Sex and sexual orientation in relation to tobacco use among young adult college students in the US: a cross-sectional study

Tobacco use is a significant public health problem in the United States. An emerging line of studies suggests that sexual minorities, defined for this study as lesbians, gays, and bisexuals (LGBs), are at higher risk for tobacco use compared to their heterosexual counterparts, especially during young adulthood [1‐7]. Despite a relatively robust literature documenting higher risk of tobacco use among sexual minorities, these findings are more complex when considering specific sexual minority groups among the different sexes, as well as the more nuanced alternative tobacco products (ATPs).

First, findings about sexual minorities in the aggregate might not necessarily represent an accurate portrayal of tobacco use profiles among subgroups of this population. Recent work suggests that not all sexual minorities experience the same prevalence and risk of tobacco use [1‐4, 8]. In general, evidence across studies shows that bisexuals report a higher tobacco use rate than gay/lesbian and heterosexuals [2, 8, 9]. Secondly, studies stratified by biological sex suggest higher rates of cigarette and ATP use among sexual minority versus heterosexual women, while these differences are not found among men [2, 8, 10]. Additionally, the increasingly prevalent use of ATPs, such as little cigars and cigarillos (LCCs), e-cigarettes, and hookah, further complicates our understanding of populations at high-risk for tobacco use [1‐3, 6, 11‐14].

Young adulthood is a particularly vulnerable period for sexual minorities, especially college-attending sexual minorities. In transition to college, sexual minority individuals may experience unwelcoming environments and struggle with incivility or harassment [15, 16]. In addition, many sexual minorities might experience challenges in acknowledging, defining, accepting, and disclosing their sexual identity while transitioning to adulthood [17‐19]. As multiple stressors increasingly challenge an individual’s coping capabilities, tobacco use may serve as an alternative coping strategy for sexual minority college students who experience “minority stress” [5, 20]. Minority Stress Theory suggests that being a sexual minority leads to excess stress and, consequently, adverse health outcomes including tobacco use [20, 21].

To date, limited research has examined the use of various tobacco products among young adult men and women representing sexual orientation statuses. While examining sexual orientation group disparities in tobacco use, few quantitative analyses have considered the effect of biological sex or included ATPs [11, 22]. Two separate systematic reviews have examined the prevalence and etiology of smoking among sexual minorities thus far [5, 23]; however, neither of them simultaneously examined smoking by sex, sexual orientation, and specific tobacco products.

As a fundamental step toward addressing the gaps in the literature, this study examined the relationship of sexual orientation (distinguishing heterosexual, gay/lesbian, and bisexual sexual orientation) and past 30-day use of tobacco (cigarette, little cigars/cigarillos [LCCs], e-cigarettes, hookah, any tobacco product used, and number of tobacco product used, respectively) among college young adult men and women, respectively.

This study examined the association between sexual orientation and use of various tobacco products, with the goal of advancing the literature regarding how biological sex and sexual minority status (gay/lesbian sexual orientation and bisexual sexual orientation) are associated with cigarette and ATP use. Our results indicated that some sexual minority subgroups are at a higher risk for using specific tobacco products. However, sexual minority women subgroups reported greater tobacco use differences compared to sexual minority men.

Among young adult men, gay sexual orientation, but not bisexual orientation, was significantly correlated with cigarette use. This finding is consistent with prior research indicating gay men were significantly more likely to smoke cigarettes, while bisexual men were no different from heterosexual men [23, 26]. However, neither gay nor bisexual orientation was associated with LCC, e-cigarette, or hookah use. Evidence has been inconsistent for ATP use among sexual minority men. For example, Emory et al. (2015) reported bisexual men were more likely to use LCCs, while gay men were less likely to use them compared to heterosexual men [2]. In contrast, Johnson and colleagues (2016) found no statistically significant difference between sexual minority men and straight men in cigar use. Instead, they found sexual minority men reported a higher rate of ever using e-cigarettes and hookah than heterosexual men [1]. The differences between findings in these aforementioned studies and current findings are difficult to discern. However, it is possible that, in the current study, the smaller number of men in the sexual minority subgroups and the small number of ATP users among men limited our statistical power to detect potential associations between sexual orientation and ATP use.

In young adult women, lesbian sexual orientation was associated with cigarette and LCC use; bisexual sexual orientation was associated with cigarette, LCCs, and e-cigarette use. These findings align with existing literature that sexual minority statuses among women are associated with the use of a range of tobacco products [1‐3, 6, 8]. This includes data drawn from a nationally representative sample of 17,087 U.S. adults, which showed that lesbians were more likely to use regular cigars and LCCs compared to heterosexual women, and bisexual women were more likely to use e-cigarettes and LCCs [2]. Our results also echo previous findings [2, 6, 8] that bisexual women might be experiencing the greatest tobacco use disparities compared to other sexual minority groups or heterosexual men and women. From the perspective of Minority Stress Theory, it is plausible that bisexual women may experience unique stressors (e.g., exclusion from heterosexual and lesbian communities) that may lead to tobacco use [27].

Race was consistently found to be a significant correlate of multiple tobacco use outcomes among young adults, especially among women in our study. However, the sample size limitation restricted further exploration attempts on how race might interact with sexual orientation as well as biological sex in influencing tobacco use. Similarly, Blosnich et al. (2011) reported a higher rate of LCCs and hookah use among Black sexual minorities compared to white sexual minorities [28]. Previous meta-analyses also suggest race is a statistically significant correlate of overall substance use among sexual minorities but do not specify tobacco use [29]. However, more evidence is needed to understand the interaction of multiple identities (i.e., sexual orientation, biological sex, race, etc.) and tobacco use disparities. School type was also a significant correlate of tobacco use in our study. Among young adult men and women attending technical college, a two-year institution, the likelihood of using cigarettes and e-cigarettes in the past 30 days was significantly higher than four-year institutions. One explanation could be that technical colleges typically represent a group of students with lower socioeconomic status (SES) compared with four-year education institutions [30] and lower SES is associated with an escalated use of tobacco [31].

Furthermore, results from the two-group comparison analysis suggest that the sexual orientation – LCC use association is statistically different between men and women, indicating being a woman magnifies the influence that being a sexual minority has on LCC use. However, for use of cigarettes, e-cigarettes, and hookah, the effect of sexual minority status did not differ between men and women. A few studies on tobacco use have documented such between-sex heterogeneity among sexual minorities. For example, Bandiera (2013) suggested that lesbian/gay and bisexual sexual orientation correlated with cigarette use among women but not among men [6]. However, none compared this heterogeneity statistically [1‐3, 6, 8‐10]. Our findings suggest that between-sex differences might be mostly prominent in LCCs use rather than other types of tobacco use in sexual minority young adults. One study suggested that LCCs are more appealing to young adults for the variety of available sweet and fruit flavored LCCs are more palatable, and using LCCs can enhance mood [32]. Bisexual women reported higher levels of depressive symptoms than gays and lesbians did, and lesbians reported higher levels of depressive symptoms than gays did [33, 34]. Based on Minority Stress Theory, it is possible that sexual minority women, especially bisexual women, use LCCs more often to deal with symptoms of depression or stress more broadly.

Nonetheless, the causes for the between-sex difference across sexual minority groups remain largely unknown. Matthews et al. (2014) found neither childhood victimization, depression, nor anxiety explained differences in smoking prevalence among sexual minority women [35]. One possible explanation may be exposure to tobacco marketing [36‐38]. A 2018 study found that sexual minorities more frequently reported exposure to tobacco-related advertisements and anti-tobacco messages [39]. Dilley et al. (2008) suggested that sexual minority women were exposed to more tobacco marketing and also were more receptive to tobacco industry marketing than heterosexual women while sexual minority men were more exposed but no more receptive than heterosexual men [40]. Similarly, Fallin et al. (2015) also found higher tobacco advertising receptivity among sexual minority women, especially bisexual women [41]. It is, therefore, possible that tobacco marketing may target not only sexual minority as a whole, but also specific sexual minority subgroups [2]. Efforts to understand the drivers of tobacco use disparities among sexual minority women, especially bisexual women, are warranted.

The current results indicating tobacco product heterogeneity across sexual minorities emphasize the importance of understanding how newer forms of tobacco products may differentially appeal to these subpopulations. Although ATPs have become increasingly popular in the U.S. [13, 14, 42, 43], the majority of existing studies on tobacco use and sexual minority often do not examine the types of tobacco products or just simply assess participants’ cigarette smoking status [4, 7, 8, 23, 35, 44, 45], making it difficult to assess the actual tobacco-related risks among disadvantaged populations such as sexual minorities. Moreover, while the specific health risks of ATPs warrant additional research, it is important to note that no tobacco is safe to use and that the newer forms of tobacco products (i.e., ATPs) do have distinctive health risks (i.e. nicotine dependence potential and toxicity) [46]. Future research should consider ATPs in addition to cigarette use to address tobacco use disparities in sexual minorities accurately.

The current study findings add to the relatively sparse literature by providing evidence on the distinctive profiles in sexual minority use of tobacco products, as well as pinpointing most at-risk subgroups for tobacco use. Despite experiencing higher rates of tobacco use, public tobacco cessation services were underused by sexual minorities [47]. Additionally, tobacco interventions that directly target sexual minorities are scarce [22, 48‐51]. Recent systematic reviews suggest that sexual minority tailored tobacco interventions, including communication campaigns and individual and group counseling programs, appear to be effective [22, 52]. However, qualitative data suggest that sexual minority communities have specific needs regarding tobacco cessation, such that programs designed to facilitate quitting should be tailored to their needs [53]. More importantly, interventions are favored when customized for their specific community (e.g., lesbian or bisexual women) rather than sexual minorities as a whole or the general population [52]. Thus, culturally-competent and inclusive messaging tailoring certain sexual minority subgroups and their patterns of tobacco use may be more effective in recruiting these subgroups. In particular, since we found that bisexual women may be more prone to tobacco use, especially LCC use, interventions might target reductions in LCC use to address the tobacco use disparities among bisexual women.

Although this study has important findings, some limitations should be noted. Although this sample was comprised of diverse young adults in terms of race, ethnicity, and socioeconomic backgrounds; diverse college campus types (e.g., private, public, two-year, HBCU); and students in rural and urban settings, the sample was comprised of college students from Georgia, limiting the generalizability of our results to the broader young adult population. However, it is also important to note that estimated state prevalence of current tobacco use among Georgian young adults (18–24 years old) and Georgian adults in general are not significantly different from national estimates [54, 55]. We also had a relatively low overall response rate (22.9%), partly because we met our sampling quota target in short time intervals (ranging from 1 day at the private schools to 7 days at the technical colleges). As such, our sample may not be representative of the entire college student population in Georgia. Our sample is largely reflective of the student populations of each school, with one exception: our study enrolled fewer male student participants (36%) than female participants (64%), which was disproportionate relative to the student enrollment at the colleges included in the study. However, given that tobacco use is less prevalent among women, having a larger proportion of women allowed us to examine tobacco use with more power. Additionally, the parent study was not designed to address this research aim and thus did not aim to specifically target recruitment of sexual minority populations or assess relevant factors related to tobacco use among sexual minorities, limiting our ability to comprehensively examine the underlying factors for sexual minority tobacco disparities. Finally, the cross-sectional design of this study can only suggest associations rather than provide tests of causality. In terms of causality, no known theoretical basis has suggested sexual orientation itself causes or conveys risks for tobacco use. Instead, it is most likely that the social environment contributes to the tobacco use disparities among sexual minorities [20, 56‐58]. To conclude, further research with larger samples of diverse young adults is needed to more comprehensively examine profiles of tobacco use, as well as the underlying mechanisms of use over time.

Among a sample of young adult college students, results indicated that among men, gay sexual orientation, but not bisexual sexual orientation, was significantly associated with cigarette use. Among women, lesbian sexual orientation was associated with cigarette and LCC use; bisexual sexual orientation was associated with cigarette, LCC, and e-cigarette use. Furthermore, the sexual orientation – LCC use association is statistically different between men and women, indicating being a woman magnifies the influence of being a sexual minority on LCC use.

Our findings provided evidence on the distinctive tobacco use patterns between heterosexual, gay/lesbian, and bisexual young adult college students, and documented that bisexual women might be experiencing the greatest tobacco use disparities compared to other young adult sexual minority groups or heterosexuals. Interventions might target reductions in LCC use to address differences in tobacco use rates among sexual minority young adult women. Further studies are needed to understand the cause for differences in tobacco use prevalence among sexual minorities.