symptoms of generalized anxiety disorder (OR = 3.81, 95% CI: 1.01–14.41), current alcohol use (OR = 11.70, 95% CI: 2.30–59.64), and current other drug use (OR = 7.42; 95% CI: 1.92–28.70). Alcohol use had the strongest associations with both current cigarette use and other tobacco product use.

Table 4.

Multivariable Logistic Regression of Predictors of Cigarette Use and Other Tobacco Product Use Among LGB Participants Using Poststratification Weights for the Full Sample

 Current cigarette use (n = 245) Current use of other tobacco product (n = 225) 
OR (95% CI) OR (95% CI) 
Age 
    18–24 years Ref. Ref. 
    25–34 years 0.99 (0.43–2.25) 1.11 (0.41–2.99) 
Gender 
    Male Ref. Ref. 
    Female 0.99 (0.43–2.28) 0.43 (0.13–1.40) 
Race/ethnicity 
    White, non-Hispanic Ref. Ref. 
    Black, non-Hispanic 1.21 (0.32–4.62) 6.95 (1.59–30.36)* 
    Other, non-Hispanic 1.45 (0.30–6.97) – 
    Hispanic 1.52 (0.45–5.13) 3.03 (0.86–10.65) 
Education 
    Less than high school 4.95 (0.70–34.83) 2.88 (0.38–21.80) 
    High school 4.27 (1.51–12.12)* 4.90 (0.98–24.52) 
    Some college or greater Ref. Ref. 
Current employment status 
    Work full-time Ref. Ref. 
    Work part-time 0.72 (0.26–1.99) 1.99 (0.51–7.85) 
    Don’t currently work for pay 1.21 (0.40–3.68) 0.83 (0.19–3.63) 
Financial situation 
    Don’t meet basic expenses 3.35 (0.86–13.06) 2.54 (0.35–18.52) 
    Just meet basic expenses 1.50 (0.54–4.16) 1.63 (0.35–7.69) 
    Meet needs with a little left Ref. Ref. 
    Live comfortably 0.74 (0.22–2.47) 1.30 (0.24–7.05) 
Self-reported health 1.14 (0.68–1.92) 1.68 (0.90–3.15) 
Major depressive disorder (PHQ-2) 0.49 (0.13–1.79) 0.33 (0.07–1.50) 
Generalized anxiety disorder (GAD-2) 1.69 (0.59–4.86) 3.81 (1.01–14.41)* 
Sensation seeking (mean) 1.04 (0.96–1.11) 0.99 (0.92–1.06) 
Current alcohol use 12.65 (2.99–53.54)** 11.70 (2.30–59.64)* 
Current marijuana use 0.37 (0.12–1.15) 0.56 (0.13–2.38) 
Current other drug use 9.67 (2.22–42.09)* 7.42 (1.92–28.70)* 
 Current cigarette use (n = 245) Current use of other tobacco product (n = 225) 
OR (95% CI) OR (95% CI) 
Age 
    18–24 years Ref. Ref. 
    25–34 years 0.99 (0.43–2.25) 1.11 (0.41–2.99) 
Gender 
    Male Ref. Ref. 
    Female 0.99 (0.43–2.28) 0.43 (0.13–1.40) 
Race/ethnicity 
    White, non-Hispanic Ref. Ref. 
    Black, non-Hispanic 1.21 (0.32–4.62) 6.95 (1.59–30.36)* 
    Other, non-Hispanic 1.45 (0.30–6.97) – 
    Hispanic 1.52 (0.45–5.13) 3.03 (0.86–10.65) 
Education 
    Less than high school 4.95 (0.70–34.83) 2.88 (0.38–21.80) 
    High school 4.27 (1.51–12.12)* 4.90 (0.98–24.52) 
    Some college or greater Ref. Ref. 
Current employment status 
    Work full-time Ref. Ref. 
    Work part-time 0.72 (0.26–1.99) 1.99 (0.51–7.85) 
    Don’t currently work for pay 1.21 (0.40–3.68) 0.83 (0.19–3.63) 
Financial situation 
    Don’t meet basic expenses 3.35 (0.86–13.06) 2.54 (0.35–18.52) 
    Just meet basic expenses 1.50 (0.54–4.16) 1.63 (0.35–7.69) 
    Meet needs with a little left Ref. Ref. 
    Live comfortably 0.74 (0.22–2.47) 1.30 (0.24–7.05) 
Self-reported health 1.14 (0.68–1.92) 1.68 (0.90–3.15) 
Major depressive disorder (PHQ-2) 0.49 (0.13–1.79) 0.33 (0.07–1.50) 
Generalized anxiety disorder (GAD-2) 1.69 (0.59–4.86) 3.81 (1.01–14.41)* 
Sensation seeking (mean) 1.04 (0.96–1.11) 0.99 (0.92–1.06) 
Current alcohol use 12.65 (2.99–53.54)** 11.70 (2.30–59.64)* 
Current marijuana use 0.37 (0.12–1.15) 0.56 (0.13–2.38) 
Current other drug use 9.67 (2.22–42.09)* 7.42 (1.92–28.70)* 

Note. OR = odds ratio; CI = confidence interval.

*p < .05; **p < .01.

DISCUSSION

This study is one of the first to examine tobacco use among young adult sexual minorities using a nationally representative sample in the United States. Findings support previous research showing significantly higher tobacco use among sexual minorities compared with heterosexual adolescents and adults, with 33% of LGB young adults reporting any current tobacco use compared with 22% of heterosexuals. These findings are also consistent with the results of state-based studies showing smoking prevalence ranging from 25% to 37% among sexual minority adults (Arizona Department of Health Services, 2006; Conron et al., 2010; Dilley et al., 2008; King et al., 2012; Maher et al., 2005; Tang et al., 2004).

Although few studies have examined other tobacco product use among the sexual minority population, our study shows higher levels of ever use of hookah, cigars, little cigars/cigarillos/bidis, and dissolvable product use in sexual minorities compared with heterosexuals, with few differences in current use between these groups. Data from the NATS confirm significantly higher cigar/cigarillo/small cigar, flavored cigar, and waterpipe prevalence among LGBTs than among heterosexuals and similar pipe smoking use (King, Dube, & Tynan, 2013; King et al., 2012), while other studies have found lower cigar and smokeless tobacco use among sexual minorities compared with heterosexuals (Gruskin, Greenwood, Matevia, Pollack, Bye et al., 2007; Remafedi, Jurek, & Oakes, 2008). One study found that Black, Hispanic, and White LGB college students smoked hookah at significantly higher rates compared with their heterosexual counterparts but found no differences among Asian and multiracial respondents (Blosnich et al., 2011). The study by Blosnich et al. (2011) also examined little cigar, cigar, and cigarillo use by sexual orientation and race/ethnicity and found higher usage among LGB groups. However, the study authors combined these measures with clove cigarette use so it is difficult to draw conclusions about other tobacco products exclusively from these findings (Blosnich et al., 2011).

Findings in this study are consistent with other nationally representative studies such as the National Longitudinal Study of Adolescent Health (Add Health). Russell et al. (2002) found fewer substance use and abuse differences based on same-sex or both-sex romantic attractions than would be expected from past studies. In this study, adolescents with bisexual partners were more likely to report alcohol, marijuana, and other drug use compared with those with opposite-sex or same-sex partners. Udry et al. (2002) found no differences in smoking for same-sex versus opposite-sex partners, but there was a difference in smoking prevalence when analyzing both-sex (bisexual) versus opposite-sex partner. In contrast, this study did not find a consistent pattern of higher tobacco product use among bisexuals compared with homosexual or heterosexual respondents, but does show a higher percentage of cigarette use in the LGB group compared with the heterosexuals.

When sexual minorities were categorized as lesbian, gay, bisexual, transgender or questioning (LGBTQ), tobacco use among the LGBTQ group was greater when compared with heterosexual respondents, though the difference lost statistical significance as the use of tobacco products decreased among those unsure of their sexual orientation (“questioning,” or Q). Our findings show that current alcohol use is the strongest predictor of tobacco use in the LGB group, which is consistent with significantly higher levels of alcohol and cigarette use across many demographic groups in young adulthood (Villanti, Rath, & Vallone, 2012), and research suggesting that substance use is used as a coping mechanism for sexual discrimination (Institute of Medicine, 2011; Meyer, 2003). Although LGB young adults reported higher levels of major depressive disorder and generalized anxiety disorder compared with heterosexuals, these were not statistically significant predictors of any current tobacco use in the multivariable models. Generalized anxiety symptoms did, however, predict current use of other tobacco products in the LGB subsample. Further research is needed to understand the complex interactions between mental health, alcohol, other drug and tobacco use, and emerging adulthood in sexual minority populations.

High school education, alcohol use, and drug use were significantly associated with cigarette use in the multivariable model when controlling for sociodemographics, health, and substance use. Blosnich et al. (2011) found that these same risk factors (education, alcohol, and drug use), while common in the general population, were elevated in the sexual minority community. In addition, the Blosnich et al. (2011) study also finds younger age as a possible risk factor for cigarette use within the LGB population.

We reviewed the limited literature related to LGB and tobacco use. This study directly addresses and successfully overcomes the three challenges of the Institute of Medicine’s call for collecting health data on sexual minorities in a longitudinal cohort (Institute of Medicine, 2011) by using validated measures of sexual identity (VanKim et al., 2010). Our estimates of the sexual minority population identifying as LGB (6.2%) are at the higher end of the national averages for adults, which range from 2.9% to 6.8% of adult men and from 1.4% to 4.6% of adult women identifying as LGB (Institute of Medicine, 2011). One possible reason for the higher estimate in our study is the online data collection method since online surveys elicit higher reports of socially undesirable behavior than interviewer-administered surveys (Parks, Pardi, & Bradizza, 2006; Tourangeau & Yan, 2007). This study also demonstrates the achievability of collecting this sensitive information in a young adult population, with only 1% of respondents selecting not to answer the sexual identity item. Lastly, the Institute of Medicine identifies the challenge of collecting quality samples from this relatively small population. This study addresses that concern by collecting a national, representative sample.

This study has several strengths, but findings should be considered within the context of some limitations. First, some analyses were limited by small sample sizes. Second, there was a high prevalence of Hispanic respondents in the transgender/other and don’t know/not sure categories. Finally, the current analysis is limited to cross-sectional data from the baseline survey. Future analyses will use longitudinal data to assess trends in young adult tobacco use over time.

To date, sexual orientation items have rarely been included on any national public health surveillance efforts. This lack of valid and accurate data prevents program developers and policy makers from addressing the health needs of sexual minorities (Lee, 2009). In addition, according to a recent article by Lee, Blosnich, and Melvin (2012), the landmark 2011 report of Institute of Medicine on LGBT health (used as a blueprint for LGBT health policy) unfortunately discounts decades of evidence that cigarette smoking is higher among the sexual minority population compared with the general population. The report of Institute of Medicine indicated limited evidence of disparities in tobacco use for the LGBT population, but Lee et al. (2012) found that their general keyword search did not include terms specific to tobacco such as “tobacco” and “smoking,” which eliminated upwards of 56 studies for their analysis on LGBT tobacco use (Lee, Blosnich, & Melvin, 2012).

Our study highlights the significant disparities in tobacco use behaviors among sexual minority populations, and the recent prioritization of this issue by the U.S. government reiterates this need to identify the LGBT population in some national health surveys, including instruments with substance use measures like NATS, National Health Nutrition Examination Survey, and the National Survey of Family Growth (Brown, 2011; King et al., 2012). As of 2013, the NHIS will collect data on sexual orientation following new standards for data collection under the Patient Protection and Affordable Care Act (Brown, 2011; Healthy People 2020, 2012). Including surveillance items for this at-risk population in all health agencies at the local, state, and federal levels will improve our understanding of the unique health risks faced by sexual minorities and our ability to develop programming to address their needs.

FUNDING

The work was supported by the American Legacy Foundation (in-house research).

DECLARATION OF INTERESTS

None declared.

REFERENCES

American Lung Association
.
2010
.
Smoking out a deadly threat: Tobacco use in the LGBT Community
 .
Washington, D.C.
Retrieved from www.lung.org/assets/documents/publications/lung-disease-data/lgbt-report.pdf
Arizona Department of Health Services
.
2006
.
Tobacco use and interventions among Arizona lesbian, gay, bisexual and transgender people
 . Retrieved from http://azmemory.azlibrary.gov/cdm/singleitem/collection/statepubs/id/3462/rec/10
Biener
L.
Albers
A. B
.
2004
.
Young adults: Vulnerable new targets of tobacco marketing
.
American Journal of Public Health
 ,
94
,
326
330
. doi:
10.2105/AJPH.94.2.326
Blosnich
J.
Jarrett
T.
Horn
K
.
2011
.
Racial and ethnic differences in current use of cigarettes, cigars, and hookahs among lesbian, gay, and bisexual young adults
.
Nicotine & Tobacco Research
 ,
13
,
487
491
. doi:
10.1093/ntr/ntq261
Blosnich
J.
Lee
J.
Horn
K
.
2013
.
A systematic review of the aetiology of tobacco disparities for sexual minorities
.
Tobacco Control
 ,
22
,
66
73
. doi:
10.1136/tobaccocontrol-2011–050181
Bowen
D. J.
Bradford
J. B.
Powers
D.
McMorrow
P.
Linde
R.
Murphy
B. C.
Han
J.
et al
2004
.
Comparing women of differing sexual orientations using population-based sampling
.
Women & Health
 ,
40
,
19
34
. doi:
10.1300/J013v40n03_02
Brown
D
. (
2011
, June 29).
Main federal health survey will ask about sexual orientation, gender identity
.
The Washington Post
 . Retrieved from www.washingtonpost.com/national/health-science/main-federal-health-survey-will-ask-about-sexual-orientation-gender-identity/2011/06/29/AGMZwMrH_story.html?wpisrc=emailtoafriend.
Burgard
S. A.
Cochran
S. D.
Mays
V. M
.
2005
.
Alcohol and tobacco use patterns among heterosexually and homosexually experienced California women
.
Drug and Alcohol Dependence
 ,
77
,
61
70
. doi:
10.1016/j.drugalcdep.2004.07.007
Centers for Disease Control and Prevention
.
2008
.
Smoking-attributable mortality, years of potential life lost, and productivity losses—United States, 2000–2004
.
Morbidity and Mortality Weekly Report
 ,
57
,
1226
1228
. Retrieved from www.cdc.gov/mmwr/preview/mmwrhtml/mm5745a3.htm
Centers for Disease Control and Prevention
. (
2011
).
Sexual identity, sex of sexual contacts, and health-risk behaviors among students in grades 9–12—Youth risk behavior surveillance, selected sites, United States, 2001–2009
.
Morbidity and Mortality Weekly Report
 ,
60
,
1
133
. Retrieved from www.cdc.gov/mmwr/pdf/ss/ss6007.pdf
Centers for Disease Control and Prevention
. (
2011
).
2010 NHIS Questionnaire
. Retrieved
April 5, 2012
, from ftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Survey_Questionnaires/NHIS/2010/English/qfamily.pdf
Conron
K. J.
Mimiaga
M. J.
Landers
S. J
.
2010
.
A population-based study of sexual orientation identity and gender differences in adult health
.
American Journal of Public Health
 ,
100
,
1953
1960
. doi:
AJPH.2009.174169 [pii] 10.2105/AJPH.2009.174169
Corliss
H. L.
Wadler
B. M.
Jun
H.-J.
Rosario
M.
Wypij
D.
Frazier
A. L.
Austin
S. B
.
2013
.
Sexual-orientation disparities in cigarette smoking in a longitudinal cohort study of adolescents
.
Nicotine & Tobacco Research
 ,
15
,
213
222
. doi:
10.1093/ntr/nts114
Danaei
G.
Ding
E. L.
Mozaffarian
D.
Taylor
B.
Rehm
J.
Murray
C. J.
Ezzati
M
.
2009
.
The preventable causes of death in the United States: Comparative risk assessment of dietary, lifestyle, and metabolic risk factors
.
PLoS Medicine
 ,
6
,
e1000058
. doi:
10.1371/journal.pmed.1000058
Dilley
J. A.
Maher
J. E.
Boysun
M. J.
Pizacani
B. A.
Mosbaek
C. H.
Rohde
K.
Stark
M. J.
et al
2005
.
Response letter to: Tang H, Greenwood GL, Cowling DW, Lloyd JC, Roeseler AG, Bal DG. Cigarette smoking among lesbians, gays, and bisexuals: How serious a problem?
Cancer Causes & Control
 ,
16
,
1133
1134
. doi:
10.1007/sl0552-005-0395-2
Dilley
J. A.
Spigner
C.
Boysun
M. J.
Dent
C. W.
Pizacani
B. A
.
2008
.
Does tobacco industry marketing excessively impact lesbian, gay and bisexual communities?
Tobacco Control
 ,
17
,
385
390
. doi:
10.1136/tc.2007.024216
Engstrom
M.
Mariolis
P
.
2010
.
The National Adult Tobacco Survey: What is it and how can I use it? Centers for Disease Control and Prevention, Office on Smoking and Health.
Retrieved from www.ttac.org/resources/pdfs/012110_NATS_Netconference.pdf
Gregor
K.
Zvolensky
M. J.
Bernstein
A.
Marshall
E. C.
Yartz
A. R
.
2007
.
Smoking motives in the prediction of affective vulnerability among young adults daily smokers
.
Behaviour Research and Therapy
 ,
45
,
471
482
. doi:
10.1016/j.brat.2006.03.019
Gruskin
E. P.
Greenwood
G. L.
Matevia
M.
Pollack
L. M.
Bye
L. L
.
2007
.
Disparities in smoking between the lesbian, gay, and bisexual population and the general population in California
.
American Journal of Public Health
 ,
97
,
1496
1502
. doi:
10.2105/AJPH.2006.090258
Gruskin
E. P.
Greenwood
G. L.
Matevia
M.
Pollack
L. M.
Bye
L. L.
Albright
V
.
2007
.
Cigar and smokeless tobacco use in the lesbian, gay, and bisexual population
.
Nicotine & Tobacco Research
 ,
9
,
937
940
. doi:
10.1080/14622200701488426
Hafez
N.
Ling
P. M
.
2005
.
How Philip Morris built Marlboro into a global brand for young adults: Implications for international tobacco control
.
Tobacco Control
 ,
14
,
262
271
. doi:
10.1136/tc.2005.011189
Healthy People 2020
.
2012
.
2020 Objectives: Lesbian, gay, bisexual, and transgender health.
Retrieved
June 1, 2012
, from www.healthypeople.gov/2020/topicsobjectives2020/overview.aspx?topicid=25
Heck
J. E.
Jacobson
J. S
.
2006
.
Asthma diagnosis among individuals in same-sex relationships
.
Journal of Asthma
 ,
43
,
579
584
. doi:
10.1080/02770900600878289
Hendlin
Y.
Anderson
S. J.
Glantz
S. A
.
2010
.
“Acceptable rebellion”: Marketing hipster aesthetics to sell Camel cigarettes in the US
.
Tobacco Control
 ,
19
,
213
222
. doi:
10.1136/tc.2009.032599
Hoyle
R. H.
Stephenson
M. T.
Palmgreen
P.
Lorch
E. P.
Donohew
R. L
.
2002
.
Reliability and validity of a brief measure of sensation seeking
.
Personality and Individual Differences
 ,
32
,
401
414
. doi:
10.1016/S0191-8869(01)00032-0
Institute of Medicine
.
2011
.
The health of lesbian, gay, bisexual, and transgender people: Building a foundation for better understanding
 .
Washington, DC
:
The National Academies Press
.
King
B. A.
Dube
S. R.
Tynan
M. A
.
2012
.
Current tobacco use among adults in the United States: Findings from the National Adult Tobacco Survey
.
American Journal of Public Health
 ,
102
,
e93
e100
. doi:
10.2105/AJPH.2012.301002
King
B. A.
Dube
S. R.
Tynan
M. A
.
2013
.
Flavored cigar smoking among U.S. adults: Findings from the 2009–2010 National Adult Tobacco Survey
.
Nicotine & Tobacco Research
 ,
15
,
608
614
. Retrieved from www.ncbi.nlm.nih.gov/pubmed/22927687
Kroenke
K.
Spitzer
R. L.
Williams
J. B. W
.
2003
.
The Patient Health Questionnaire-2: Validity of a two-item depression screener
.
Medical Care
 ,
41
,
1284
1292
. doi:
10.1097/01.MLR.0000093487.78664.3C
Kroenke
K.
Spitzer
R.
Williams
J
.
2007
.
Anxiety disorders in primary care: Prevalence, impairment, comorbidity, and detection
.
Annals of Internal Medicine
 ,
146
,
317
326
. Retrieved from www.annals.org/content/146/5/ 317.short
Lee
J
.
2009
.
Social ecology of tobacco surveillance data for sexual and gender minority populations
.
Nicotine & Tobacco Research
 ,
11
,
908
909
. doi:
10.1093/ntr/ntp069
Lee
J.
Blosnich
J. R.
Melvin
C. L
.
2012
.
Up in smoke: Vanishing evidence of tobacco disparities in the Institute of Medicine’s report on sexual and gender minority health
.
American Journal of Public Health
 ,
9
,
1
3
. doi:
10.2105/AJPH.2012.300746
Lee
J.
Griffin
G. K.
Melvin
C. L
.
2009
.
Tobacco use among sexual minorities in the USA, 1987 to May 2007: A systematic review
.
Tobacco Control
 ,
18
,
275
282
. doi:
10.1136/tc.2008.028241
Maher
J. E.
Boysun
M. J.
Rohde
K.
Stark
M. J.
Pizacani
B. A.
Dilley
J.
Mosbaek
C. H.
Pickle
K. E
.
2005
.
Are Latinos really less likely to be smokers? Lessons from Oregon
.
Nicotine & Tobacco Research
 ,
7
,
283
287
. doi:
10.1080/14622200500056259
Mayer
K. H.
Bradford
J. B.
Makadon
H. J.
Stall
R.
Goldhammer
H.
Landers
S
.
2008
.
Sexual and gender minority health: What we know and what needs to be done
.
American Journal of Public Health
 ,
98
,
989
995
. doi:
10.2105/AJPH.2007.127811
McCabe
S. E.
Boyd
C.
Hughes
T. L.
D’Arcy
H
.
2003
.
Sexual identity and substance use among undergraduate students
.
Substance Abuse
 ,
24
,
77
91
. doi:
10.1023/A:1023768215020
McKirnan
D. J.
Tolou-Shams
M.
Turner
L.
Dyslin
K.
Hope
B
.
2006
.
Elevated risk for tobacco use among men who have sex with men is mediated by demographic and psychosocial variables
.
Substance Use & Misuse
 ,
41
,
1197
1208
. doi:
10.1080/10826080500514503
Meyer
I. H
.
2003
.
Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: Conceptual issues and research evidence
.
Psychological Bulletin
 ,
129
,
674
697
. doi:
10.1037/0033-2909.129.5.674
Miller
K.
Ryan
J. M
.
2011
.
Design, development and testing of the NHIS sexual identity question
. Retrieved from www.lgbttobacco.org/files/Final Report Sexual Identity.pdf
Mokdad
A. H.
Marks
J. S.
Stroup
D. F.
Gerberding
J. L
.
2005
.
Actual causes of death in the United States, 2000
.
Journal of the American Medical Association
 ,
293
,
1238
1245
. doi:
10.1001/jama.291.10.1238
National Cancer Institute
.
2006
.
2006 Tobacco use supplement to the current population survey
. Retrieved from http://riskfactor.cancer.gov/studies/tus-cps/surveys/tuscps_english_2006.pdf
Parks
K. A.
Pardi
A. M.
Bradizza
C. M
.
2006
.
Collecting data on alcohol use and alcohol-related victimization: A comparison of telephone and Web-based survey methods
.
Journal of Studies on Alcohol
 ,
67
,
318
323
. Retrieved from www.ncbi.nlm.nih.gov/pubmed/16562415
Pizacani
B. A.
Rohde
K.
Bushore
C.
Al
E
.
2009
.
Smoking-related knowledge, attitudes and behaviors in the lesbian, gay and bisexual community: A population-based study from the U.S. Pacific Northwest
.
Preventive Medicine
 ,
48
,
555
561
. doi:
10.1016/j.ypmed.2009.03.013
Rath
J. M.
Villanti
A. C.
Abrams
D. A.
Vallone
D
.
2012
.
Patterns of tobacco and dual use in U.S. young adults: The missing link between youth prevention and adult cessation
.
Journal of Environmental and Public Health
 . doi:
10.1155/2012/679134
Remafedi
G.
Jurek
A. M.
Oakes
J. M
.
2008
.
Sexual identity and tobacco use in a venue-based sample of adolescents and young adults
.
American Journal of Preventive Medicine
 ,
35
(
Suppl. 6
)
S463
S470
. doi:
10.1016/j.amepre.2008.09.002
Russell
S. T.
Driscoll
A. K.
Truong
N
.
2002
.
Adolescent same-sex romantic attractions and relationships: Implications for substance use and abuse
.
American Journal of Public Health
 ,
92
,
198
202
. doi:
10.2105/AJPH.92.2.198
Schiller
J. S.
Lucas
J. W.
Peregoy
J. A
.
2012
.
Summary health statistics for U.S. adults: National Health Interview Survey, 2011
.
National Center for Health Statistics. Vital and Health Statistics
 , series
10
, number 256. Washington, DC: U.S. Department of Health and Human Services.
Senseman
S. E
.
2008
.
Cognitive testing of an LGBT surveillance question. The network for LGBT tobacco control
. Retrieved from www.lgbttobacco.org/files/Cognitive Testing on an LGBT Surveillance Question.pdf
Stall
R. D.
Greenwood
G. L.
Acree
M.
Paul
J.
Coates
T. J
.
1999
.
Cigarette smoking among gay and bisexual men
.
American Journal of Public Health
 ,
89
,
1875
1878
. doi:
10.2105/AJPH.89.12.1875
StataCorp
.
2009
.
Stata Statistical Software: Release 11
 .
College Station, TX
:
StataCorp LP
.
Stevens
P.
Carlson
L. M.
Hinman
J. M
.
2004
.
An analysis of tobacco industry marketing to lesbian, gay, bisexual, and transgender (LGBT) populations: Strategies for mainstream tobacco control and prevention
.
Health Promotion Practice
 ,
5
(
Suppl. 3
)
129S
134S
. doi:
10.1177/ 1524839904264617
Substance Abuse and Mental Health Services Administration
.
2012
.
Results from the 2011 National Survey on Drug Use and Health: Summary of national findings. NSDUH Series H-44, HHS Publication No. (SMA) 12–47
 .
Rockville, MD
.
Tang
H.
Greenwood
G. L.
Cowling
D. W.
Lloyd
J. C.
Roeseler
A. G.
Bal
D. G
.
2004
.
Cigarette smoking among lesbians, gays, and bisexuals: How serious a problem? (United States)
.
Cancer Causes & Control
 ,
15
,
797
803
. doi:
10.1023/B:CACO.0000043430.32410.69
Tourangeau
R.
Yan
T
.
2007
.
Sensitive questions in surveys
.
Psychological Bulletin
 ,
133
,
859
883
. doi:
10.1037/0033-2909.133.5.859
Trocki
K. F.
Drabble
L. A.
Midanik
L. T
.
2009
.
Tobacco, marijuana, and sensation seeking: Comparisons across gay, lesbian, bisexual, and heterosexual groups
.
Psychology of Addictive Behaviors
 ,
23
,
620
631
. doi:
10.1037/a0017334
U.S. Department of Health and Human Services
.
2012
.
Preventing tobacco use among youth and young adults: A report of the surgeon general
 .
Atlanta, GA
:
U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health.
Retrieved from www.surgeongeneral.gov/library/reports/preventing-youth-tobacco-use/full-report.pdf
Udry
J. R.
Chantala
K
.
2002
.
Risk assessment of adolescents with same-sex relationships
.
Journal of Adolescent Health
 ,
31
,
84
92
. doi:
10.1016/S1054-139X(02)00374-9
VanKim
N. A.
Padilla
J. L
.
2010
.
New Mexico’s progress in collecting lesbian, gay, bisexual, and transgender health data and its implications for addressing health disparities
 .
Albuquerque, NM
. Retrieved from www.nmtupac.com/reports/new/2010_LGBT_Report.pdf
VanKim
N. A.
Padilla
J. L.
Lee
J. G.
Goldstein
A. O
.
2010
.
Adding sexual orientation questions to statewide public health surveillance: New Mexico’s experience
.
American Journal of Public Health
 ,
100
,
2392
2396
. doi:
10.2105/AJPH.2009.186270
Villanti
A. C.
Rath
J. M.
Vallone
D. M
.
2012
.
Changing patterns of alcohol, tobacco, and marijuana use by age in young adults
 .
Poster presented at the 12th Annual Scientific Meeting of the American Academy of Health Behavior
.
Austin, TX
.
Washington
H. A
.
2002
.
Burning Love: Big tobacco takes aim at LGBT youths
.
American Journal of Public Health
 ,
92
,
1086
1095
. doi:
10.2105/AJPH.92.7.1086