Perspectives on Cigarette Use, Vaping, and Antitobacco Campaigns Among Adolescent Sexual Minority Males and Gender Diverse Youth

Abstract

Purpose:

This qualitative study examined perceived benefits and drawbacks of smoking/vaping and attitudes toward antitobacco campaigns among adolescent sexual minority males and gender-diverse (ASMM/GD) youth.

Methods:

In July 2019, 215 U.S. ASMM/GD youth (mean_age 16.78, 95.3% cisgender male, 60.0% racial/ethnic minority) answered questions about smoking/vaping behaviors, motivations for smoking/vaping, and attitudes toward antitobacco campaigns via an online survey. Data were analyzed with thematic analysis.

Results:

Overall, 17.2% of participants had smoked cigarettes, and 34.9% had vaped. Teens described psychological (e.g., stress relief), chemical (e.g., nicotine buzz), and social incentives (e.g., fitting in with peers) for smoking/vaping. Teens also reported concerns about physical health, costs, and self-image as drawbacks of smoking/vaping. Most considered antitobacco campaigns unrelatable and uninteresting, while others reported that campaigns reinforced their decisions to not smoke/vape. Most participants wanted antitobacco campaigns to be tailored to the sexual and gender minority (SGM) community.

Conclusions:

These findings shed light on ASMM/GD youth's perspectives of smoking/vaping and antitobacco campaigns. Results suggest that equipping teens with skills to cope with minority stress and resisting peer pressure could indirectly reduce smoking/vaping, and that SGM-inclusive campaigns may better reach SGM adolescents.

Introduction

Sexual and gender minority (SGM) adolescents are twice as likely to smoke cigarettes as cisgender heterosexual teens, placing them at higher risk of tobacco-related health problems (e.g., cancer, respiratory illnesses).¹ The popularity of e-cigarettes (vaping) among adolescents exacerbates tobacco use/addiction.² One survey found higher cigarette use among sexual minority teens than heterosexual youth, but no group differences in other tobacco products.³ Among SGM teens, smoking/vaping is more prevalent among adolescent sexual minority males than teens assigned female at birth, and the risk for smoking/vaping is higher for transgender teens than cisgender teens.⁴

Most research has quantitatively examined psychosocial correlates of,^4,5 and demographic differences in smoking/vaping among SGM adolescents and young adults.^6–8 However, little is known about their motivations to smoke/vape. Qualitative research could elicit more nuanced information on SGM youth's motivations to smoke/vape and the sociodevelopmental contexts influencing smoking/vaping, which could inform prevention/cessation efforts.

The tobacco industry has historically targeted SGM individuals as potential consumers (e.g., Project Subculture Urban Marketing for gay individuals in San Francisco).⁹ Yet, there have been limited efforts to reduce smoking/vaping among SGM individuals,^10,11 including SGM-tailored antitobacco campaigns.¹² The This Free Life campaign is the first and only large-scale antitobacco campaign designed for SGM adults in 2016. Through online videos and advertisements, it garnered >3 billion online impressions and promoted greater awareness of risks associated with smoking/vaping.¹³

No antitobacco campaigns have focused on SGM teens, who are in a developmental stage that requires different messaging than adults.¹⁴ Specifically, adolescent campaigns may need to focus more on resisting peer pressure to smoke/vape.^14,15 In addition, SGM teens may experience minority stressors (e.g., identity disclosure), which are associated with increased smoking/vaping.^16,17 Compared with their heterosexual peers, SGM teens who are unsure of their sexual identity and experience SGM victimization are more likely to smoke/vape.^18,19 Research has also demonstrated that SGM-specific tobacco-cessation programs are more effective than those designed for the general population.^20,21

Therefore, a richer understanding of adolescents' reasons for smoking/vaping and their perspectives on antitobacco campaigns can inform future interventions that resonate with SGM adolescents. This study used an online mixed-methods survey to examine adolescent sexual minority males/gender-diverse (ASMM/GD) youth's motivations for and perceived drawbacks of smoking/vaping, and their attitudes toward antitobacco campaigns.

Methods

In July 2019, we conducted an online survey study of HIV/sexually transmitted infection (STI) prevention messaging among ASMM/GD youth²² that assessed other health behaviors including smoking/vaping. Participants were recruited via social media advertisements (Facebook/Instagram) and research registries maintained by the investigative team. The advertisements directed participants to an online screener to verify the following eligibility criteria: assigned male at birth (due to parent study's focus on HIV/STI prevention), same-sex attraction, 15–18 years old, and ability to read in English. The screener also included photo-identification tasks to verify human participants (i.e., “Please pick the word that best fits what is shown in the corresponding photo [an apple]”; orange, swimming, apple, walking).

Study staff emailed eligible participants an individualized link to the online survey. After consenting, participants who completed this survey received a $25 Amazon gift card. Study procedures followed research-informed protocols to detect fraudulent entries^23,24 and were approved by the Northwestern University's Institutional Review Board with a waiver of parental permission for minors younger than 18 years.

Measures

Demographics

Participants completed items assessing their age, race/ethnicity, sexual attraction (please let us know about the individuals you are attracted to: only guys, mostly guys but some girls, guys and girls equally, mostly girls but some guys), gender identity (please describe your gender identity: gender nonconforming, gender queer, men, women, not listed), and outness to parents/caregivers.

Cigarette/e-cigarette use

Items adapted from the Youth Risk Behavior Survey²⁵ assessed participants' lifetime tobacco use in a single item (Have you ever smoked cigarettes or used nicotine vaping products [even one or two puffs]?). Questions also assessed past month (During the past 30 days, on how many days did you smoke cigarettes; and during the past 30 days, how many times did you use a nicotine vapor product/e-cigarette/disposable e-cigarette [blu, JUUL, NJOY, vaping pens] per day?), and daily cigarette/e-cigarette use (During the past 30 days, how many cigarettes did you smoke per day; and during the past 30 days, how many times did you use a nicotine vapor product/e-cigarette/disposable e-cigarette per day?). Participants who had ever smoked/vaped also reported the specific type of tobacco products they used (please select all smoking or nicotine vaping products you have ever tried [even one or two puffs]: cigarettes, disposable e-cigarettes, e-cigarettes/nicotine vape products).

In addition, questions assessed whether participants had attempted to terminate cigarette/e-cigarette use (Have you ever tried to stop smoking cigarettes; and have you ever tried to stop using e-cigarettes/nicotine vapor products?).

Perceived benefits/drawbacks

Participants who ever smoked/vaped received four open-ended questions about their perceived benefits/drawbacks of smoking/vaping: What do you get out of smoking cigarettes, if anything; what do you get out of using e-cigarettes/nicotine vapor products, if anything; what are the drawbacks of smoking cigarettes for you, if any; and what are the drawbacks of using e-cigarettes/nicotine vapor products for you, if any?

Perspectives on online health campaigns

All participants received two open-ended questions that elicited their perceptions of online antitobacco campaigns: please explain why you do not think you would benefit from seeing antismoking/antinicotine vaping campaigns on social media; please explain why you think you would benefit from seeing antismoking/antinicotine vaping campaigns on social media. A survey item assessed participants' preferences for lesbian, gay, bisexual, transgender, queer+ (LGBTQ+) specific online health campaigns. It's important to me that social media health campaigns are LGBTQ+ specific (1 = strongly disagree; 4 = strongly agree). All participants also received an open-ended question: please explain why it's important to you that social media health campaigns be LGBTQ-specific.

Data analysis

Dedoose²⁶ was used to compute descriptive statistics and conduct qualitative analyses.²⁷ The first author reviewed all excerpts and developed a list of potential codes. The second author reviewed this list and identified additional codes. Coders combined their notes, met to address discrepancies, and consulted with the senior author to resolve disagreements. Upon reaching consensus, the first author applied finalized codes to the excerpts. The second author then independently conducted reliability testing using the finalized codebook and derived pooled Kappas ranging from 0.75 to 1.0, suggesting substantial reliability.²⁸ Fisher's exact test also explored associations between teens' demographics and smoking/vaping.

Results

The sample included 215 ASMM/GD youth aged 15 to 18 (mean_age = 16.78 years; standard deviation = 1.07; 60.0% racial/ethnic minority; 95.3% cisgender man; Table 1). A total of 39.5% (n = 85) had smoked/vaped before. Of those, 17.2% ever used cigarettes, 5.1% ever used disposable e-cigarettes, and 34.9% ever used e-cigarettes with nicotine vapor. Out of the 85 teens who have ever smoked/vaped, 27.1% (n = 23) attempted to stop using cigarettes, and 43.5% (n = 37) tried to stop vaping. Most teens (62.3%) endorsed the importance of SGM-specific antitobacco campaigns (Table 2).

Table 1.

Participant Characteristics (N = 215)

Age (M = 16.78; SD = 1.07)	N	%
15	35	16.3
16	46	21.4
17	66	30.7
18	68	31.6
Race
American Indian	7	3.3
Asian	36	16.7
Black	28	13.0
Hispanic	39	18.1
Native Hawaiian	12	5.6
Non-Hispanic White	82	38.1
Other	7	3.3
No answer	4	1.9
Gender identity
Gender nonconforming	8	3.7
Genderqueer	1	0.5
Men	205	95.3
Women	0	0
Not listed	1	0.5
Gender of sexual attraction
Only guys	139	64.7
Mostly guys, but some girls	39	18.1
Guys and girls equally	22	10.2
Mostly girls, but some guys	15	7.0
Outness to mother/female caregiver
Yes	136	63.3
No	66	30.7
No answer	13	6.0
Outness to father/male caregiver
Yes	103	47.9
No	97	45.1
No answer	15	7.0

M, mean; SD, standard deviation.

Table 2.

Cigarette/E-Cigarette Use (N = 215)

	N	%
Ever used cigarette or e-cigarettes
Yes	85	39.5
No	130	60.5
Ever used cigarettes
Yes	37	17.2
No	178	82.8
Ever used disposable e-cigarettes
Yes	11	5.1
No	204	94.9
Ever used e-cigarettes/nicotine vapor
Yes	75	34.9
No	140	65.1
Cigarette use in the past month (n = 37)
0 days	18	48.6
1–2 days	10	27.0
3–5 days	2	5.4
6–9 days	2	5.4
10–19 days	3	8.1
All 30 days	2	5.4
Cigarettes per day (n = 19)
Less than 1 per day	8	42.1
1 per day	4	21.1
2–5 per day	7	36.8
E-cigarette use in the past month (n = 76)
0 day	31	40.8
1–2 days	14	18.4
3–5 days	12	15.8
6–9 days	9	11.8
10–19 days	2	2.6
20–29 days	5	6.6
All 30 days	3	3.9
E-cigarettes per day (n = 45)
Less than 1 per day	17	37.8
1 per day	3	6.7
2–5 per day	8	17.8
6–10 per day	10	22.2
11–20 per day	3	6.7
More than 20 per day	4	8.9
Ever tried to quit cigarettes (n = 37)
Yes	23	62.2
No	14	37.8
Ever tried to quit e-cigarettes (n = 76)
Yes	37	48.7
No	37	48.7
I don't want to answer	2	2.6
It's important to me that social media health campaigns are LGBTQ+ specific
Strongly disagree	11	5.1
Disagree	45	20.9
Agree	91	42.3
Strongly agree	43	20.0
I don't want to answer	25	11.6

LGBTQ+, lesbian, gay, bisexual, transgender, queer+.

In addition, greater percentages of teens who were not out about their SGM identity to their mothers ever smoked/vaped (79.72%) than those who were out (56.28%; p = 0.03). No other significant sociodemographic differences in smoking/vaping were found, and there were no meaningful differences in qualitative responses between teens with and without smoking/vaping experience.

Benefits and drawbacks of cigarette/e-cigarette use

From participants who had ever smoked/vaped (n = 85), 75 participants provided codable responses (i.e., intelligible excerpts with relevant information) about perceived benefits of smoking/vaping. We identified four codes as follows: relieves psychological/physical distress; chemical incentives; social incentives; and advantages of e-cigarettes compared with cigarettes. Fifteen responses to these two items indicated no benefits from smoking/vaping (Table 3).

Table 3.

Codes, Definitions, and Examples: Perceived Benefits and Drawbacks of Tobacco Use

Reasons for using cigarettes/e-cigarettes
Parent code	Subcode	Definition	Examples
Reliever of psychological and physical distress (n = 29)		Excerpts referencing the use of cigarettes/e-cigarettes to relieve psychological stress (e.g., for relaxation and time to breath) and physical pain.	“It just calms me down and makes me feel better than how I felt before if I'm angry for example or if I'm extremely anxious.”; “It is a pain [reliever] and relives my stress.”
Chemical (n = 23)	Nicotine buzz (n = 19)	Excerpts referencing the use of cigarettes/e-cigarettes for bodily/sensory pleasure induced by nicotine.	“Nicotine high, it makes me get a head rush and feel good for a while.”
	Drugs (n = 4)	Excerpts referencing the use of cigarettes/e-cigarettes to intensify other illicit drugs' effects; or as alternatives to other illicit drugs.	“A buzz and it boosts every other drug”; “To keep me off of hard drugs.”
Social (n = 18)	Just for fun (n = 8)	Excerpts referencing the use of cigarettes/e-cigarettes out of curiosity (e.g., just for fun; out of boredom).	“Enjoyment.”
	Social and networking (e-cigarettes only; n = 8)	Excerpts referencing cigarette use for social and networking purposes (e.g., desire to fit in and keep up with friends; use at parties and gatherings).	“My use of Nicotine is mostly social. I'll use if others in a group are using, but I wouldn't use on my own.”
	Physical health (e-cigarettes only; n = 2)	Excerpts referencing the use of e-cigarettes to improve one's physical health.	“I can breathe better.”
No benefits (n = 15)		Excerpts referencing the lack of perceived benefits of cigarette/e-cigarette use.
Specific advantages of e-cigarettes (n = 5)	Comparison between cigarettes and e-cigarettes (e-cigarettes only; n = 2)	Excerpts referencing comparisons of perceived benefits between cigarettes and e-cigarettes.	“The buzz of the nicotine isn't as strong as the cigarettes, which is why I smoked one cigarette.”
	Flavor (e-cigarettes only; n = 2)	Excerpts referencing the various flavor and types of e-cigarettes.	“I like how there's so much smoke and how it smells like shisha which I love yet only RARELY do.”
	Versatility (e-cigarettes only; n = 1)	Excerpts referencing accessibility and versatility of e-cigarettes.	“They are more universal and can be used indoors.”
Drawbacks of cigarette/e-cigarette use
Physical health (n = 29)		Excerpts referencing concerns about physical health problems.	“Nausea”; “dizziness”; “sore throat”; “bad breath”; “shorter lung capacity.”
Limited practicality (n = 20)	Addiction (e-cigarettes only; n = 14)	Comments citing concerns of becoming addicted to e-cigarettes.	“Addictive.”
	Financial burden (e-cigarettes only; n = 5)	Excerpts referencing concerns about the financial burdens of e-cigarette use.	“They are expensive.”
	Inconvenience (cigarettes only; n = 1)	Excerpts referencing concerns about the limitations of cigarette use.	“Have to be used outside, inconvenient with time.”
Self-image and stigma (n = 8)	Bad odor (cigarettes only; n = 3)	Excerpts referencing complaints about odorous smell caused by cigarettes.	“They have a very apparent smell.”
	Negative impression (n = 3)	Excerpts referencing concerns about the negative social impression and stigma associated with cigarette use.	“Looking dumb.”
	Bad breath (cigarettes only; n = 2)	Excerpts referencing complaints about bad breath caused by cigarettes.	“The taste in your mouth afterwards.”
No drawbacks (n = 8)		Excerpts referencing the lack of perceived drawbacks of cigarette/e-cigarette use.

The most frequently reported benefit was that cigarette/e-cigarette use would provide relief from psychological/physical distress (n = 29; 38.7%). Teens described that they felt calmer and less stressed after smoking/vaping (e.g., It is a pain [reliever] and [relieves] my stress, an 18-year-old Black teen). Participants attributed their less anxious state to the chemical incentives that cigarettes/e-cigarettes provide (n = 23; 30.7%). Within this code, 19 participants talked about the sensory pleasure from nicotine buzzes, and 4 teens mentioned using nicotine products to intensify the effects of other drugs (“A buzz and it boosts every other drug,” a 17-year-old Asian/White teen) or as alternatives to other substances (“To keep me off of hard drugs,” an 18-year-old Black teen). In other words, cigarette/e-cigarette use could be a double-edged sword, as they may either promote or prevent the use of illicit drugs.

In addition, teens were motivated to smoke/vape for social incentives (n = 18; 24.0%). Participants mentioned the desire to conform to group norms, build new social networks, or the fun of smoking/vaping with friends. Finally, five participants (6.7%) reported the advantages of e-cigarettes compared with cigarettes, including flavors, versatility, and the ease of obtaining e-cigarettes than cigarettes (“They are more universal and can be used indoors,” a 16-year-old White teen).

Fifty-seven participants who ever smoked/vaped (26.5% of the full sample) provided codable responses about drawbacks of smoking/vaping. Out of the responses, eight excerpts indicated no drawbacks. The following three codes emerged: concerns for physical health, limited practicality, and self-image and stigma (Table 3). The most commonly cited drawback was concern for physical health (n = 29; 50.9%), ranging from short-term (e.g., headache) to long-term health outcomes (e.g., cancer). Twenty adolescents (35.1%) referenced the practical limitations of smoking/vaping, such as cost or inconvenience. Adolescents who vaped were concerned about addiction and the cost of e-cigarettes, while adolescents who smoked mentioned that cigarettes felt limiting since they could only smoke cigarettes outside.

Moreover, participants were concerned about self-image and the stigma against smoking/vaping (n = 8; 14.0%), such as the lingering odor on clothes and bad breath (cigarettes only). Adolescents were also apprehensive about what others would think of their smoking/vaping, such as fears of “looking dumb” (18-year-old Asian teen).

Drawbacks and benefits of antitobacco campaigns

All participants responded why they would not benefit from seeing antitobacco campaigns on social media, of which 62.8% of the full sample (n = 135) provided a codable response (Table 4). Teens reported the following three overarching drawbacks: awareness of the negative effects on health (n = 91; 67.4%), ineffectiveness (n = 41; 30.4%), and autonomy (n = 3; 2.2%). Most adolescents (n = 91) did not perceive antitobacco campaigns as beneficial because they did not need such reminders, either because they never smoked/vaped or because they were already aware of the negative effects on health. Teens described antitobacco campaigns as ineffective because they are uninteresting, show unoriginal/repetitive content, or are unrelatable to adolescents. Several participants stated that they perceived health campaigns in general to be unhelpful. In addition, three teens dismissed antitobacco campaigns due to the belief that teens should have the autonomy to make their own decisions about smoking/vaping.

Table 4.

Codes, Definitions, and Examples: Attitude Toward Antitobacco Campaigns

Drawbacks of antitobacco campaigns
Parent code	Subcode	Definition	Example
Negative effects on health (n = 91)	Nonuser of cigarettes/e-cigarettes (n = 68)	Excerpts referencing those who rejected antismoking/vaping campaigns because they did not use cigarettes/e-cigarettes.	“Because I personally have never used a nicotine product.”
	Awareness of consequences (n = 17)	Excerpts referencing those who were already aware of the negative consequences of cigarettes/e-cigarettes; or those who already agreed with antismoking/vaping campaigns.	“I already disagree with smoking so seeing those campaigns would not sway my decision.”
	Indifference (n = 4)	Excerpts referencing those who were indifferent about antismoking/vaping campaigns.	“I don't care that much.”
	Negligence of campaigns (n = 2)	Excerpts referencing those who either lacked access to the internet or did not pay attention to online antismoking/vaping campaigns.	“I don't use social media.”
Ineffectiveness (n = 41)	Vapidity (n = 12)	Excerpts referencing the lack of attractiveness of antismoking/vaping campaigns.	“I would ignore it. Social media vape ads are laughable usually. They aren't enticing and wouldn't encourage me to stop.”
	General comments (n = 11)	Excerpts referencing the ineffectiveness of antismoking/vaping campaigns without providing specific reasons.	“Anti-smoking ads never work for me or my peers.”
	Cliché (n = 8)	Excerpts referencing the lack of originality and repetitiveness of antismoking/vaping campaigns.	“...in fact, most seem at least 4 or 5 years behind in slang and attitudes.”
	Irrelevance (n = 7)	Excerpts referencing the lack of connection between antismoking/vaping campaigns and adolescents' daily lives.	“None of them are in touch with their audience.”
	Counterproductiveness (n = 3)	Excerpts referencing the counterproductive effects of antismoking/vaping campaigns.	“seeing anti-smoking ads just makes me want to do it just for the sake of doing it.”
Autonomy (n = 3)		Excerpts referencing the opinion that individuals should make their own decisions on cigarette/e-cigarette use.	“Smoking is a personal decision. It should be up to the individual whether or not smoking is right for them.”
Benefits of antitobacco campaigns
General well-being (n = 29)	Awareness cultivation (n = 19)	Excerpts referencing antismoking/vaping campaigns' helpfulness to cultivate the awareness of cigarettes/e-cigarettes' negative consequences.	“It could help promote awareness that vaping contains nicotine and can be deadly.”
	Children/youth (n = 6)	Excerpts referencing that antismoking/vaping campaigns are good resources for cigarette/e-cigarette use prevention among children.	“because I think it benefits young kids on why not to try drugs or nicotine.”
	Physical health (n = 2)	Excerpts referencing antismoking/vaping campaigns' helpfulness to individuals' physical health.	“Because it's healthy.”
	Societal welfare (n = 2)	Excerpts referencing antismoking/vaping campaigns' contribution to the general societal welfare.	“We all benefit overall as a society if young people stop using these products.”
Reinforce decisions to not use cigarettes or e-cigarettes (n = 20)	Motivation (n = 16)	Excerpts referencing antismoking/vaping campaigns' effect on motivating the desire to stop using cigarettes/e-cigarettes; or to keep people from considering using cigarettes/e-cigarettes.	“It would make me want stop more.”
	Validation (n = 2)	Excerpts referencing antismoking/vaping campaigns' validating effect; make people feel taken care of.	“It would make me feel good inside to know that someone cares enough to put the message out there that smoking, and nicotine is not good for you.”
	Integrity (n = 2)	Excerpts referencing antismoking/vaping campaigns' effect as a source of self-discipline.	“I wish to maintain my integrity by not smoking or using nicotine products, so I need to not be inclined to try such products.”

Fewer participants (n = 49, 22.8% of the sample) described the benefits of antitobacco campaigns, with the following two subcodes: general well-being (n = 29; 59.2%) and reinforce decisions to not smoke/vape (n = 20; 40.8%). Adolescents (n = 20) highlighted campaigns' role in motivating individuals to stop smoking/vaping. Those who were already committed to not smoking/vaping or who had already stopped viewed these campaigns as beneficial for self-discipline (“Wish to maintain my integrity by not…using nicotine products,” a 17-year-old White teen). Moreover, participants (n = 29) felt that such campaigns promote general health/well-being among teens (e.g., promoting awareness of negative consequences of smoking/vaping).

Benefits of SGM-specific antitobacco campaigns

Two-thirds of participants (65.6% of the full sample; n = 141) answered questions on why social media health campaigns should be SGM specific (Table 5). Responses unanimously reflected a sentiment that health campaigns should reflect diverse communities. First, participants perceived SGM-specific campaigns as beneficial because they provided information relevant to SGM individuals' health needs (n = 75; 53.2%). A 15-year-old White teen remarked “LGBT people face distinct health risks, especially…more dangerous penetrative sex.” Adolescents reported that these campaigns helped promote awareness of the negative impacts of smoking/vaping in the SGM community. In addition, adolescents (n = 66; 46.8%) mentioned that SGM-specific campaigns promoted solidarity/representation within the SGM community (e.g., “It makes the LGBTQ+ community stronger and feel included,” an 18-year-old Asian teen).

Table 5.

Codes, Definitions, and Examples: Importance of Sexual and Gender Minority-Specific Antitobacco Campaigns

Parent code	Subcode	Definition	Example
Diversity and inclusion (n = 141)	LGBTQ-specific information (n = 75)	Excerpts referencing LGBTQ+ specific campaigns' helpfulness, as they are tailored to LGBTQ-specific health needs.	“Because we have very specific health needs.”
	Inclusion and solidarity (n = 66)	Excerpts referencing that LGBTQ-specific campaigns are able to promote inclusion, solidarity, and representation of the SGM community.	“I mean it would be nice and be more welcoming to the LGBT community and make people feel more accepted.”

SGM, sexual and gender minority.

Discussion

Smoking/vaping is more prevalent among SGM adolescents than cisgender, heterosexual youth.^3,4 However, little is known about ASMM/GD youth's perspectives of smoking/vaping and antitobacco campaigns. Overall, 39.5% of the sample had ever smoked/vaped, echoing prior observations of adolescent gay (43.3%) and bisexual (47.3%) boys,¹ as well as transgender (32.5%) and nonbinary teens (22.4%).⁴

The most commonly cited motivation for smoking/vaping was seeking out psychological relief, echoing previous research on SGM youth.¹⁸ Although we did not assess minority stress, the fact that identity concealment to mothers was associated with greater rates of smoking/vaping may suggest minority stress' role in SGM teens' smoking/vaping behavior. Research has also highlighted the benefits of identity disclosure among SGM youth, as outness is associated with higher self-esteem and may reflect youth's resilience,²⁹ demonstrating the importance for future antitobacco campaigns to incorporate identity disclosure in a campaign design.

Research with cisgender, heterosexual teens has also identified experimentation, tobacco's flavorful taste, and “just for fun” as key facilitators of tobacco use.^30–32 This contrasts with our observation that psychosocial stressors were a primary motivation for smoking/vaping among SGM teens. Teaching SGM teens about links between minority stress and substance use, and offering adaptive coping skills (e.g., cognitive restructuring)³³ may help indirectly reduce their reliance on smoking/vaping as stress reduction. Antitobacco campaigns for SGM teens should include resources that can both address SGM identity-related stress and smoking/vaping cessation (e.g., adolescent-friendly community organizations).

Social incentives were also frequently cited as motivations for smoking/vaping. Many youth reported casual smoking/vaping when in a social gathering. Research has shown that heterosexual teens,^34,35 and SGM teens³⁶ and adults³⁷ tend to not see themselves as “smokers” when they smoke/vape socially. However, even casual smoking/vaping may have a negative impact on teens' health and can contribute to elevated risk of cardiovascular disease and cancer.^38,39 Given that most participants were acutely aware of the negative health consequences of smoking/vaping and believed that campaigns focused on such consequences seemed irrelevant, future antitobacco campaigns should avoid rehashing this information and focus on other types of content (e.g., addressing social motivations for smoking/vaping). The prominent role of peer influence on SGM teens' smoking/vaping behaviors⁴⁰ and the successful use of peer-led smoking interventions among heterosexual teens⁴¹ suggest that future antitobacco campaigns may include peer testimonials or promote peer-guided cessation to reduce SGM teens' smoking/vaping.

Participants were aware of the health risks from smoking/vaping. Although this finding is promising on the surface, the fact that most teens perceived extant antitobacco campaigns as ineffective indicates that simply informing teens of health risks may not change behaviors. This is consistent with the Information-Motivation-Behavioral Skills Model in that information must be coupled with self-efficacy, motivation for, and social norms toward behavior change.⁴² Echoing research on adults,⁴³ teens reported smoking/vaping to manage daily stress despite awareness of its negative consequences. Smoking/vaping may confer a sense of control over the stressors in teens' lives (e.g., school, relationships to minority stressors),⁴⁴ and acute distress may outweigh more distal physical health concerns.

Participants commented on the benefits/drawbacks of antitobacco campaigns. Although nonsmokers said that such campaigns reinforced their decision not to smoke/vape, most participants considered such campaigns unhelpful. Teens remarked that antitobacco campaigns are “uninteresting,” implying practical implications for future campaign design. First, teens' feedback may be addressed by a youth-centric graphic design, as well as including teenage models and testimonials from SGM teens to facilitate relatability. Portraying teens in their daily lives (e.g., in a friend group) may also promote campaigns' relatability to their target audience and address norms.

Changes in campaign implementation may also be warranted to better reach teens. Instead of traditional delivery methods (e.g., television advertisements), designers could promote these campaigns on social media spaces frequented by teens. All of these considerations assume that the campaign content needs to address teens' underlying motivations to smoke/vape. Hence, involving adolescents in campaign development may ensure that messaging resonates with SGM teens. Finally, it was notable that no participants reported difficulty accessing tobacco products, suggesting that structural policies to reduce smoking/vaping (e.g., age limits) are ineffective.

Limitations

This study is not without limitations. First, most participants were cisgender males. A sample with more gender-diverse adolescents and sexual minority girls may have revealed other motivations for smoking/vaping (e.g., gender minority stress). Given that most participants did not smoke/vape, their preferences for antitobacco campaigns might differ from SGM teens who all had experience with smoking/vaping.

Second, most open-ended questions did not ask participants to make a connection between smoking/vaping and their SGM identity; thus, we cannot directly speak to whether teens attributed their smoking/vaping to SGM-related minority stressors, although the association between identity concealment and elevated smoking/vaping suggests some relationship. In addition, we categorized participants' ASMM/GD identity based on their sexual attraction and gender identity because some teens may not have fully developed/understood their sexual identity/behaviors. Indeed, prior research⁴⁵ has shown that attraction may be a better measure than identity for adolescents. However, our study highlighted a possible link between minority stress/resiliency and smoking/vaping. Future research is needed to assess the motivations for smoking/vaping among ASMM/GD.

Third, participants were not provided with background information about antitobacco campaigns and were not asked about specific delivery methods (e.g., websites, digital posters); such granular questions may be useful in narrowing down teens' campaign preferences in the future.

As the parent study focused on sexual health, we asked limited questions on smoking/vaping, precluding us from a deeper understanding of teens' needs for health campaigns. As we have only recently begun to understand smoking/vaping in SGM adolescents, and as e-cigarette use escalates in youth, future studies should continue to understand SGM teens' smoking/vaping experiences and involve them in intervention development.

Conclusion

This study extends the literature by identifying motivations/drawbacks for smoking/vaping among ASMM/GD youth. Antitobacco campaigns should be inclusive of ASMM/GD youth and address social and community reasons to discontinue this behavior, instead of relying on messaging about negative health consequences and focusing on broader populations of youth. Future studies should examine perspectives on antitobacco campaigns among more diverse samples of SGM adolescents and develop antitobacco messages together with SGM teens themselves.

Authors' Contributions

The authors confirm contributions to the article as follows: study conception (A.J.K., D.A.M., J.B., and K.M.); data collection (J.B.) and data analysis/interpretation (J.M., A.J.K., C.O., and K.M.); and article writing/revision (J.M., A.J.K., C.O., D.A.M., J.B., and K.M.). All authors reviewed and approved the article before submission, and agree to be accountable for the scientific accuracy and integrity of this work.

Disclaimer

The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health or the Delaney Family Foundation.

Author Disclosure Statement

No competing financial interests exist.

Funding Information

We thank the Delaney Family Foundation for a grant that supported the data collection of this study (PI: J.B.). During article preparation, A.J.K. was supported by a postdoctoral fellowship funded by the National Center for Advancing Translational Sciences (TL1TR001423).