Association between exposure to LGBTQ-targeted tobacco marketing and tobacco use behaviors among US young adults

Abstract

Background

A risk factor for tobacco use among sexual and gender minority people is exposure to tobacco marketing. This study aimed to assess exposure to tobacco marketing by sexual and gender identity via general venues (e.g., bars/clubs, newspapers/magazines), determine the frequency of targeted marketing via LGBTQ venues, and examine how exposure to tobacco marketing in LGBTQ venues relates to tobacco use among sexual and gender minority young adults.

Methods

We conducted an online survey of US young adults (ages 18–30 years) between July and August 2023. We estimated exposure to tobacco marketing in general and LGBTQ venues. We conducted adjusted logistic regression analyses to examine the association between frequency (“0 times [never]”, “1 time”, “2 times”, “3 times”, “4 times”, “5 times or more”) of tobacco marketing exposure in general and LGBTQ venues and current (past-30-day) tobacco use among sexual and gender minority young adults. The models were adjusted for age, sex, race, alcohol and cannabis use.

Results

Among respondents (N=1378), n=682 (49.5%) identified as sexual and gender minority individuals. The top 3 LGBTQ venues for tobacco marketing were websites (15%), shows on streaming services (14%), and social media/apps (13%). More frequent exposure to LGBTQ marketing in LGBTQ stores (aOR=1.58, 95% CI=1.18, 2.11, p=0.002), newspapers/magazines (aOR=2.07, 95% CI=1.30, 3.30, p=0.002), and at events like Pride Festivals (aOR=1.38, 95% CI=1.11, 1.71, p=0.003), were associated with current tobacco use among LGBTQ young adults.

Conclusions

This study highlights implications for tobacco marketing regulation such as regulation of tobacco marketing presence in LGBTQ venues.

INTRODUCTION

Tobacco-related health disparities in priority populations including sexual and gender minority individuals are well-documented.¹ In 2021, current tobacco use in the United States among sexual minority adults was 27.4%, which is significantly higher than heterosexual/straight adults (18.4%).² Tobacco use among sexual and gender minority individuals increases the risk of long-term negative health outcomes such as cancer, cardiovascular diseases, other chronic diseases (e.g., diabetes, lung conditions), and other substance use.³ Understanding risk factors for tobacco use among sexual and gender minority individuals is critical to inform tobacco prevention strategies for these priority populations.

A well-known risk factor for tobacco use among sexual and gender minority individuals is exposure to tobacco marketing. The tobacco industry has historically targeted sexual and gender minority populations. For instance, the tobacco industry frequently features Lesbian, Gay, Bisexual, Transgender and Queer (LGBTQ)-related symbols (e.g., rainbow flags) in their advertisements.⁴ Furthermore, it commonly places advertising in venues that sexual and gender minority individuals frequent, such as gay and lesbian bars and Pride festivals.^4,5 Previous studies have observed that sexual minority individuals are more likely to be exposed to tobacco marketing in general venues such as newspapers/magazines, TV, and the internet.^6–8

There is still a knowledge gap in the extent to which tobacco marketing LGBTQ individuals currently are being targeted through traditional channels such as brick-and-mortar venues (e.g., retail stores, nightclubs and bars) and newer venues (e.g., social media and dating apps). Understanding the frequency of LGBTQ-targeted tobacco marketing exposure among sexual and gender minority populations is important to inform future research and tobacco regulatory policies on monitoring and regulation of LGBTQ-targeted marketing. Further, the number of LGBTQ venues where individuals were exposed to tobacco marketing is also important given that more frequent exposure to tobacco marketing is associated with high levels of tobacco use behaviors.^9–11

Therefore, this study aimed to assess exposure to tobacco marketing by sexual and gender identity among young adults via various venues (e.g., bars/clubs, newspapers/magazines, social media, radio, festivals); to determine the frequency of targeted marketing among sexual and gender minority participants via various LGBTQ venues (e.g., LGBTQ bars/clubs as a subset of all bars/clubs); to examine how exposure to tobacco marketing relates to tobacco use among sexual and gender minority young adults; and to determine relationships between the number of LGBTQ venues that LGBTQ individuals were exposed to tobacco marketing and current tobacco use.

METHODS

Recruitment and Data collection

We conducted a nationwide, anonymous, online survey of US young adults (ages 18–30 years) between July and August 2023. Survey respondents were recruited by Prolific Online Sample, which is a secure, third-party, market research, data collection service. All participants already had voluntarily signed up to be research panelists on Prolific. Survey respondents provided demographic information (e.g., age, sex, race, sexual identity), and reported on their tobacco use when they registered as panelists. This information was used to create targeted survey email invitations to fill the quotas described below.

We used quota sampling procedures (similar to stratified sampling) based on respondents’ sexual identity, tobacco use status, sex, age and race. For this study, we limited participants to those residing in the United States. To increase the representation of priority populations that are disproportionately impacted by tobacco marketing exposure, we oversampled sexual and gender minority individuals, those reporting past-30-day tobacco product use, individuals ages 18–20 years (i.e., underage for tobacco product purchase in the US), and those of racial/ethnic groups other than non-Hispanic White.

When our study was posted, Prolific emailed participants who were likely to be eligible for the study based on the demographic information they provided. Interested participants were instructed to click on a link within the email that directed them to the study eligibility questions. Participants also could see currently available studies (including ours) that they were likely to be eligible for by going to their study dashboard on Prolific, and, if interested, clicking a link. Eligible participants were transferred to the Yale Qualtrics platform where consent was obtained, and data were collected. To prevent fraudulent responses within Qualtrics, we prevented multiple submissions (by IP address or email), used Bot detection, and blocked security scanners and search engines from initiating our survey.¹² Paired with Prolific’s extensive screening process, this helped to ensure high-quality data from real, human participants. As an additional safeguard, we ensured that participants’ reported gender, biological sex, age, and LGBTQ status (no/yes) aligned with similar previously-answered questions in the Prolific database. This study was approved by the Yale University Institutional Review Board (IRB# 2000035253).

Measures

Sexual and gender identity

Sexual identity was assessed using the questions recommended by the National Academies of Sciences, Engineering, and Medicine’s report on “Measuring Sex, Gender Identity, and Sexual Orientation”¹³: “Which of the following best represents how you think of yourself?” (“straight [heterosexual],” “non-straight, gay or lesbian,” “non-straight, bisexual,” and “non-straight, I used a different term (e.g., non-binary, asexual, pansexual).” Gender identity was assessed using the question: “How do you currently describe yourself (select all that apply)?” (“female,” “male,” “transgender,” and “I do not identify myself as female or male. I use a different term (e.g., non-binary).”

Our analytic sample of interest was all respondents (N=1378), including those who identified themselves as sexual or gender minority identities such as gay or lesbian, bisexual, transgender, and other sexual and gender minority identities such as asexual, pansexual, queer, non-binary individuals (N=687).

Current tobacco use

Current tobacco use was assessed as follows: “Which of the following products have you used in the past 30 days? For each product, please select either no or yes.” Tobacco products included e-cigarettes/vapes, heated tobacco like IQOS, cigarettes, hookah (waterpipe used to smoke tobacco), cigar or cigarillo, smokeless tobacco, and nicotine pouches like Zyn, Velo, or On!. From this question, we created a dichotomous variable reflecting any past-30-day tobacco use (0=None; 1= Any). The tobacco use questionnaires used in this study were well-validated and used in previous studies that assessed tobacco use among youth and young adults.^14,15

General tobacco marketing exposure

General tobacco marketing exposure was assessed through a two-step process. First, all participants were asked if they had engaged in the following activities in the past year: 1) going to a physical store; 2) reading a newspaper or magazine; 3) listening to the radio; 4) listening to a podcast; 5) watching a movie or show on a streaming service like Netflix, Hulu, HBO Max, or Amazon Prime; 6) watching a movie or show on regular television/cable; 7) watching a movie at the theater; 8) going to an event like a fair, festival, or sporting event; 9) going to a nightclub, bar, or music concert; 10) visiting a website online; 11) visiting social media sites or using a social media app; and 12) using a dating app.

When participants endorsed engaging in a given activity, they were asked to report on the frequency with which they were exposed to advertisements or promotions for tobacco products through that channel in the past year (responses: “0 times (Never),” “1 time,” “2 times,” “3 times,” “4 times,” “5 times or more”). For example, if a participant endorsed going to a nightclub, bar, or concert, they were asked how many times in the past year they were exposed to tobacco advertisements or promotions at a nightclub, bar, or concert. These tobacco marketing exposure measures were adapted from National Youth Tobacco Survey (NYTS)¹⁶ and the Population Assessment of Tobacco and Health (PATH) Study.¹⁷

Tobacco marketing exposure in LGBTQ venues

Tobacco marketing exposure in LGBTQ venues was assessed only among sexual and gender minority individuals. First, we created LGBTQ-specific parallels to the 12 general activities. For instance, the general activity of reading a newspaper/magazine was translated to reading LGBTQ-related a newspaper/magazine like OUT, PRIDE, or Gay City News. The full list of general and LGBTQ venues is provided in Supplemental Table 1. If a LGBTQ participant reported engagement in a general activity (e.g., going to a bar), exposure to advertising in a general venue (e.g., at a bar), and engagement in the LGBTQ activity (e.g., going to an LGBTQ bar), they were then asked about exposure to LGBTQ-specific tobacco marketing in that LGBTQ venue (i.e., ads or promotion in an LGBTQ bar). This structure prevented erroneous responses. For instance, if one reported never being exposed to tobacco marketing at any bar, it would not be possible for them to report exposure at an LGBTQ bar. Similar to general venues, when participants endorsed engaging in a given activity in LGBTQ-related venues, they were asked to report on the frequency with which they were exposed to advertisements or promotions for tobacco products through that LGBTQ-related channel in the past year (responses: “0 times (Never),” “1 time,” “2 times,” “3 times,” “4 times,” “5 times or more”).

Statistical Analyses

STATA 16.1 (College Station, TX) was used for statistical analyses. We first conducted descriptive analyses within the total sample. To assess exposure to tobacco marketing by sexual and gender identity among young adults via various venues (e.g., bars/clubs, newspapers/magazines, social media, radio, festivals), we assessed unadjusted differences in exposure to tobacco marketing in general venues by sexual identity using Pearson chi-square tests among the total sample. To determine the frequency of targeted marketing among sexual and gender minority participants via a range of LGBTQ-venues that map onto the broader categories assessed in general venues (e.g., LGBTQ bars/clubs as a subset of all bars/clubs), we estimated the exposure to LGBTQ-targeted tobacco marketing in each LGBTQ venue (presented in n and %).

To examine how exposure to tobacco marketing relates to tobacco use among sexual and gender minority young adults, we conducted 12 separate adjusted logistic regressions assessing current tobacco use (any vs. none) by frequency of exposure to LGBTQ-targeted tobacco marketing (treated as continuous) through each of the respective the 12 LGBTQ-specific activities. Based on previous literature related to tobacco use in sexual and gender minority individuals,^18,19 we selected age, biological sex, race, past-30-day alcohol use, and past-30-day cannabis use as covariates. To adjust for multiple comparisons, we used Bonferroni adjustment and set up 0.004 (=0.05/12) as a statistical cut-off. Only effects that are significant at the corrected level are discussed in the manuscript, but additional findings that were significant at the unadjusted value of p < .05 are presented in Table 2 as these may be signals for areas of future research.

Table 2.

Results of the adjusted associations between exposure to LGBTQ-targeted tobacco marketing and tobacco use among sexual and gender minority young adults (n=687).

	Outcome: Current tobacco use (Any)
	Adjusted OR (95% CI)	P-value
Predictors: frequency of LGBTQ-targeted tobacco marketing exposure in each LGBTQ venue a
1. At a physical (brick-and-mortar) LGBTQ-related store (e.g., drag shops)	1.58 (1.18, 2.11)	0.002
2. In a LGBTQ-related newspaper or magazine like OUT, PRIDE, or Gay City News	2.07 (1.30, 3.30)	0.002
3. On a LBGTQ-related radio station or show (e.g., Pride Radio)	2.01 (1.16, 3.47)	0.013
4. On a LGBTQ-related podcast (e.g., Getting curious)	1.55 (1.07, 2.24)	0.020
5. In a LGBTQ-related show or movie on regular TV/cable	1.26 (1.00, 1.58)	0.047
6. In a LGBTQ-related show or movie on streaming service (Netflix, Hulu, HBO Max)	1.17 (1.00, 1.38)	0.054
7. In a LGBTQ-related movie at the theater	1.51 (1.00, 2.27)	0.049
8. At a LGBTQ-related event like a PRIDE festival or a LGBTQ night at a sporting event	1.38 (1.11, 1.71)	0.003
9. At a LGBTQ nightclub, bar, or music event	1.21 (1.03, 1.43)	0.021
10. On a LGBTQ-related website on the internet	1.15 (0.99, 1.35)	0.074
11. On a LGBTQ-related social media site or app	1.17 (0.99, 1.38)	0.061
12. On a LGBTQ-related dating app	1.24 (0.92, 1.66)	0.164

Note: We ran 12 separate models (one for each LGBTQ-targeted marketing venue), so the cutoff for statistical significance was set to 0.004 (0.05/12) to adjust multiple comparisons.

The models were adjusted for age, gender, race, current alcohol use, current cannabis use.

^a:Response options for each predictor were: “0 times (Never),” “1 time,” “2 times,” “3 times,” “4 times,” “5 times or more”

To determine the relationships between the number of LGBTQ venues that participants were exposed to tobacco marketing and current tobacco use among sexual and gender minority young adults, we first dichotomized exposure to LGBTQ-targeted marketing in each of the 12 LGBTQ venues (i.e., no vs. yes for each) and created a variable reflecting the total sources of any exposure (range: 0–12). We then conducted an adjusted binomial logistic regression on current tobacco use (any vs. none) by the number of LGBTQ-targeted tobacco marketing exposures (treated as continuous). The model controlled for age, biological sex, race, past-30-day alcohol use, and past-30-day cannabis use.

RESULTS

The average duration of survey completion was 8.2 minutes. Table 1 shows the sample characteristics of the respondents. Among all respondents (N=1378), 50.5% identified as heterosexual (straight), 11.1% as gay/lesbian, 30.7% as bisexual, 5.3% as transgender, and 7.7% as “other sexual identity” (e.g., asexual, pansexual), 6.7% as “other gender identity” (e.g., queer, non-binary, gender fluid, gender nonconforming). Participants were 23.9 years old (SD=3.6) on average, 55.9% female, and 17.9% Black or African American. Overall, 47.6% reported tobacco product use, 68.7% reported alcohol use, and 44.4% reported cannabis use.

Table 1.

Sample characteristics among overall respondents (N=1378)

	Overall respondents (N=1378)
Demographics
Age, Mean (SD)	23.9 years (3.6)
Female	n=770 (55.9%)
Black or African American	n=246 (17.9%)
Sexual identity
Heterosexual (Straight)	n=696 (50.5%)
Gay/Lesbian	n=153 (11.1%)
Bisexual	n=423 (30.7%)
Others (e.g., asexual, pansexual)	n=106 (7.7%)
Transgender
No	N=1305 (94.7%)
Yes	N=73 (5.3%)
Other gender identities
Cisgender	N=1285 (93.3%)
Queer, non-binary, gender-nonconforming	N=93 (6.7%)
Past 30 days substance use
Any tobacco use	n=654 (47.6%)
Alcohol use	n=946 (68.7%)
Cannabis use	n=611 (44.4%)

Note: sexual identity, transgender identity and gender identities are not mutually exclusive

Figure 1 shows the levels of general tobacco marketing exposure by sexual and gender identity among the total sample. Heterosexual young adults, compared to sexual and gender minority young adults, reported significantly higher levels of exposure to tobacco marketing in the general venues “radio” (22% vs. 16%, p=0.009), “TV” (32% vs. 25%, p=0.004) and “social media sites or apps” (59% vs. 53%, p=0.010). Sexual and gender minority young adults, compared to heterosexual young adults, reported significantly higher levels of exposure to general tobacco marketing in any general venue (94% vs. 91%; p=0.046), “physical stores” (86% vs. 81%, p=0.005) and dating apps (5% vs. 3%, p=0.035). No other comparisons were significant.

Figure 1.

Exposure to general tobacco marketing by sexual and gender identity

Note: ***:<0.001, **:<0.01, *: <0.05

Figure 2 shows the levels of LGBTQ-targeted tobacco marketing exposure in each LGBTQ venue among sexual and gender minority young adults (n = 687). Overall, 30% of sexual and gender minority young adults reported exposure to LGBTQ-targeted marketing. The top 5 LGBTQ venues through which sexual and gender minority young adults were exposed to tobacco marketing were LGBTQ websites (15%), LGBTQ shows on streaming services (e.g., Netflix, HBO Max, Hulu, Amazon Prime) (14%), LGBTQ social media or app (12%), LGBTQ nightclubs and bars (11%), and LGBTQ events like a Pride festival (9%).

Figure 2.

Exposure to LGBTQ-targeted marketing in LGBTQ venues among sexual and gender minority young adults (n=687)

Table 2 shows the results of the 12 adjusted binomial logistic regression models on current tobacco use by frequency of exposure to LGBTQ-targeted marketing in each LGBTQ venue among sexual and gender minority young adults (n=687). Current tobacco use was significantly more likely to be reported by sexual minority young adults who reported more frequent exposure to LGBTQ-targeted tobacco marketing in “LGBTQ stores” (aOR=1.58, 95% CI=1.18, 2.11, p=0.002), “LGBTQ newspaper and magazines” (aOR=2.07, 95% CI=1.30, 3.30, p=0.002), and “LGBTQ events like Pride Festival” (aOR=1.38, 95% CI=1.11, 1.71, p=0.003).

Table 3 shows the relationship between the number of LGBTQ venues where participants were exposed to tobacco marketing and current tobacco use among sexual and gender minority young adults (n=687). Sexual and gender minority young adults who reported exposure to LGBTQ-targeted tobacco marketing through a greater number of LGBTQ sources were more likely to report current tobacco use, compared to sexual and gender minority young adults who reported less frequent LGBTQ-targeted tobacco marketing exposure (aOR=1.14, 95% CI=1.04, 1.24; p=0.005).

Table 3.

Results of the relationship between the number of LGBTQ venues that sexual and gender minority young adult participants were exposed to tobacco marketing (N=687).

	Current tobacco use (Any)
	Adjusted OR (95% CI)	P-value
Number of LGBTQ venues that participants were exposed to tobacco marketing
Continuous (ranges from 0–12)	1.14 (1.04, 1.24)	0.005

The model was adjusted for age, gender, race, current alcohol use, current cannabis use.

DISCUSSION

The current study found that sexual and gender minority young adults reported higher levels of tobacco marketing exposure in physical, brick-and-mortar stores (e.g., a gas station, supermarket, convenience store, kiosk/storefront, shopping center, or other retail store) than did heterosexual young adults. Frequency of exposure to LGBTQ-targeted tobacco marketing in LGBTQ venues was also associated with tobacco use among sexual and gender minority young adults. These LGBTQ venues included LGBTQ stores, newspapers/magazines, and events like Pride festivals.

In addition, sexual and gender minority young adults who were exposed to tobacco marketing across a greater number of LGBTQ venues were more likely to currently use tobacco products than those who reported exposure in fewer LGBTQ venues. This is consistent with previous studies determining that a greater number of exposures to tobacco marketing is associated with tobacco use behaviors in general populations.^9–11 LGBTQ individuals might be exposed to greater tobacco marketing than their heterosexual peers because they may be exposed to tobacco marketing in general venues as well as in the LGBTQ venues.²⁰

It is well documented that the tobacco industry has historically targeted sexual and gender minority people for tobacco promotion and placed their tobacco advertisements in LGBTQ venues. Strategies that the tobacco industry has used include branded sponsoring of Pride Festivals, ^21,22 LGBTQ magazines,²³ and community outreach efforts (e.g., LGBTQ bar nights).²⁴ Despite the efforts of LGBTQ communities, researchers, and regulatory policies (e.g., counter-messaging campaigns), LGBTQ individuals continue to be targeted by LGBTQ-focused tobacco marketing. Future studies should examine how specific tobacco products (e.g., e-cigarettes, nicotine pouches) are promoted to LGBTQ individuals and their appeal and influence on tobacco product use.

The most common sources of LGBTQ-targeted tobacco marketing exposure were LGBTQ websites (15%) and LGBTQ social media sites (13%). Tobacco promotion is prevalent on websites and social media,²⁵ and exposure to it on social media is associated with tobacco use among youth and young adults.²⁶ Potential online and social media marketing targeting sexual and gender minority populations might use LGBTQ-targeted tobacco promotion tactics from traditional media, such as featuring LGBTQ symbols or themes (e.g., rainbow flags) in their online tobacco advertisement.³ Future research is needed to understand what tobacco marketing sexual and gender minority young adults are being exposed to and whether generic ads are posted on LGBTQ sites and/or ads contain LGBTQ-related content to further target and appeal to the community.

We also observed that many LGBTQ young adults reported being exposed to tobacco marketing via LGBTQ TV and streaming shows (14%). Indeed, general tobacco presence is common in TV shows and films on TV and streaming services. A recent content analysis analyzed 12 films and 113 TV episodes from 12 series on Netflix original films (from June 2020 to May 2021) and found that 13% had e-cigarette-related content such as characters holding e-cigarettes and mentioning vaping.²⁷ Such presence might also be common in LGBTQ-themed shows. Given that exposure to tobacco use in TV shows is associated with tobacco and e-cigarette initiation in youth and young adults,^28,29 future studies should examine the presence of LGBTQ-targeted tobacco marketing in LGBTQ-themed TV shows.

It is also noteworthy to mention two novel marketing venues that might target sexual and gender minority young adults: LGBTQ podcasts and LGBTQ dating apps. “A podcast” is “a program (as of music or talk) made available in digital format for automatic download over the Internet.”³⁰ In 2022, 67% of US young adults ages 18 to 29 years reported that they had listened to a podcast.³¹ People can choose their topics of interest from podcast lists, and young adults consider podcasts a new source of learning and entertainment. Despite the relatively modest prevalence (5.3% of our sexual and gender minority young adult sample), understanding the tobacco marketing presence in podcasts is extremely understudied. LGBTQ dating apps are also notable as a potential novel marketing channel for tobacco promotion. Dating apps represent relatively novel social venues for LGBTQ individuals to seek short-term or long-term romantic relationships or friends. In 2022, sexual minority US adults reported higher rates of dating app use than their heterosexual peers (ever use: 51% of sexual minority adults vs. 28% of heterosexual adults).³² As such, the popularity of dating apps among LGBTQ populations makes the potential tobacco marketing presence concerning. Future studies should examine the content presence and appeal of LGBTQ-targeted tobacco marketing in these LGBTQ venues.

Limitations

The limitations of this study should be noted. First, due to the observational and cross-sectional nature of this study, a recall bias might exist and we cannot establish causal relationships. Second, we used a non-probabilistic convenience sampling method for recruitment, which warrants larger scale, weighted random sampling methods to be representative of the US population. Third, we did not assess the content or appeal of tobacco marketing. Future research should use qualitative approaches (e.g., content analyses and focus group interviews, marketing surveillance) to understand these. Fourth, we cannot calculate cumulative exposure to tobacco marketing (i.e., non-LGBTQ plus LGBTQ) because we did not specify whether the “general” venues were LGBTQ or not. We also did not assess exposure to LGBTQ venues among individuals who identified as straight, and it is certainly possible that this happened (e.g., allies attending a LGBTQ festival or bar).

Conclusion

In sum, the current study found that sexual and gender minority young adults reported high levels of tobacco marketing exposure both in general venues and LGBTQ venues, and its association with their current tobacco use status. This study highlights implications for tobacco marketing regulation and tobacco prevention strategies. For example, several anti-tobacco campaigns are tailored for sexual and gender minority individuals, including “This Free Life” (FDA Center for Tobacco Products),³³ Outlast Tobacco (LGBT Cancer Network),³⁴ and Truth Initiative Campaigns (Truth Initiative).³⁵ These health communication messages and materials could be leveraged and placed specifically in LGBTQ venues to counter commercial tobacco marketing in these places. Further, given that tobacco advertisement and promotion might be prevalent in traditional and novel marketing channels, particularly targeting LGBTQ populations, surveilling and prohibiting tobacco marketing in those channels is also important. As of November 2023, marketing on streaming services, podcasts, and dating apps is not included under the United States Food and Drug Administration’s regulatory authority. Surveillance and regulation of tobacco marketing presence in such novel marketing channels should be considered by future tobacco regulatory authorities.