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. Author manuscript; available in PMC: 2016 Jan 6.
Published in final edited form as: J LGBT Youth. 2015 Jul 6;12(3):323–342. doi: 10.1080/19361653.2015.1022242

Exploring young adult sexual minority women’s perspectives on LGBTQ smoking

Emily J Youatt 1, Michelle M Johns 1, Emily S Pingel 1, Jorge H Soler 1, José A Bauermeister 1
PMCID: PMC4617757  NIHMSID: NIHMS626779  PMID: 26508993

Abstract

Smoking rates are higher among lesbian, gay, bisexual, transgender, and queer (LGBTQ) individuals than among heterosexuals. These disparities are exacerbated during the transition from youth to young adulthood. The current study uses in-depth qualitative interviews to understand perceptions of LGBTQ smoking among LBQ-identified women (N=30, ages 18-24). Major themes identified include the belief that smoking was a way of overcoming stressors faced by heterosexual and LGBTQ young adults alike, a mechanism to relieve sexuality-related stressors, and an ingrained part of LGBTQ culture. Results suggest unique stressors influence LGBTQ smokers. Implications for smoking cessation interventions for LGBTQ youth are discussed.

Introduction

Smoking is a persistent public health problem, as tobacco related deaths remain the leading cause of death in the United States (Mokdad, Marks, Stroup, & Gerberding, 2004). Yet, tobacco use and its negative health consequences do not afflict all groups equally, with members of stigmatized groups suffering disproportionately (Pampel, Krueger, & Denney, 2010; Ziedonis et al., 2008). Significant disparities in smoking behavior exist between heterosexual and sexual minorities: lesbian, gay, bisexual, transgender, and queer (LGBTQ) individuals smoke at higher rates than heterosexuals (Lee, Griffin, & Melvin, 2009). Among LGBTQ individuals, smoking prevalence is highest among sexual minority women (SMW; Gruskin, Greenwood, Matevia, Pollack, & Bye, 2007). Population-based health statistics indicate that lesbian and bisexual women have two and three times the odds (respectively) of being a smoker then do heterosexual women (Conron, Mimiaga, & Landers, 2010). Indeed, sexuality-based smoking disparities are a pressing public health problem (United States Department of Health and Human Services, 2010), and understanding the etiology of LGBTQ tobacco use is critical to decreasing smoking and improving health for sexual minorities (Lee, Blosnich, & Melvin, 2012).

Recently, researchers have begun examining sexuality-based differences in smoking rates through a developmental lens. Mounting evidence suggests sexuality-based disparities in smoking behavior begin in adolescence and increase during young adulthood (Marshal, Friedman, Stall, & Thompson, 2009; Talley, Sher, & Littlefield, 2010). Using data from the Youth Risk Behavior Surveillance System (YRBSS), researchers noted that compared to heterosexual youth, smoking behaviors were greater among SMW whether they identified as lesbian, bisexual, or had same-sex sexual experiences (but did not identify as lesbian or bisexual) (Kann et al., 2011). Interestingly, compared to exclusively heterosexual women, SMW’s smoking behavior continues to increase at a greater rate during young adulthood (Marshal et al., 2012). This trend is particularly troubling as longitudinal data suggest smoking behavior during young adulthood is highly predictive of smoking in adulthood (Chassin, Presson, Rose, & Sherman, 1996). Given high rates of smoking among SMW (Tang et al., 2004) and new evidence on increasing disparities between heterosexual and SMW as women enter adulthood (Marshal et al., 2012), it is important to better understand young adult SMW’s perspective on tobacco use. A deeper understanding of the developmental and sexuality-specific contributors to LGBTQ individuals’ smoking behaviors is important to designing interventions to effectively reduce smoking among SMW.

Three perspectives inform the literature on young adults’ smoking behaviors: (1) social influences from parents and peers; (2) coping with generalized stress; and (3) perceived outcomes gained by smoking. Having parents (Mayhew, Flay, & Mott, 2000; White, Pandina, & Chen, 2002) or friends (Bernat, Klein, & Forster, 2012; Tercyak, Rodriguez, & Audrain-McGovern, 2007) who smoke is associated with greater smoking initiation among young adults. Life transitions experienced by young adults may increase their experiences or perceptions of stress (Dornbusch, 2000); leading some young people to engage in smoking behavior as a coping strategy. Indicators of socioeconomic status, including not holding or pursing a college degree, being unemployed or having a job in the blue color sector, and having a low annual household income, are also associated with increases in smoking likelihood among young adults (Green et al., 2007). Young adult women are also less likely to initiate smoking and are more likely to quit if they marry or enter into a committed romantic relationship (McDermott, Dobson, & Owen, 2009). Bernat and colleagues (2012), for example, reported that smoking initiation among young adults was linked to smoking-related outcome expectations. In their study, they found that young adults were more likely to begin smoking if they believed smoking improves mood, it helps control one’s weight, or that smoking helps one calm down when upset or angry. Taken together, these three perspectives may inform factors influencing smoking behaviors of LGBTQ young adults.

Beyond social influences, generalized stressors, and smoking related-outcome expectations that may be experienced by heterosexual and LGBTQ individuals alike, additional factors may influence the smoking behaviors of LGBTQ young adults (Johns, Pingel, et al., 2013). Indeed, a recent review article highlights smoking risk factors that may be specific to LGBTQ individuals (Blosnich, Lee, & Horn, 2013). Higher smoking rates among LGBTQ individuals may be the result of the tobacco industry’s marketing efforts directed toward this demographic (Stevens, Carlson, & Hinman, 2004; Washington, 2002). From the infamous R.J. Reynolds Project Scum campaign of the mid-1990’s targeting San Francisco’s Castro and Tenderloin districts (Engardio, 2001; R.J. Reynolds Tobacco Company, 1995; Washington, 2002) to modern-day sponsorship of LGBTQ-specific events, tobacco companies have long directed their advertisements at sexual minority communities. Empirical assessments of these advertisements show them to be prevalent in LGBTQ-themed media (Smith, Offen, & Malone, 2005, 2006). These targeted marketing efforts may influence smoking behaviors among LGBTQ individuals (Washington, 2002). Another body of work has noted smoking is a negative coping strategy to deal with and mitigate experiences of minority stress (Meyer, 2003), and report associations between minority stress and smoking among LGBTQ youth (Bontempo & D’Augelli, 2002; Ortiz-Hernández, Gómez Tello, & Valdés, 2009). Others hypothesize the close affiliation between smoking, bar attendance, and the LGBTQ community may explain elevated smoking rates among LGBTQ individuals (Leibel, Lee, Goldstein, & Ranney, 2011). Lastly, negative disclosure experiences, specifically, being rejected by one’s friends and family after coming out to them, has also been linked to higher smoking rates among LGBTQ adolescents and young adults, though these elevated rates decrease in adulthood as sexual minorities may mitigate some of the homonegativity present in their lives over time (Rosario, Schrimshaw, & Hunter, 2009).

Exploring smoking in the LGBTQ community from the perspectives of those who smoke the most, young adult SMW, may offer important insight into elevated smoking rates among this cohort. To date, scholarly attempts to document these perspectives are rare, with two notable exceptions. Remafedi (2007) interviewed adolescent current, former, and never smokers regarding their perceptions on what puts LGBTQ individuals at risk for smoking, and what factors prevent members of the LGBTQ community from smoking, among other topics. Participants in this study commonly cited stress, a desire to fit in with peers, and peer pressure as factors that contribute to LGBTQ smoking (Remafedi, 2007). A small number of participants also mentioned addiction, socializing in venues that permit smoking, rebelliousness, and tobacco marketing as factors that influence LGBT smokers (Remafedi, 2007). This study provides important foundational work to understanding LGBTQ smoking perspectives and offers a diverse cross section of voices from within the LGBTQ community (by gender, race, sexual identity and urbanicity). Our study seeks to further explore themes identified by Remafedi, and to examine how these themes may differ when speaking exclusively to female members of the community. Our study also focuses solely on the perspectives of young adults as their experiences may be different than those of adolescents.

In a study specifically examining sexual minority women’s perspectives on LGBTQ smoking, Gruskin, Byrne, Altschuler, and Dibble (2008) compared heterosexual and lesbian women’s smoking experiences. In one-on-one interviews, Gruskin and colleagues asked heterosexual and lesbian women between the ages of 18 and 70 about their smoking history and quit attempts, and asked lesbian participants specifically about stress experiences, mental health struggles, and participation in the lesbian community. Although the majority of study participants (heterosexual and lesbian alike) linked their personal smoking behavior to stressful experiences and emotional regulation, lesbian participants additionally discussed smoking in response to sexuality-related stressors (Gruskin, Byrne, Altschuler, & Dibble, 2008). We build on Gruskin and colleagues’ findings by examining whether these narratives also extend to bisexual and queer identified women’s experiences. Furthermore, contrary to other studies examining smoking beliefs with participants in a broad age range or across multiple genders, we focus our attention on sexual minority women (ages 18-24) given that, although their smoking rates are highest, their experiences have not been thoroughly examined. Consequently, understanding their experiences may provide an opportunity to identify and develop smoking prevention and cessation programs.

We endeavored to understand SMW’s views on smoking within the LGBTQ community, and to explore how factors associated with smoking in young adulthood (i.e. peer influences, life transitions), as well as stressful experiences, social settings, and LGBTQ community involvement shape smoking beliefs and behaviors. As the subgroup with the highest smoking prevalence, we hoped to gain new insight about smoking among LGBTQ individuals. Their responses will inform future smoking cessation intervention development, and may importantly contribute to a clearer understanding of other sexuality-based health disparities.

Methods

Recruitment

Thirty SMW participated in semi-structured qualitative interviews seeking to better understand their thoughts and feelings about smoking and tobacco cigarettes. To be eligible for participation, recruits had to be between the ages of 18 and 24 at the time of the interview (i.e., born between 1987 and 1993), self-identify as non-heterosexual (i.e., lesbian, bisexual, questioning, etc.), currently reside in Michigan, and report having sex with women. Participants were recruited through advertisements on social networking sites, advertisements to LGBTQ listservs, and flyers posted at various local venues frequented by SMW. Promotional materials displayed a synopsis of eligibility criteria, mentioned the $25 Visa gift card incentive, and provided a phone number to call if interested. Social network (i.e. Facebook™) advertisements were visible only to women who listed themselves as interested in other women (or men and women) and who fit our target age range.

Participant Characteristics

The sample’s median age was 22 years old. The racial/ethnic composition of our sample (N=30) was as follows: 24 self-identified as White, four as African American/Black, and two as Mixed Race (White/Latino and White/Latino/Other). Fifteen participants self-identified as lesbian, thirteen identified as bisexual, and two identified as other (queer and pansexual). Regarding smoking status, 16 participants were current smokers, six were former smokers, eight were never-smokers (participants with no personal smoking history).

Procedure

Research assistants trained in qualitative interviewing techniques conducted the interviews over the phone. The interviewers began by reading a detailed consent form to each participant, explaining the purpose of the study (i.e., speaking with SMW young adults about their experiences and attitudes toward smoking, and questions about their sexual identity) and their rights as participants. SMW were asked to consent both to the interview process and to the use of an audio recorder. Using a semi-structured interview guide, the research assistants then conducted an in-depth interview covering topic areas such as family smoking history, personal smoking history, attitudes toward smoking, smoking in the LGBTQ community, tobacco advertising in the LGBTQ community, and desired smoking cessation intervention characteristics. Interviews typically lasted sixty to ninety minutes. All study procedures were approved by the Institutional Review Board of the University of Michigan, Ann Arbor.

Qualitative Analysis

We transcribed all audio-recordings into text. We then created a codebook using the principles of thematic analysis and with the interview guide as a rubric of potential themes (Braun & Clarke, 2006). The codebook included themes, definitions, and inclusion and exclusion criteria. To begin, the research team coded a single specified transcript and then met as a group to compare results. This triangulation process ensured the reliability of the codebook as an instrument to be consistently utilized in future coding. After this initial session, each subsequent transcript was coded independently by two members of the team who then met to resolve any discrepancies between their codes. In the course of the coding process, questions and concerns which arose in regard to individual codes were addressed by the research team, and the codebook appropriately amended. After coding all 30 transcripts, each finalized version was entered into NVivo, a software program designed to facilitate qualitative data analysis.

Given our interest in understanding how SMW young adults perceive smoking in the LGBTQ community, we sought to describe the factors that SMW believe influence the smoking behaviors of the LGBTQ community. Consistent with thematic analysis (Boyatzis, 1998), we analyzed data coded with the “smoking facilitators in the LGBTQ community” thematic descriptor. Additionally, the primary author read the transcripts in their entirety to discern whether beliefs about LGBTQ smoking behaviors existed elsewhere in the transcripts but had not been captured in the “smoking facilitators” code. Finally, we identified modal responses, and omitted recurrent or repetitious text from this manuscript. To illustrate the diversity of voices in the narratives, we have assigned pseudonyms to participants and removed characteristics that may identify them otherwise.

Results

Main themes

Participants identified a number of beliefs about smoking among LGBTQ individuals, including the belief that smoking as a way to overcome stressors common to heterosexual and LGBTQ individuals, helps relieve sexuality-related stressors, and that smoking is an ingrained part of LGBTQ culture. We expand and discuss these themes below.

Smoking as a Coping Mechanism

Smoking Related to Generalized Stressors

Some participants equated smoking with factors unrelated to sexual identity. Brianna, a lesbian never-smoker, described the stressors related to entrance into adulthood: specifically the stresses of college life, including the competing demands of living in a new environment and balancing school, work, and social responsibilities:

“… I think the-the influence would be um, just college. Um, you know a lot of people at college smoke because it’s a new environment. Ah my age could also be stress because you know, we’re in college, that’s kind of stressful, you know we have jobs, we have social lives and we have school to worry about.”

According to Brianna, smoking was one way to deal with the multiple burdens of young adulthood. Sharon, a lesbian current smoker, also viewed smoking a way to deal with stress. Sharon saw smoking was a way to cope with the new financial demands that may arise for young adults. Sharon remarked:

“Um, maybe stress, you know, older. By bein’ older maybe like bills or somethin’, you know, bills, money issues maybe. For some people.”

Kathleen perceived smoking as a way to buffer social isolation and to fit in with a group. A never smoker, Kathleen discussed how she had been personally tempted to start smoking as a way to fit in and avoid socially uncomfortable situations:

“Being social, cause I know, like even I’ve been tempted to go outside and hang out with the people, cause if a whole table leaves when you’re in, like, the café to go smoke, it’s kind of awkward to have no one to talk to.”

For Brianna, Sharon, and Kathleen, smoking was viewed as a way to cope with life stressors that may be broadly shared by many young adults – stress related to competing demands on one’s time, due to financial strain, and managing social interactions. Participants also mentioned generalized stressors such as worrying about grades and dealing with their partners, parents, or children as universal stressors that may lead people to smoke.

Smoking to Cope with Sexual-Related Stressors

Beyond life stressors common to many young adults, participants cited various sexuality-specific stressors as factors influencing smoking among members of the LGBTQ community. Sexuality-related stressors included one’s personal feelings or struggles dealing with their sexual identity (internalized stressors), and experiences of prejudice or discrimination encountered in daily life (environmental stressors). Throughout the narratives, participants underscored how sexuality-based stressors are accumulated on top of existing generalized stressors, and in some cases, heavily influenced their personal smoking behavior.

Smoking to Cope with Internalized Negative Feelings about being LGBTQ

Several participants connected their smoking habits, and those of other LGBTQ individuals, as a way to cope with internalized negative feelings about their sexual identity. Susan, a lesbian current smoker, remarked that smoking was her way of coping when she started to realize her same-sex attraction. Susan stated:

“Um, I mean I know it’s hard as a kid or young teen or young adult or whatever to figure out that you’re gay and come to that realization. For some it’s really hard and you know you, I guess a stress reliever cause. That’s what it [smoking] is for me, that’s what it is for a lot of people.”

Like other study participants, Susan cited how her internal struggle of figuring out her sexual identity was a motivator for her smoking behavior. Participants often noted that their experiences were common among LGBTQ people. Lydia, a bisexual current smoker, for example, connected LGBTQ smoking with internalized sexual identity struggles:

“Even the struggle to figure out who you are and what you identify as is something that would cause you to smoke.”

Smoking was viewed as a coping strategy to address internalized negative emotions ascribed to their same-sex attractions. In their narratives, however, participants also noted how smoking was embedded in their coming out process. Coming out (i.e., acknowledging to oneself and others of one’s same-sex attraction) is a significant and recurrent process for LGBTQ individuals. Among smoker and non-smoker alike, participants cited the stress associated with coming out as one of the key factors motivating smoking behavior among members of the LGBTQ community. Amy, a lesbian never-smoker, described two stress-inducing aspects of the coming out process: concealing one’s sexual identity and disclosing that identity to others. Both the effort to hide one’s sexuality identity and the act of telling others about one’s LGBTQ identity were identified as common stressors for sexual minorities. When asked what might influence smoking habits among LGBTQ individuals, Amy remarked:

“Probably the fact that they’re under a lot of stress if they’re closed about it to their family, because being a teenager’s hard enough, let alone trying to figure out your sexuality and telling your parents about it.”

Susan, a lesbian current smoker, also mentioned the stress related to coming out as a factor that may influence smoking among sexual minorities. Referencing both internal identity struggles and a need to cope with coming out stress, Susan stated:

“I mean, sure a lot of LGBT people have a little bit more stress sometimes just because you know some of us find it hard to cope with either being gay or coming out or stuff like that.”

In addition to internalized stressors, participants also faced exterior or environmental stressors that accompany disclosing one’s LGBTQ identity. For Stephanie, a queer-identified current smoker, coming out potentiates rejection both by people that are close to you and broader societal rejection:

“I mean, there’s just a lot—I think there’s a lot more stress in being different, no matter how you’re different. If you’re—you know, there’s a lot of, there’s been, there’s a lot of added—no, no one chooses to be gay, why would you choose to put yourself underneath and that much more stress. Everyone, it’s really—it’s a huge stress experience… the sheer amount of stress of coming out and trying to deal with individuals in your life and trying to— who might not be okay with you being out or, you know, trying to deal with pressure from society.”

In discussing the coming out process, participants overlapped same-sex attractions (being attracted to someone of the same sex) with sexual identities (e.g., a self-claimed label regarding one’s sexuality such as lesbian, bisexual, queer), and discussed norms associated with these sexual identities. Participants, for example, viewed smoking as an integral aspect of building connections among LGBTQ individuals. Stephanie articulated:

“And I think either the fact that other people smoke in that community and it helps bond a sense of community together… You know, it’s just if you’re smoking with someone, especially if they’re a gay-identified or queer-identified, you know, it bolsters a sense of a smoke—a little community where, you know it’s just you guys.”

For Stephanie, the act of smoking draws members of the LGBTQ community together and helps create new bonds within that community. Other participants described how for some young people smoking may be inextricably tied to their sexual identity. Liz, a lesbian former smoker exemplifies this perspective:

“Just like being stressed out or seeing their peers do it and thinking it’s cool, like they want to be a part of the group or maybe if their friends that may be gay you know, they do it so they think it’s like the thing to do among like the LGBT community.”

From her point of view, Liz believes that some members of the LGBTQ community, particularly younger members, may see LGBTQ peers smoking and assume smoking is a cultural signifier of gay identity.

In sum, based on both personal experiences and their perspectives on the community, our participants indicated that smoking is a strategy to cope with the stress associated throughout the coming out process. Whether concealing or proclaiming their sexual same-sex attraction to friends and family, our participants cited coming out as a stressor influencing sexual minorities’ smoking habits. In addition, participants noted how smoking may help young adults who identify as LGBTQ connect with others members of the LGBTQ community.

Smoking to Cope with Discrimination, Prejudice, and Bullying

LGBTQ individuals may experience discrimination, prejudice, or ill-treatment in response to their sexuality. Participants provided vivid personal examples of work-based discrimination, ill-treatment from families and former friends, and encounters of bias or hostility from strangers – all because of their sexual orientation. Many participants cited such mistreatment, and the need to cope with the resultant negative feelings, as smoking motivators for themselves and likely reasons for smoking among other members of the LGBTQ community. Liz, a lesbian former smoker, mentioned how the concealment of one’s sexual identity and the fear of discrimination could influence smoking behavior. Liz described smoking coping strategy for members of the LGBTQ who encounter discrimination:

“Um… like the stresses of being discriminated. Or, hm let’s see, yeah I think that just like maybe the discrimination, that puts stress and when people think of cigarettes they just think of them like a stress reliever almost, like that’s how I’ve always been you know thought of it as…Being discriminated, being stressed out, with like not being able to come out or something like that, that’s how I think of it.”

Even without its enactment, the idea of discrimination itself was associated with smoking. Allison, a bisexual current smoker, described how smoking could help her cope were she to feel mistreated by others:

“I’d probably just say, like, like, the bullying, you know? Like, I mean, that, that definitely makes me start smoking more. You know, I mean if…someone was pickin’ on me, and, you know, it’s, it’s kinda like that, that one extra thing, just to, to be the outcast, you know?”

A number of participants echoed Allison’s belief that specific experiences of bullying or ill-treatment, particularly toward LGBTQ teens, increased the likelihood of smoking among members of the LGBTQ community. Other participants, like Mary Anne, a bisexual current smoker, described smoking as means of coping with a general, gnawing feeling of being treated as “different”:

“I would say probably more likely just because of the crap that they’ve been through. ‘Cause like I know for a lot of gay people it’s not an easy life and it’s not, they’re not treated the same way as others and that’s stressful.”

Grace, a lesbian current smoker, acknowledged that LGBTQ individuals feel stressed because of sexuality-based discrimination, and equated discrimination experienced by other minority groups:

“Um, I think it’s—I don’t think it’s any different from straight people as far as tying it in with smoking. It’s kind of we go through a little bit more of a stressful period with discrimination, but that also can go for the same way as different races go through discrimination, so I don’t think it serves as something to be, um— I don’t think there’s much of a tie into it.”

The concept of “difference” – and particularly a distancing from the idea that LGBTQ individuals are different from heterosexuals – was a recurring theme among participants. While participants like Liz, Allison, and Mary Anne cited sexuality-related stressors as motivating factors for smoking, other participants (like Grace) did not perceive any differences in smoking patterns based on sexual orientation, and did not endorse the idea of sexuality-specific stressors as motivating smoking. Relying on the etiology of homosexuality (e.g., genetics), for example, some participants stated that there were no social differences between heterosexual and LGBTQ individuals. Though these comments were rare, we found participants’ lack of awareness of the association between sexual identity and increased smoking prevalence among sexual minorities as noteworthy.

In sum, while many participants definitively linked sexuality-related stressors to LGBTQ individual’s smoking behaviors, a small number of participants did not think these stressors would influence LGBTQ smoking because it would suggest that LGBTQ individuals are different than heterosexuals.

Smoking as Part of LGBTQ Culture

When asked to explain contemporary smoking patterns in the LGBTQ community, a number of participants linked present-day smoking behaviors to historical influences. Referencing the historical prominence of institutions known as meeting places or safe havens for gay-identified individuals (e.g. bars, clubs, the military), these spaces were also noted as historically permitting – and in some cases, promoting – smoking. Nancy, a lesbian current smoker, connected present-day smoking habits to LGBTQ individuals’ historical involvement with the armed services and “bar culture”:

“I think it comes from a history in the bar culture. Um, it comes from a history also for a lot of people in the military where there’s a lot smoking. And that became kind of part of our history.”

For Nancy, bar attendance and belonging to the military are historical relics of LGBTQ-identity that she connected to LGBTQ individuals’ modern-day smoking habits. Similarly, Joan, a bisexual current smoker, mentioned the longstanding relationship between the LGBTQ community and bars as a motivator for smoking:

“Um… I guess maybe… like the atmosphere of the bars and stuff because even though now days, um, in my state like you’re not allowed to smoke in bars, in most states like you can. So, that’s kind of like. And one of the biggest places where LGBTQ people can meet in a community is bars. And that’s been the case for you know generations and I think it’s still pretty prominent now days.”

As these statements by Nancy and Joan make evident, some participants referenced LGBTQ history – and its influence on the modern-day community – as shaping current smoking trends. Smoking and bar attendance went hand in hand for many participants. For some, bars offered both a space to openly express their sexual identity and to meet other LGBTQ individuals. As Amy, a lesbian non-smoker explained, bars are one of the few social spaces sexual minorities can be in an accepting, explicitly LGBTQ-friendly place:

“I think smoking is very common, I mean, at least when, you know, you go out, you see a lot of girls smoking or a lot of boys smoking. I know, my gay friend [male name] smokes, a lot of my gay friends smoke actually so… I think it’s something that goes along with being in the, like, the night scene… I think that that’s kinda a common thing among gay people, because they have to go out to meet people … they go out to find social acceptance, cause they want to find people that are like them to hang out with, and, I mean, really, other than gay bars, there’s really not a gay-identified, like, restaurant or something like that to go to. . .”

For Amy and other participants, going out to bars is viewed as the best – or only – social outlet for members of the LGBTQ community to find social acceptance and to meet up with other same-sex attracted individuals. As she alluded to, bar attendance is a milestone in LGBTQ-identity formation and social life, and smoking is an expected feature of spending time in that social environment. Numerous participants discussed bars and other social spaces (clubs, parties, or “going out”) as contexts that influence their personal smoking behavior or the smoking habits of LGBTQ peers.

Other participants suggested identifying as LGBTQ is a form of rebellion or rejection of societal expectations, and therefore goes hand-in-hand with other forms of rebellion, including smoking. According to Sally, a bisexual current smoker, because LGBTQ individuals may be more willing than other members of society to defy social norms, they also may be more willing to reject social anti-smoking norms:

“Mm. Well, let’s see I could say that um they’re [LGBTQ individuals] more willing to step out of boundaries, to be different, to take risks. And I guess that would definitely increase in smoking, you know, um rebellion.”

Similarly, Erin, a lesbian never-smoker, suggested that smoking is an additional affront to society, and a habit LGBTQ individuals’ might embrace as evidence of a wide-spread rejection of social norms:

“Probably…I’d say if anything, it would be the whole…like, rebellious side, I guess, like, for those, or, for, like, a jury of those who were never accepted kind of thing, it was like, “You know, screw it, I’ll do what I want, and they won’t take that. I don’t care if I smoke or not, because they can’t control that either”, so, I don’t know.”

Other participants regarded smoking as a way to gain favor with other marginalized groups. Sarah, a lesbian never-smoker, viewed smoking as a way to gain entry or acceptance among some crowds:

“I guess being gay would be kind of seen as a rebellious thing so they might be tempted to fall in with the more rebellious crowd. And of course one of the hugest buy ins when you’re at that age is, ‘Oh I’m going to start smoking before I’m supposed to’ kind of thing.”

Though a LGBTQ identity might ostracize one from certain sects of society, from Sarah’s point of view, smoking may serve as a bridge to forge connections between LGBTQ individuals and other social groups. Other participants viewed same-sex attraction a reification of, or deviance from social norms, suggesting that defying sexuality norms may render one more likely to accept other stigmatized norms (e.g., smoking).

Discussion

To design interventions that meet the unique needs of same-sex attracted young adults, it is imperative to understand their concerns and perspectives related to LGBTQ smoking. Participants’ reflections on smoking within the LGBTQ community provide a lens to better understand elevated smoking prevalence among LGBTQ youth, and have important implications for future interventions addressing smoking among this minority group. These results build on the findings of Remafedi (2007) and Gruskin and colleagues (2008), interrogating more specifically the perceived meaning and motivators for smoking among young adult SMW.

LGBTQ individuals face a number of stressors similar to those faced by heterosexual smokers. Like heterosexual smokers, cigarettes were cited as a coping strategy to deal with life stressors commonly encountered in young adulthood by SMW (Croghan et al., 2006). Similar to previous studies in this area, SMW participants linked smoking behaviors to stressors related to multiple demands on their time (school, work, social lives), growing financial concerns, and a desire to fit in or avoid social isolation when transitioning out of high school and into college or the workplace. Young adult SMW in our study echo the importance of generalized stressors, consistent with other studies of SMW (Gruskin et al., 2008; Johns, Pingel, et al., 2013), indicating that stress reduction programs may be suitable intervention components. Interventions targeting LGBTQ smokers must offer coping strategies to deal with common life stressors, and may well utilize program materials designed for a general population of young adult smokers.

Research indicates that the transition to adulthood remains a time when sexual minorities are likely to grapple with sexual identity development and coming out alike (Morgan, 2013), stressors noted by participants in our study. As a result, LGBTQ individuals may experience additive, sexuality-related stressors. In alignment with Meyer’s (2003) conceptual framework for understanding how sexuality stressors operate in the lives of LGBTQ individuals, our participants related how smoking eased their internalized homonegativity, their fears of concealment or disclosure of same-sex attractions to others, and to acts or perceptions of societal discrimination and prejudice. These sexuality-related stressors are congruent with Blosnich and colleagues (2013) findings, and may be especially pronounced for young adult members of the LGBTQ community, who may still be coming to terms with their sexual identity or may be in the initial stages of the coming out process (Rosario, Hunter, Maguen, Gwadz, & Smith, 2001; Rosario, Schrimshaw, Hunter, & Levy-Warren, 2009). Consequently, interventions directed at curbing LGBTQ smoking behavior will need to account for the role of sexual minority stressors, and employ different intervention points and strategies to address these stressors.

Targeting interventions directly at the sources of sexual minority stress will counter some of the factors that instigate smoking among young adults in the LGBTQ community, and offer benefits extending beyond reductions in smoking behavior. Prevention campaigns seeking to deter smoking initiation for LGBTQ individuals, for example, may wish to include affirming messages about same-sex attraction. By reinforcing positive messages about their sexuality, same-sex attracted young adults may have opportunities to reduce feelings of internalized homophobia irrespective of sexual identity (Rosario, Schrimshaw, Hunter, & Braun, 2006). Such programs may take place outside of traditional LGBTQ venues (i.e. instead of community centers or bars and clubs, utilizing social media) to better reach those who do not identify as LGBTQ. The focus on same-sex attraction may be particularly relevant for younger women who have yet to identify as LGBTQ, have not disclosed their sexuality, or engage in same-sex sexual activity without identifying as a sexual minority (Johns, Zimmerman, & Bauermeister, 2013). In addition, future interventions may seek to bolster social support for individuals struggling with concealing or disclosing their same-sex attraction as they come out. Given that smoking was perceived as a marker of gay identity and offered a way to connect with other same-sex attracted individuals, it will be vital to develop and implement intervention strategies and social marketing campaigns that help LGBTQ communities be aware of the existing smoking disparities and the long-term implications it may have on the community’s well-being. Efforts currently underway to disentangle the relationship between smoking and the LGBTQ community include “The Last Drag” initiative, a free quit smoking program for LGBTQ smokers. Based on the American Lung Association’s Freedom from Smoking® educational materials, the program also offers participants information about smoking within the LGBTQ community and provides education within an LGBTQ-specific support group (Eliason, Dibble, Gordon, & Soliz, 2012). This program is currently being implemented in the San Francisco area, with an initial evaluation reporting a 60% quit rate following the intervention period, and a 36% smoking cessation rate at six-month follow-up (Eliason et al., 2012). These regional results are promising and suggest similar intervention approaches may be effective in reducing LGBTQ smoking rates. Given the geographic context of the intervention, however, some modifications (e.g. web-based strategies) may be necessary to achieve similar cessation rates in areas of the country where the LGBTQ community is less densely located.

The role of smoking as a social facilitator remains an important motivator for LGBTQ smokers. Participants highlighted how smoking was contextualized by their attendance at bars and clubs. Although Michigan had already implemented the Smoke Free Air Law, which prohibits smoking in restaurants, bars and businesses, at the time of data collection, participants still noted the saliency of smoking in the premises directly outside of these settings. These findings are consistent with Liebel, Lee, Goldstein, and Ranney’s (2011) acknowledgement of the importance of bars and clubs in the social lives of LGBTQ individuals, and reiterate the potential for these venues as intervention sites. Indeed, LGBTQ-friendly bars and clubs offer an efficient venue to reach groups of same-sex attracted smokers. Although smoking policies may help reduce smoking among LGBTQ smokers in public places, we must also provide community-based solutions beyond bars and clubs. Intervention approaches that include a social component where LGBTQ individuals may meet and connect with one another in a safe, smoke-free space may be warranted. Specifically, interventions that create or promote access to venues LGBTQ young adults an opportunity to meet and socialize without the ubiquitous influences of alcohol and tobacco may serve to disassociate LGBTQ identities with smoking.

Lastly, participants linked smoking among LGBTQ individuals with a rebellious persona, implying in their statements an association between smoking, sexuality, and deviance. Disconnecting these ideologies from one another will require broader, multisectoral social interventions, and are particularly important for adolescent and young adult LGBTQ individuals. Development of a LGBTQ-themed campaign that parallels the Truth campaign (Farrelly, Nonnemaker, Davis, & Hussin, 2009; Richardson, Green, Xiao, Sokol, & Vallone, 2010) may be an effective approach to promote critical consciousness among younger LGBTQ community members. Public health officials may facilitate these efforts by promoting greater social acceptance of same-sex attraction and implement stigma-reduction campaigns in the community. Broader understanding and tolerance of same-sex attraction may result in fewer instances of prejudice and discrimination of same-sex attracted individuals, and will undermine the perception of LGBTQ individuals as deviant. Finally, public health officials may strive to include broader visibility of LGBT health disparities in their programming and/or provide tailored services for LGBTQ populations when appropriate.

By soliciting the perspectives of young adult sexual minority women, these findings extend our understanding of smoking behavior in the LGBTQ community. SMW share some of the beliefs about smoking already noted in the literature (e.g., smoking behavior is motivated by sexuality-related stressors and time spent in bars and clubs), yet also identify smoking facilitators that are less commonly mentioned by researchers when theorizing on LGBTQ smoking prevalence (generalized stressors related to the transition to adulthood and smoking as part of LGBTQ identity and culture). Addressing these beliefs and developmentally specific smoking facilitators may potentiate future interventions designed to reduce smoking in the LGBTQ community.

Acknowledgments

None.

Funding This work was supported by the University of Michigan Comprehensive Cancer Center.

Footnotes

Declarations of Interest None.

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