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. Author manuscript; available in PMC: 2021 Jul 13.
Published in final edited form as: Drugs (Abingdon Engl). 2018 Jul 23;26(6):475–483. doi: 10.1080/09687637.2018.1490391

The Role of Multiple Social Identities in Discrimination and Perceived Smoking-Related Stigma among Sexual and Gender Minority Current or Former Smokers

Sharon Lipperman-Kreda 1,*, Tamar MJ Antin 1,2, Geoffrey P Hunt 2
PMCID: PMC8276780  NIHMSID: NIHMS988916  PMID: 34262244

Abstract

Aims:

We investigated how intersections of being a racial minority (i.e. being African American) and economically-disadvantaged (i.e. housing insecurity) may influence experiences with discrimination and perceptions of smoking-related stigma among sexual and gender minority (SGM) current and former smokers. Methods: Survey data were collected from 227 SGM current and former smokers in California (19-65 years old), oversampling African American participants. Participants reported their race, ethnicity, past month housing insecurity, number of lifetime experiences with SGM discrimination, and perceptions of smoking-related stigma.

Findings:

Using univariate General Linear Models and controlling for age, ethnicity, and SGM visibility, we found a significant interaction between being African American and facing housing insecurity on experiences with SGM discrimination [F(1,220)=7.21, p=0.01], perceived smoker stigma [F(1,220)=5.48, p=0.02], perceived differential treatment due to smoking [F(1,220)=10.03, p=0.00], and social withdrawal from non-smokers [F(1,220)=6.18, p=0.01]. These interactions suggest that economically-disadvantaged African American SGM current or former smokers experience increased levels of discrimination and perceive more smoking-related stigma compared to other SGM current and former smokers. Conclusions: Results suggest that people’s multiple identities intersect to intensify oppression and inequities for some people and raise questions about the unintended consequences of stigmatizing smokers for reducing smoking among SGM adults.

Keywords: Gay/lesbian/bisexual/transgender, Public health, Survey research, Stigma, intersectionality

INTRODUCTION

Sexual and gender minority (SGM) populations have among the highest rates of cigarette smoking in the United States and in California (Burgard, Cochran, & Mays, 2005; California Department of Public Health, 2013; Emory et al., 2016; Fallin, Goodin, Lee, & Bennett, 2015; Gamarel et al., 2016; Johnson et al., 2016; Lee, Griffin, & Melvin, 2009; McCabe, Boyd, Hughes, & d'Arcy, 2003; Miller & Grollman, 2015; Rath, Villanti, Rubenstein, & Vallone, 2013). Estimates from the 2015 California Adult Tobacco Survey suggest that sexual minority adults smoke more than 2 times as much as heterosexual adults in the state (27.4%, 12.9% respectively); and though similar data on smoking prevalence for transgender and gender nonconforming (trans*) adults were not collected, past Californian and recent national estimates suggest that trans* adults are 2 times more likely to use cigarettes compared to cisgender adults (i.e. adults whose gender identity corresponds to their sex assigned at birth) (Buchting et al., 2017; Bye, Gruskin, Greenwood, Albright, & Krotki, 2005). Not only do the high rates of cigarette smoking among SGMs increase risk of tobacco-related diseases including coronary heart disease, stroke, and multiple types of cancers (Centers for Disease Control and Prevention), but smoking also triggers SGMs’ susceptibility to consequences associated with the increasing stigmatization of smoking (Evans-Polce, Castaldelli-Maia, Schomerus, & Evans-Lacko, 2015; Roberts & Weeks, 2017; Stuber & Galea, 2009).

Smoking-related stigma refers to the negative social meanings and stereotypes associated with smoking that marks smoking as shameful and socially unacceptable (Bell, Salmon, Bowers, Bell, & McCullough, 2010; Evans-Polce et al., 2015; Farrimond & Joffe, 2006; Ritchie, Amos, & Martin, 2010). Smoking-related stigma may be experienced by smokers in multiple negative ways (Major & O'Brien, 2005; Stuber & Galea, 2009). People who perceive a high degree of smoking-related stigma may (1) feel that not just smoking as a behavior but also the people who smoke are devalued by others (i.e., smoker stigma), (2) experience discrimination through differential treatment because of their smoking (e.g., being turned down for a job, being social excluded), (3) avoid social situations with non-smokers, or (4) conceal smoking status from others to avoid embarrassment or negative opinions or consequences (e.g., health care providers, social environments). Existing research suggests the potential negative consequences of smoking-related stigma for some people’s health, including diminished self-efficacy or increased social isolation, leading some scholars to argue that tobacco prevention and policy efforts designed to denormalize smoking may be iatrogenic for some cigarette smokers (Bell et al.,2010; Evans-Polce et al., 2015; Graham, 2012; Stuber, Galea, & Link, 2008). However, to our knowledge, research has yet to investigate perceptions of smoking-related stigma among SGM adults.

Importantly, even less is known about whether smoking-related stigma is experienced differently among subgroups of smokers who are subjected to other forms of stigma, for example racism and classism, and who have fewer social and economic resources to help them quit smoking (Greaves & Hemsing, 2009; Kristin Voigt, 2010). Guided by principles of intersectionality (Bowleg, Teti, Malebranche, & Tschann, 2013; Crenshaw, 1991; Hankivsky & Christoffersen, 2008; McCall, 2005), the current study examined perceptions of SGM discrimination and smoking-related stigma among SGM smokers and former smokers who face multiple social disadvantages (e.g., being an ethnic minority, experiencing housing insecurity) to begin to fill this research gap. In this study, we focused on perceptions of smoking-related stigma among the people who are likely to have experienced this stigma (i.e., current and former smokers).

Recently, calls for an intersectional approach to SGM health have emphasized the importance of understanding the heterogeneity among SGM individuals (Bogart, Revenson, Whitfield, & France, 2014; Institute of Medicine, 2011). Intersectionality is a sociological paradigm that emphasizes how people’s multiple identities (e.g. race, social class) intersect and intensify oppression and inequities for some people (Bowleg et al., 2013; Crenshaw, 1991; Hankivsky & Christoffersen, 2008; McCall, 2005). Specifically, experiences with discrimination and perceptions of smoking-related stigma may be shaped not just by one’s sexual or gender minority identity but also by other overlapping identities that may be additionally stigmatized. As such, this paper will consider two additional disadvantaged categories (i.e. economic disadvantage and racial minority status) to study whether smoking-related stigma is experienced inequitably across subgroups of SGM people who smoke (Centers for Disease Control and Prevention; Delva et al., 2005; Max, Sung, Tucker, & Stark, 2010). We focused on African Americans because compared to non-Hispanic Whites, African Americans experience high levels of stigma and discrimination and suffer disproportionately from tobacco-related morbidity and mortality in the United States and California (Bowleg et al., 2013; Delva et al., 2005; Max et al., 2010; Reed et al., 2013; Sakuma et al., 2016). Of note, we considered housing insecurity rather than household income as a proxy for economic disadvantage. Because household income accounts only for household revenues and not necessary expenditures, household income may underestimate economic hardship (Dunn, Hayes, Hulchanski, Hwang, & Potvin, 2006), especially for people in areas with a high cost of living such as the San Francisco Bay Area.

To this end, we tested the following hypotheses to examine how the intersections of race (i.e. being African American) and economic disadvantage among SGM current and former smokers are associated with experiences with discrimination and perceptions of smoking-related stigma:

  1. Economically-disadvantaged SGM current and former smokers will experience more discrimination and perceive higher levels of smoking-related stigma than non- economically-disadvantaged SGM current and former smokers.

  2. African American SGM current and former smokers will experience more discrimination and perceive higher levels of smoking-related stigma than non-African American SGM current and former smokers.

  3. The association between being African American and levels of experiences with discrimination will be moderated by housing insecurity, such that African American SGM current and former smokers with housing insecurity will experience higher levels of discrimination than African American SGM current and former smokers without housing insecurity.

  4. The associations between being African American and perceptions of smoking-related stigma will be moderated by housing insecurity, such that African American SGM current and former smokers with housing insecurity will perceive higher levels of smoking-related stigma than African American SGM current and former smokers without housing insecurity.

METHODS

Study Sample and Methods

Survey data for the study were collected as a complement to a larger qualitative study on SGM adults and smoking stigma. The study targeted sexual and gender minority current or former cigarette smokers in California (19-65 years old), oversampling African American participants. We used a multi-tiered approach to recruit participants including posting messages on social media sites catering to SGM adults (e.g., Facebook, twitter), posting flyers in places and organizations where SGM young adults may be highly represented (e.g., community-based organizations, bars, coffee shops, clothing stores, universities, and community colleges), and by referrals. We limited the number of referrals from any one participant to three to minimize selection bias. Twenty-two participants were recruited through referrals.

During recruitment, we briefly described the study to participants and screened for eligibility (i.e., age, living in California, English speaker, sexual and gender identity, and cigarette smoking). We used the following questions to assess sexual and gender identity. First, in addition to asking participants about sex assigned at birth, we asked whether they consider themselves (1) a man, (2) a woman, (3) transgender, (4) genderqueer, or (5) other. Participants could select more than one option. Those who identified as transgender were also asked which of the following applies to them including (1) transgender, male to female (2) transgender, female to male (3) transgender, gender non-conforming, or (4) other. To assess sexual identity, we asked participants if they had to select just one identity, which would most closely fit how they self-identify. Response options included (1) gay/lesbian, (2) bisexual, (3) queer, (4) asexual, (5) straight/heterosexual, or (6) other. SGM adults included all sexual and gender identities other than straight/heterosexual, cisgender1 man or woman. Participants were also screened for smoking at least 100 cigarettes in their lifetime and either smoking cigarettes in the past 30 days (i.e., current smokers) or not (i.e., former smokers).

Prior to the qualitative interviews, participants were asked to respond to a 30-minute online survey. The survey was administered through SurveyGizmo.com. The survey was offered in English. We generated a unique URL for each survey entry and sent the link to participants via email or text. Within five days of receiving the initial invitation, we emailed or texted a reminder notice and made a reminder phone call to all eligible participants who had not completed the online survey. A second reminder was sent before the in-person interview to improve response rates. Participants who did not complete the survey prior to the interview were asked to complete it at the beginning of the interview. Participants were compensated for completing the online survey. Institutional review board approval was obtained prior to implementation of the study.

Overall, survey data were collected from 295 SGM current and former smokers, of whom 200 also participated in open-ended in-person interviews. The current analysis is based on survey data from 227 participants who provided complete data for all study measures (M age = 37.0 years, SD=12.6). Of the 227 participants, 135 (60%) identified as a sexual minority only, 9 (4%) identified as a gender minority only, and 83 (36%) identified as both a sexual and a gender minority. In terms of specific SGM groups, 48 (21%) participants identified as gay cisgender man, 31 (14%) identified as lesbian cisgender woman, 28 (12%) identified as gay/lesbian transgender, 14 (6%) identified as bisexual cisgender man, 24 (11%) identified as bisexual cisgender female, 17 (7.5%) identified as bisexual transgender, 8 (3.5%) identified as queer cisgender man, and 8 (3.5%) identified as queer cisgender woman. The remining participants (n=48) reported various combinations of sexual and gender identities. Sample characteristics are in Table 1.

Table 1:

Sample characteristics and descriptive statistics of study measures (n=227)

Percent Mean (SD) Range
Sexual and gender identities
  Sexual minority only 59.5
  Gender minority only 4.0
  Sexual and gender minority 36.6
Perceived SGM visibility 3.0 (1.2) 1-5
Current (past month) smoker 76.0
Age 37.0 (12.6) 19-65
Hispanic/Latina 29.1
Being African American 46.3
Any past month housing insecurity 33.0
Number of types of discrimination experiences, lifetime 5.6 (3.1) 0-11
Perceived smoker stigma, score 2.6 (0.7) 1-4
Perceived differential treatment due to smoking, score 0.5 (0.8) 0-3
Perceived social withdrawal from nonsmokers, score 2.7 (0.6) 1-4
Concealing cigarette smoking, score 1.3 (1.1) 0-3
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Measures

Lifetime experiences with SGM discrimination.

We used a modified everyday unfair treatment scale (Krieger, Smith, Naishadham, Hartman, & Barbeau, 2005) consisting of 11 items asking participants to indicate whether they were treated unfairly because they were assumed to be part of a LGBTQ+ community. Items in this scale included (1) treated with less respect than other people, (2) people have acted as if they were afraid of you, (3) been followed around in public places, such as a shop, (4) been threatened or physically attacked, (5) been subject to slurs or jokes, (6) received poor service than others (e.g., in restaurants, shops), (7) been treated unfairly in a healthcare setting, (8) been made to feel unwelcome at a place of worship or religious organization, (9) been treated unfairly by an employer in hiring, pay, or promotion, (10) been rejected by a friend or family member, and (11) been treated unfairly when looking for housing. Response options included 1. Never happened, 2. Happened more than a year ago, and 3. Happened within the past year. Cronbach's alpha of these items was 0.83. We summed the number of types of lifetime experiences with SGM discrimination (past year or more than a year ago).

Smoker stigma scale.

Using items from the smoker-related stigma scale (Stuber et al., 2008), we asked participants how much they disagree or agree with the statements that (1) most people believe that cigarette smoking is a sign of personal failure, and (2) most people think less of a person who smokes cigarettes. Response options were on a four-point Likert scale ranging from strongly disagree to strongly agree. The correlation between these two items was relatively strong (r =0.51). A mean summary score was used to measure perceived smoker stigma.

Differential treatment due to smoking.

Participants were asked to reply yes or no to the following questions: (1) have you had difficulty renting an apartment or finding housing because of your smoking? (2) were you turned down for a job for which you were qualified because of your smoking? and (3) were you refused or charged more for health insurance because of your smoking? The correlations among these three items were weak to moderate in strength (r = 0.11 - 0.28). We summed the number of yes responses to these items to measure perceived differential treatment due to smoking (0-3).

Social withdrawal from non-smokers.

We asked participants how much they disagree or agree with the statements that (1) for a cigarette smoker it is awkward to socialize with nonsmokers, (2) cigarette smokers socialize more with other smokers than nonsmokers, and (3) cigarette smokers avoid people with negative opinions about smokers. Response options were on a four-point Likert scale ranging from strongly disagree to strongly agree. The correlations among these three items were moderate in strength (r = 0.27 - 0.30). A mean summary score was used to measure perceived social withdrawal from non-smokers.

Concealing smoking status.

We assessed concealing cigarette smoking status by asking participants to reply yes or no to the following questions: (1) have you ever kept your smoking a secret from your doctor or other health care provider? (2) have you ever kept your smoking a secret from a close friend or family member? and (3) have you kept your smoking a secret from an employer? The correlations among these three items were moderate in strength (r = 0.27 - 0.30). We summed the number of yes responses to these items to create a measure of concealing cigarette smoking status.

Demographics.

Participants reported their age, race, and ethnicity. Age was treated as a continuous measure, we coded race as being African American (yes or no), and ethnicity as being Hispanic/Latinx (yes or no) to test study hypotheses. Also, we asked participants whether in the past 30 days they have spent at least one night (1) in a shelter, (2) in a public space not intended for sleeping (e.g., bus station, car, abandoned building), (3) on the street or anywhere outside (e.g., park, sidewalk), (4) temporarily doubled up with a friend or family member, (5) in a temporary housing program, and (6) in a welfare or voucher hotel/motel. We used responses to these items to indicate any past month housing insecurity.

SGM visibility.

Since some SGM individuals may experience more discrimination because of visible characteristics that signal to others sexual or gender minority identities (Maddox, 2004; Tomori et al., 2016), we asked participants to indicate how often people who do not know them assume that they are SGM based on their appearance or affect. Possible response options were never (1), occasionally (2), sometimes (3), most of the time (4), or always (5).

Data Analysis

Analyses were limited to participants who provided complete data for all study measures (N=227). Descriptive statistics were used to describe the study sample and measures. To preliminarily examine our hypotheses, we used t-tests to examine differences in experiences with discrimination and perceptions of smoking-related stigma between participants who faced housing insecurity and those who did not as well as between African Americans and non-African Americans. We then used univariate General Linear Models (GLM) to investigate main effects and interactions between being African American and facing housing insecurity on number of lifetime experiences with discrimination (Model 1), perceived smoker stigma (Model 2), perceived differential treatment due to smoking (Model 3), perceived social withdrawal from non-smokers (Model 4), and concealing smoking status (Model 5). All models controlled for age, ethnicity, and SGM visibility. Analyses were conducted with SPSS version 21.

RESULTS

Description of Study Sample and Measures

Sample characteristics are in Table 1. Participants were 37.0 years old on average (SD=12.5) and 46% percent were African Americans. Most participants (76%) were current cigarette smokers and all others were former smokers. Of study participants, 35% reported that people who do not know them assume that they are members of the SGM community always or most of the time.

On average, participants reported experiencing 6 types of discrimination in their lifetime (SD=3.1). Also, participants tended to agree that smokers are stigmatized (M=2.6, SD=0.7) and that cigarette smokers tend to avoid social interactions with non-smokers (M=2.7, SD=0.6). Perceived differential treatment due to smoking was low in our sample, with an average of less than one type of lifetime experience with differential treatment due to smoking (M=0.5, SD=0.8), though about 12% of the sample reported experiencing such treatment more than once. Finally, on average participants reported concealing smoking status in more than one situation in lifetime (M=1.3, SD=1.1), with approximately 40% who concealed cigarette smoking status in 2 or 3 situations.

Descriptive Statistics

We used t-tests to examine differences in experiences with discrimination and perceptions of smoking-related stigma between participants who faced housing insecurity and those who did not. Results showed a significant difference in lifetime experiences with discrimination between participants who faced housing insecurity (M=6.7, SD=3.0) and those who did not (M=5.1, SD=3.0); t (225) = −3.6, p=0.00. Results also showed significant differences in smoker stigma and in perceived differential treatment between SGMs who faced housing insecurity (M=2.8, SD=0.7; M=0.9, SD=0.8, respectively) and those who did not (M=2.6, SD=0.7; M=0.4, SD=0.7, respectively); t (225) = −2.8 p=0.01 and t (127.8) = −4.8, p=0.00, respectively. No differences between these two groups were found for social withdrawal or concealing cigarette smoking status.

Similarly, we examined differences between African Americans and non-African Americans in these concepts. T-test results showed no differences between SGM African Americans and SGM non-African Americans in their lifetime experiences with SGM discrimination, in smoker stigma, or in social withdrawal. Differences were found in perceived differential treatment due to smoking and in concealing cigarette smoking between these two groups. Specifically, SGM African Americans perceived more differential treatment due to smoking (M=0.7, SD=0.8) than non-African American SGMs (M=0.4, SD=0.6); t (195.1) =−3.1, p=0.00. However, SGM African Americans reported less concealing of cigarette smoking status (M=1.1, SD=1.0) compared to non-African American SGMs (M=1.5, SD=1.1); t (223.7) =3.2, p=0.00.

Univariate General Linear Models

Results of univariate General Linear Models to investigate associations between being African American and facing housing insecurity on lifetime experiences with discrimination and on perceptions of smoking-related stigma are in Table 2. Controlling for age, ethnicity, and SGM visibility, we found a significant interaction between being African American and facing housing insecurity on lifetime experiences with SGM discrimination [F(1,220)=7.21, p=0.01], perceived smoker stigma [F(1,220)=5.48, p=0.02], perceived differential treatment due to smoking [F(1,220)=10.03, p=0.00], and social withdrawal from non-smokers [F(1,220)=6.18, p=0.01]. Means and standard deviations of study outcomes by housing insecurity and African American are Table 3. The nature of the interactions was similar across all models and indicate that economically-disadvantaged African American SGM current or former smokers experience increased levels of discrimination and perceive more smoking-related stigma compared to other SGM current and former smokers. Figure 1 illustrate these findings. Results of main effects for housing insecurity and being African Americans are similar to those found in the t-tests.

Table 2:

Results of Univariate General Linear Models to investigate associations between being African American and facing housing insecurity on lifetime experiences with discrimination and on perceptions of smoking-related stigma (N=227).

df Mean Square F P
Model 1: Lifetime types of discrimination1
Age 1 0.87 0.10 0.75
SGM visibility 1 72.83 8.57 0.00
Hispanic/Latina 1 25.67 3.02 0.84
Housing Insecurity 1 74.99 8.83 0.00
African American 1 0.29 0.04 0.85
Housing Insecurity*African American 1 61.22 7.21 0.01
Error 220 8.50
Model 2: Perceived smoker stigma2
Age 1 7.48 15.71 0.00
SGM visibility 1 0.02 0.03 0.86
Hispanic/Latina 1 0.22 0.45 0.50
Housing Insecurity 1 1.85 3.89 0.05
African American 1 0.01 0.02 0.88
Housing Insecurity*African American 1 2.61 5.48 0.02
Error 220 0.48
Model 3: Perceived differential treatment3
Age 1 0.19 0.38 0.54
SGM visibility 1 0.32 0.64 0.43
Hispanic/Latina 1 0.22 0.44 0.51
Housing Insecurity 1 6.65 13.46 0.00
African American 1 4.84 9.79 0.00
Housing Insecurity*African American 1 4.96 10.03 0.00
Error 220 0.49
Model 4: Perceived social withdrawal4
Age 1 0.47 1.39 0.24
SGM visibility 1 0.03 0.09 0.76
Hispanic/Latina 1 0.35 1.04 0.31
Housing Insecurity 1 0.87 2.55 0.11
African American 1 0.02 0.05 0.83
Housing Insecurity*African American 1 2.10 6.18 0.01
Error 220 0.34
Model 5: Concealing cigarette smoking5
Age 1 17.59 17.47 0.00
SGM visibility 1 4.06 4.03 0.05
Hispanic/Latina 1 1.58 1.58 0.21
Housing Insecurity 1 0.46 0.46 0.50
African American 1 3.85 3.83 0.05
Housing Insecurity*African American 1 0.90 0.89 0.35
Error 220 1.01
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1

R Squared = 0.14;

2

R Squared = 0.14;

3

R Squared = 0.15;

4

R Squared = 0.05;

5

R Squared = 0.13

Table 3:

Means and standard deviations of outcome variables by housing insecurity and African American (N=227).

Mean SD
Lifetime types of discrimination
African Americans with housing insecurity 7.22 3.02
African Americans without housing insecurity 4.50 3.26
Non-African Americans with housing insecurity 5.69 2.87
Non-African Americans without housing insecurity 5.52 2.78
Model 2: Perceived smoker stigma
African Americans with housing insecurity 2.94 0.71
African Americans without housing insecurity 2.38 0.79
Non-African Americans with housing insecurity 2.63 0.71
Non-African Americans without housing insecurity 2.65 0.66
Model 3: Perceived differential treatment
African Americans with housing insecurity 1.10 0.81
African Americans without housing insecurity 0.36 0.69
Non-African Americans with housing insecurity 0.42 0.58
Non-African Americans without housing insecurity 0.38 0.66
Model 4: Perceived social withdrawal
African Americans with housing insecurity 2.87 0.52
African Americans without housing insecurity 2.56 0.67
Non-African Americans with housing insecurity 2.72 0.49
Non-African Americans without housing insecurity 2.80 0.58
Model 5: Concealing cigarette smoking
African Americans with housing insecurity 1.12 0.99
African Americans without housing insecurity 1.10 1.01
Non-African Americans with housing insecurity 1.42 1.30
Non-African Americans without housing insecurity 1.58 1.01
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Figure 1.

Figure 1

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Housing insecurity as a moderator of the association between being African American and levels of experiences with discrimination.

DISCUSSION

Our findings showed that economically-disadvantaged African American SGM current or former smokers reported significantly more SGM discrimination and perceived more smoking-related stigma compared to other SGM current and former smokers. In other words, though all SGM adults in this study may be susceptible to SGM discrimination and smoking-related stigma, experiences with discrimination and the stigmatization of smoking may be experienced differently among SGM current and former smokers relative to the intersection of other stigmatized social markers, like racial minority status and economic disadvantage. Specifically, economically-disadvantaged African American SGM current or former smokers are more likely to perceive smoker stigma, to experience differential treatment due to their smoking, and to report socially withdrawing from nonsmokers— arguably, all experiences that may operate to intensify inequality and result in continued smoking rather than smoking cessation (Burris, 2008).

Tobacco denormalization is a widely accepted tobacco control strategy and is credited with reducing smoking at the population level, in part by reinforcing the notion that tobacco use, most notably smoking, is not a mainstream or socially acceptable practice (Al-Delaimy et al., 2010; Alamar & Glantz, 2006; Centers for Disease Control and Prevention, 2014; Lightwood & Glantz, 2013). However, an important question is whether efforts to address one public health problem might have contributed to the intensification of stigma among some marginalized populations. Scholars have argued that tobacco denormalization and smoking-related stigma exacerbate tobacco-related inequities where, for example, smoking becomes concentrated among those who are already subjected to other forms of stigma (Bayer & Stuber, 2006; Bell et al., 2010). There are multiple potential ways in which tobacco denormalization approaches may amplify tobacco-related inequities. First, stigmatized people who internalize negative societal perceptions of one’s stigmatized status may experience low self-esteem and self-efficacy (Corrigan, Watson, & Barr, 2006; Meyer, 2003) that translates into fatalistic attitudes about one’s ability to change (Lea, de Wit, & Reynolds, 2014; Pachankis, Hatzenbuehler, & Starks, 2014). Also, stigmatized people might evade stigma by rejecting a smoking identity which may result in reduced likelihood to attempt to quit smoking (Berg et al., 2009). A study found that 12.3% of all smokers in California could be considered “non-identifying smokers”, and ethnic minority smokers were more than 3 times as likely to reject the label of smoker compared to non-Hispanic whites (Leas, Zablocki, Edland, & Al-Delaimy, 2015). Third, to avoid stigma, smokers may withdraw from non-smokers and segregate themselves into communities that are accepting of smoking (Thompson, Pearce, & Barnett, 2007). For SGMs, nightlife locations are considered safe spaces and represent settings that traditionally are accepting of smoking and targeted by the tobacco industry (Leibel, Lee, Goldstein, & Ranney, 2011). Lastly, smokers may conceal smoking status from health care providers or others to avoid embarrassment, negative opinions or consequences (Bell et al., 2010). This may result in reduced access to cessation programs offered by healthcare providers.

Our results also suggest that multiple and intersecting forms of stigma shape SGM adults’ experiences with discrimination and perceptions of smoking-related stigma. SGM adults who smoke are already vulnerable to “intersectional stigma” in that their experiences with smoking-related stigma intersect with the stigma associated with their sexual or gender minority identities (Berger, 2010; Triandafilidis, Ussher, Perz, & Huppatz, 2017). However, as our study suggests, other layers of stigma, like those resulting in racism and classism, significantly magnify one’s experiences with discrimination and perceptions of smoking-related stigma, arguably resulting in the intensification of their inequality. Therefore, future studies should investigate how multiple forms of stigma influence tobacco-related inequities to better understand the heterogeneity of SGM communities.

A few study limitations should be noted. First, our data were drawn from a non-probability sample of participants in California, so study results are not necessarily representative of SGM populations in California and do not necessarily represent other states. It will be important to replicate this study in a representative sample and in locations with less restrictive tobacco controls. Second, due to the diversity of our sample in terms of specific SGM groups, our study did not have the power to consider specific sexual and gender minority groups in the analysis. This is important considering research showing a high prevalence of cigarette smoking among specific SGM groups such as sexual minority women (Burgard et al., 2005; Fallin et al., 2015; McCabe et al., 2003). Third, in this study we oversampled African Americans and, due to power issues, could only focus on this racial group. Future studies should investigate whether similar patterns occur in other racial or ethnic groups. Fourth, our self-reported measures of experiences with discrimination may have been limited by recall and social desirability biases, and focused only on discrimination due to a SGM identity. Fifth, our sample included former and current smokers and does not allow us to gain insight about perceptions of smoking-related stigma among non-smokers to better understand the determinants of these perceptions. Finally, our study included no survey measures of perceptions of tobacco denormalization approaches to directly investigate the sources of smoking-related stigma among former and current smokers. However, we are currently investigating this question in the qualitative component of this study.

CONCLUSIONS

Results of this study suggest that multiple and intersecting forms of stigma (i.e., race and economic disadvantage) shape SGM adults’ experiences with discrimination and perceptions of smoking-related stigma. As the population-level prevalence of smoking has decreased substantially overtime and smoking remains concentrated among the most socially marginalized groups, it is important to consider effects of smoking-related stigma in these groups and to investigate potential sources of that stigma as well as non-stigmatizating approaches to address tobacco-related health inequities. For example, one promising direction for exploration may be the adaption of stigma reduction initiatives to tobacco prevention including the reduction of both structural and internalized stigma (Hatzenbuehler, Jun, Corliss, & Austin, 2014). A Trauma-Informed Approach may be another alternative approach to address tobacco-related health inequities by recognizing and integrating knowledge about traumatic experiences, such as experiences with discrimination and smoking-related stigma (e.g., differential treatment due to smoking or social withdrawal from non-smokers) into policies, procedures, and practices at organizational or community contexts (e.g., a community-level stigma reduction campaigns or training to providers in primary care systems to address trauma issues at the organization levels) (Greaves, 2015; Substance Abuse and Mental Health Services Administration, 2014). Finally, denormalization of the tobacco industry rather than denormalizing smoking may contribute to reductions in cigarette smoking in marginalized populations (Hammond, Fong, Zanna, Thrasher, & Borland, 2006; Malone, Grundy, & Bero, 2012; K. Voigt, 2013). Future research should consider to what extent inequities in smoking may decrease if experiences with discrimination and smoking-related stigma are reduced.

Acknowledgments

Role of the funding source: This research and preparation of this manuscript were supported by grant R01-CA190238-01A1 from the National Cancer Institute (NCI) of the National Institutes of Health (NIH). The content is solely the responsibility of the authors and does not necessarily represent the official views of the NCI or NIH.

Footnotes

Declarations of interest: None.

1

Cisgender refers to adults whose gender identity corresponds to their sex assigned at birth.

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