Youths Coming Out as Bisexual Have Double the Odds of Cigarette Smoking Initiation

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Study Authors: Alyssa F. Harlow, Dielle Lundberg, et al.

Target Audience and Goal Statement: Pediatricians, primary care physicians, psychiatrists, public health and policy specialists, pulmonologists

The goal of this study was to assess whether young people who change their sexual identity have higher risks of cigarette smoking initiation and current smoking compared with youth with consistent sexual identities.

Question Addressed:

• Was changing sexual identity in youth associated with a higher risk of cigarette smoking initiation and current smoking compared with those with consistent sexual identities?

Study Synopsis and Perspective:

Cigarette use varies significantly by sexual identity and sex, with evidence that sexual minority adults are more likely to be smokers after adjusting for other factors. It is estimated that 22% of young people who are lesbian, gay, bisexual, or another non-heterosexual identity (LGB+) smoke cigarettes — often starting at earlier ages and smoking more heavily — compared with 14% of heterosexual youth.

Compared with their straight peers, likelihood of tobacco product use among LGB individuals varied by sex, by product, and by sexual identity (gay/lesbian vs bisexual), an analysis of 2016 Behavioral Risk Factor Surveillance System data suggested.

According to a recent analysis of federal survey data, the risk of cigarette smoking initiation was particularly increased among young people undergoing a change in sexual identity.

The odds that adolescents and young adults would take up smoking were 72% higher, after adjustment, for those who reported changing sexual identities (95% CI 34%-120%) relative to those consistently reporting heterosexual identity, wrote Alyssa F. Harlow, MPH, of Boston University School of Public Health, and colleagues in JAMA Pediatrics.

“People who have recently come out may be experiencing new forms of discrimination and stress, leading to smoking as a coping mechanism,” Harlow told MedPage Today. “They may also be meeting new people or engaging in new social groups within the LGB+ community, where there are higher rates of smoking.”

The risk was concentrated among youth identifying as bisexual — such that, compared with consistently heterosexual participants, the risk of starting to smoke (after adjustment for covariates) was higher for those:

• Coming out as bisexual after identifying as heterosexual (adjusted odds ratio [aOR] 2.24, 95% CI 1.72-2.29)
• Coming out as bisexual after identifying as lesbian or gay (aOR 1.99, 95% CI 1.20-3.29)
• Coming out as bisexual after identifying with other sexual identities such as queer or asexual (aOR 2.20, 95% CI 1.40-3.46)
• Consistently identifying as bisexual throughout the study (aOR 1.60, 95% CI 0.89-2.88)

The researchers studied data from four waves of the longitudinal Population Assessment of Tobacco and Health survey, beginning in 2013-2014 and ending in 2016-2018. Harlow and colleagues compared smoking rates among LGB+ and heterosexual respondents 14-29 years of age who were non-smokers at the first wave of the survey.

In total, 7,843 smoking-naive individuals with a mean age of 20.1 years participated. Some 87% of participants reported being consistently heterosexual throughout the study period, while 5% came out as LGB+ across various waves of the study. The remainder were consistently LGB+ (3.6%) or had some other LGB+ pattern (4.4%).

At wave 4, 6% of the cohort was currently smoking, defined as smoking “even one or two puffs” within the past 30 days. Compared with consistently heterosexual respondents, a higher risk of current smoking was shown in people who consistently reported being LGB+ (aOR 1.63, 95% CI 1.00-2.66), and who had other LGB+ patterns such as changing from heterosexual to asexual (aOR 1.63, 95% CI 1.03-2.56).

There was no increased risk of smoking noted in respondents who came out as lesbian, gay, or another sexual identity (aOR 0.91, 95% CI 0.52-1.60); respondents who consistently reported being lesbian, gay, or another unlisted sexual identity (aOR 0.90, 95% CI 0.43-1.87); or those with other LG+ patterns (aOR 0.91, 95% CI 0.55-1.49).

It’s possible some respondents identified as LGB+ in the survey but not publicly, which is a limitation, Harlow and team noted. This community is also very diverse and there may be factors that were unaccounted for that are influencing the association, such as family supports or social environments.

“Our work demonstrates [that] the timing and type of sexual identity development matters with regard to smoking behaviors in young people,” the researchers wrote. “Public health professionals should recognize the nuances of sexual identity and its effect on health behaviors rather than homogenizing young people into binary and static sexual identities … especially considering that in this nationally representative sample of youth and young adults, a majority of LGB+ participants reported a change in sexual identity over the 3-year follow-up.”

Source Reference: JAMA Pediatrics 2020; DOI: 10.1001/jamapediatrics.2020.3565

Study Highlights and Explanation of Findings:

Changing sexual identities was associated with an increased risk of smoking initiation among young people, according to federal survey data.

“In this longitudinal nationally representative study, we found that participants who came out as bisexual or reported changes in their identity to/from being bisexual were twice as likely to initiate smoking and to be current smokers compared with consistently heterosexual participants,” Harlow and team noted.

The findings reflect observations in a wider population of people in emerging adulthood (ages 18-25), which linked life event transitions (e.g., losing a job, change in romantic partners, entering college) with increased risks of smoking and alcohol use.

“Importantly, our results indicate that the smoking risk associated with changing sexual identities was entirely attributed to coming out as bisexual or reporting other changes in identity to/from being bisexual, rather than coming out as LG+,” Harlow and co-authors wrote.

They cited a review that reported a higher prevalence of mental disorders among LGB individuals compared with heterosexuals, which was conceptualized in terms of minority stress, whereby stigma, prejudice, and discrimination create a hostile and stressful social environment that causes mental health problems.

Notably, smoking is more prevalent among LGB adults than among heterosexual adults (20.5% vs 15.3%), according to CDC data. Similarly, alcohol use is more prevalent among members of sexual minority groups, and along with tobacco use, was found to be associated with greater odds of psychiatric comorbidities.

Recently out LGB+ individuals may smoke as a reaction to newly experienced discrimination, Harlow suggested. The bisexual community may experience greater psychological distress than gay, lesbian, or heterosexual communities, although this was not something directly examined in the current study. Additionally, “bisexual young people might experience stigma from both the heterosexual population as well as from within the LGB+ community,” she noted.

A 2015 longitudinal analysis of sexual orientation identity change and depressive symptoms noted that social identities and interactions with similarly identified persons are critical for validating in-group norms within a broader social context that seeks to invalidate their identities.

Toward validating in-group norms and providing meaning and a sense of purpose, the Trevor Project offers support to bisexual youth and an introductory educational resource that covers a wide range of topics and best practices for supporting bisexual youth.

Tobacco addiction is not only more prevalent among sexual minorities, it is also noted to take a much heavier toll on these groups. Compared with heterosexual smokers, smoking among lesbians has been linked with greater risks of breast cancer and colorectal cancer, as well as an increased risk of HIV infection and potentially accelerated progression to AIDS in gay men.

Sexual and gender minority individuals are a marginalized population and suffer both health and healthcare disparities, as characterized by the Institute of Medicine’s 2018 report, “The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding.”

Given the well-known associations between smoking and increased risks of lung cancer, heart disease, stroke, and other health consequences, addressing smoking initiation among LGB+ young people is an important public health priority, Harlow and co-authors said.

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