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. Author manuscript; available in PMC: 2023 Jun 1.
Published in final edited form as: Addict Behav. 2022 Feb 2;129:107265. doi: 10.1016/j.addbeh.2022.107265

Differences between adult sexual minority females and heterosexual females on menthol smoking and other smoking behaviors: Findings from Wave 4 (2016–2018) of the population assessment of tobacco and health study

Sarah J Ehlke a,*, Ollie Ganz b,c, Darla E Kendzor a,d, Amy M Cohn a,e
PMCID: PMC9673077  NIHMSID: NIHMS1849737  PMID: 35139462

Abstract

Background:

Sexual minority females have higher rates of cigarette smoking than heterosexual females. Additionally, menthol cigarette use disproportionately impacts minority smokers, including sexual minority individuals. This study examined differences between sexual minority and heterosexual females on several smoking variables, including initiation with a menthol cigarette, and past 30-day cigarette and menthol cigarette use.

Methods:

Participants were female ever smokers (N = 11,576; n = 1,474, 12.7% sexual minority) who completed Wave 4 of the Population Assessment of Tobacco and Health Survey. Participants reported on the age they began smoking regularly (≤18 years old, 18–24, >25), whether they initiated with a menthol cigarette, past 30-day cigarette smoking and menthol cigarette use, cigarettes smoked per day (≤10, 11–20, >20), cigarette dependence (smoke ≤ 5 min of waking or > 5 min of waking), and whether they were a current (someday/every day) or former (no past year/current use) established smoker (≥100 lifetime cigarettes), or an experimental smoker (<100 lifetime cigarettes). Chi-square and multivariable logistic regression analyses examined differences between sexual minority females and heterosexual females on smoking variables.

Results:

Sexual minority female smokers began smoking regularly at an earlier age and smoked fewer cigarettes per day than heterosexual females. Sexual minority females were more likely to initiate smoking with a menthol cigarette (aOR = 1.27), report past 30-day smoking (aOR = 1.36) and menthol cigarette use (aOR = 1.24) compared to heterosexual females. There were no differences on cigarette dependence.

Conclusions:

Given the high rates of initiation and current menthol smoking, policies to regulate menthol may decrease smoking disparities for sexual minority females.

Keywords: Sexual minority females, Cigarette smoking, Menthol, Tobacco, Smoking initiation, PATH

1. Introduction

Sexual minority women (e.g., lesbian, bisexual) are more likely to smoke cigarettes than heterosexual women (see Li, Berg, Weber, Vu, Nguyen, Haardörfer, Windle, Goodman, & Escoffery, 2020 for a review). The high rates of cigarette use among sexual minority females are alarming given the negative health consequences of smoking (West, 2017). Despite a decrease in cigarette consumption among adults in the United States, the majority of this decline has been for nonmenthol rather than menthol cigarette use (Delnevo, Giovenco, & Villanti, 2020b), which is the only flavor legally available in cigarettes (Prevention & Act, 1256, 2009). This slower decline in menthol smoking may be due to its minty, soothing, and cooling properties that impart positive sensations in the mouth and throat, enhancing the appeal and the perceived ease of smoking (Ahijevych & Garrett, 2010; Cohn et al., 2020; Cohn, Rose, D’Silva, & Villanti, 2019a). Plausibly, menthol cigarettes contribute to the higher smoking rates among sexual minority females. In fact, one study using data from the National Adult Tobacco Survey found that 45.1% of sexual minority women currently smoke menthol cigarettes, which was higher than that for heterosexual women (34.4%) (Johnson et al., 2016). Additionally, recent findings from the National Survey of Drug Use and Health revealed that among past 30-day smokers, 50.9% of lesbian and 54.0% of bisexual females used menthol cigarettes, compared to 42.6% of heterosexual females (Ganz & Delnevo, 2021).

Perhaps there are factors unique to menthol smoking among sexual minority females, which could be targeted in future prevention messaging or interventions. The current study used data from Wave 4 of the Population Assessment of Tobacco and Health (PATH) Study to examine differences between sexual minority and heterosexual females on initiation with a menthol cigarette, past 30-day cigarette smoking, and past 30-day use of menthol cigarettes. Differences between sexual minority and heterosexual females on the age at initiation of regular cigarette use, cigarettes smoked per day, and nicotine dependence were also examined.

2. Methods

2.1. Participants and procedures

The PATH Study is a nationally representative, longitudinal cohort study of tobacco use risk factors and behaviors among non-institutionalized individuals in the U.S. who are aged 12 and older. The current study used data from Wave 4 of the adult (ages 18 +) public use data file (N = 33,822) (see prior research for details on the study design; Hyland et al., 2017; Inter-university Consortium for Political and Social Research, 2019). In Wave 4, the original longitudinal sample was supplemented with a probability-based refreshment sample to account for attrition. Demographic information, including sex, sexual identity, race, ethnicity and annual household income was collected. To assess sex, participants were asked “What is your sex” with response options male, female, don’t know, and refused. To assess sexual identity, participants were asked “Do you think of yourself as” (a) gay/lesbian or gay, (b) straight, that is not gay or straight that is, not lesbian or gay, (c) bisexual, or (d) something else. The analytic sample for the current study (n = 11,576) included adult female ever cigarette smokers who completed the Wave 4 survey and did not having missing data regarding sexual identity.

2.2. Materials

At each wave, participants were asked if they had ever smoked cigarettes fairly regularly. Those who endorsed smoking fairly regularly were asked, “How old were you when you first started smoking cigarettes fairly regularly?” For the current study, responses for the age a person began smoking fairly regularly were grouped as follows: <18 years old, 18–24, and 25 years or older. For ease of interpretation, henceforth we refer to fairly regular use as regular use. Participants were also asked, “In the past 30 days, have you smoked a cigarette, even one or two puffs?” (0 = no, 1 = yes). Those who reported some day and every day smoking reported the average number of cigarettes smoked per day, which were categorized as ≤ 10, 11–20, and > 20 cigarettes per day, similar to prior research (Kaplan, Alrumaih, Breland, Eissenberg, & Cohen, 2020). Those who reported initiating smoking since the prior wave (or ever smokers at Wave 1) were asked whether they started smoking with cigarettes flavored to taste like menthol or mint (0 = no, nonmenthol, 1 = yes, menthol). Additionally, participants who reported smoking in the past 30-days were asked “In the past 30 days, were any of the cigarettes you smoked flavored to taste like menthol or mint?” (0 = no, 1 = yes). Those who selected “I don’t know” for either menthol variable were coded as missing (initiation: n = 292; past 30-days: n = 114). Participants also reported the amount of time until they had their first cigarette after waking. This variable was dichotomized for analyses (0=≤5 min and 1=>5 min) which is similar to prior studies (Cohn, Zhou, Cha, Perreras, & Graham, 2019b; Neisler et al., 2018). Current (reported using cigarettes somedays or every day) and former (did not report smoking in the past year or no current smoking) established (reported smoking ≥ 100 cigarettes in their lifetime) and experimental (reported smoking < 100 cigarettes in their lifetime) cigarette smokers were also identified. Data from prior waves (i.e., Waves 1–3) were pulled into the current dataset for the longitudinal cohort when applicable (i.e., age of regular cigarette use, initiation with menthol).

2.3. Data analysis

Weighted chi-square analyses examined differences between sexual minority females and heterosexual females on demographic and smoking variables (age first used cigarettes regularly, initiation with a menthol cigarette, past 30-day cigarette use, cigarettes smoked per day, past 30-day menthol cigarette use, and cigarette dependence). Weighted multivariable logistic regression analyses were conducted for each of the outcome variables of interest (initiation with a menthol cigarette, past 30-day cigarette use, and past 30-day menthol cigarette use). Sexual identity (sexual minority female vs. heterosexual female) was used as the predictor variable. Age, race, ethnicity, and income were examined as covariates for multivariable logistic regression analyses. Only covariates significantly associated with the outcome variable when all variables were included were retained in the final models for parsimony. Data were weighted (single wave, cross-sectional weights) to be nationally representative and to adjust for non-response and over sampling. Replicate weights (calculated using Fay’s variant of balanced repeated replication) were used to calculate standard errors. Variance estimation procedures were used to account for stratification and clustering utilized in sampling.

3. Results

As shown in Table 1, approximately 12.7% of the sample identified as a sexual minority female. Chi-square analyses revealed that a greater proportion of sexual minority female smokers were younger (18–24: 25.62%, p < .001), Black (15.21%, p < .001), Hispanic/Latina/Spanish origin (18.37%, p<.001), had lower educational attainment (<high school: 12.46%, p<.001), and lower income (<$10,000: 24.01%, p<.001), compared to heterosexual female smokers (18–24: 6.97%; Black: 10.93%; Hispanic/Latina/Spanish: 12.43%; <high school: 9.31%; <$10,000: 12.45%). Additionally, sexual minority females were more likely to report: regular cigarette smoking at an earlier age (<18: 58.21%, p=.002), initiating smoking with a menthol cigarette (50.80%, p<.001), past 30-day cigarette smoking (48.38%, p<.001), smoking fewer cigarettes per day (≤10: 67.37%, p=.029), and past 30-day menthol cigarette use (56.42%, p<.001), compared to heterosexual female smokers (regular use<18: 48.93%; initiation with menthol cigarette: 38.67%; past 30-day cigarette use: 28.61%; ≤10 cigarettes per day: 62.16%; past 30-day menthol cigarette use: 43.55%). Sexual minority females were also more likely to be current established cigarette smokers (39.50%, p<.001) than heterosexual females (24.17%). Further, sexual minority females were less likely to be current experimental cigarette smokers (1.67%, p<.001) and former established cigarette smokers (27.61%, p<.001), compared to heterosexual females (current experimental: 4.76%; former established: 40.65%). There were no differences between sexual minority and heterosexual females on cigarette dependence (p=.295) and former experimental cigarette smoker status (p=.141).

Table 1.

Weighted Demographic and Smoking Characteristics of Sexual Minority and Heterosexual Females.

Total Sample of Female Ever Smokers N = 11,576 Sexual Minority Ever Smokers n = 1,474 Heterosexual Ever Smokers n = 10,102 p
Demographic Variables % (95% CI) % (95% CI) % (95% CI)
Agea (n = 11,575) <0.001
18–24 years old 8.35 (8.03, 8.69) 25.62 (23.53, 27.82) 6.97 (6.65, 7.29)
25–34 years old 15.73 (14.94, 16.56) 30.01 (26.67, 33.58) 14.59 (13.74, 15.47)
35–44 years old 16.19 (15.39, 17.01) 18.40 (15.27, 22.00) 16.01 (15.15, 16.90)
45–54 years old 18.08 (17.14, 19.06) 16.00 (12.71, 19.93) 18.24 (17.28, 19.26)
55 to 64 years old 19.96 (18.75, 21.23) 6.92 (4.99, 9.53) 21.01 (19.74, 22.35)
65 years or older 21.68 (20.73, 22.67) 3.06 (1.65, 5.58) 23.18 (22.12, 24.28)
Racea (n = 11,576) <0.001
White 81.24 (80.27, 82.17) 74.41 (70.94, 77.60) 81.79 (80.78, 82.75)
Black 11.25 (10.71, 11.81) 15.21 (12.71, 18.10) 10.93 (10.33, 11.56)
Other 7.51 (6.77, 8.32) 10.38 (8.77, 12.25) 7.28 (6.52, 8.13)
Hispanic/Latina/Spanish origina (n = 11,576) 12.87 (12.20, 13.57) 18.37 (15.31, 21.88) 12.43 (11.76, 13.12) <0.001
Educationa (n = 11,550) <0.001
< High school 9.55 (8.82, 10.32) 12.46 (10.24, 15.09) 9.31 (8.59, 10.09)
GED 5.12 (4.62, 5.68) 6.49 (5.14, 8.15) 5.01 (4.49, 5.59)
High school graduate 22.80 (21.79, 23.84) 22.09 (19.09, 25.43) 22.85 (21.74, 24.00)
Some college or Associates degree 33.07 (32.11, 34.04) 36.82 (33.22, 40.58) 32.77 (31.80, 33.76)
Bachelor’s or advanced degree 29.46 (28.60, 30.34) 22.13 (19.10, 25.50) 30.05 (29.15, 30.97)
Incomea (n = 10,980) <0.001
< $10,000 13.33 (12.48, 14.23) 24.01 (20.72, 27.63) 12.45 (11.54, 13.43)
$10,000–$24,999 20.75 (19.64, 21.91) 26.41 (23.31, 29.75) 20.28 (19.12, 21.50)
$25,000–$49,999 21.28 (20.19, 22.42) 21.48 (18.53, 24.75) 21.27 (20.12, 22.47)
$50,000–$99,999 25.51 (24.26, 26.81) 17.21 (14.28, 20.60) 26.20 (24.83, 27.61)
$100,000 or higher 19.20 (17.92, 20.38) 10.90 (8.34, 14.12) 19.80 (18.53, 21.13)
Smoking Variables
Age used cigarettes regularlyb (n = 6,397) 0.002
< 18 years old 49.70 (47.73, 51.67) 58.21 (52.89, 63.36) 48.93 (46.84, 51.03)
18–24 years old 42.09 (40.17, 44.04) 36.46 (31.74, 41.77) 42.60 (40.55, 44.67)
25 and older 8.21 (7.14, 9.42) 5.32 (3.57, 7.88) 8.47 (7.33, 9.77)
Initiated with menthol cigarettea (n = 10,559) 39.53 (38.15, 40.93) 50.80 (46.55, 55.04) 38.67 (37.21, 40.16) <0.001
Past 30-day cigarette usea (n = 11,573) 30.08 (29.06, 31.12) 48.38 (44.46, 52.33) 28.61 (27.56, 29.67) <0.001
Cigarettes per daya (n = 5,616) 0.029
≤ 10 62.79 (61.18, 70.71) 67.37 (63.85, 70.71) 62.16 (60.44, 63.85)
11–20 31.33 (29.93, 32.76) 26.76 (23.48, 30.32) 31.96 (30.43, 33.54)
> 20 5.88 (5.31, 6.50) 5.87 (4.26, 8.04) 5.88 (5.26, 6.56)
Past 30-day menthol cigarette usec (n = 5,279) 45.11 (43.48, 46.75) 56.42 (53.01, 59.76) 43.55 (41.77, 45.35) <0.001
Cigarette dependencea (n = 5,831) 0.295
First cigarette ≤ 5 min after waking 25.58 (24.21, 26.99) 23.77 (20.38, 27.53) 25.82 (24.39, 27.31)
First cigarette > 5 min after waking 74.42 (73.01, 75.79) 76.23 (72.47, 79.62) 74.18 (72.69, 75.61)
Current, established cigarette smoker (n = 11,568) 25.31 (24.40, 26.24) 39.50 (36.04, 43.06) 24.17 (23.22, 25.14) <0.001
Current, experimental cigarette smoker (n = 11,570) 1.90 (1.67, 2.16) 1.67 (1.45, 1.93) 4.76 (3.68, 6.13) <0.001
Former established cigarette smoker (n = 10, 575) 39.57 (38.10, 41.07) 27.61 (23.60, 32.01) 40.65 (39.03, 42.29) <0.001
Former experimental cigarette smoker (n = 10, 577) 28.14 (26.70, 29.63) 25.02 (21.11, 29.39) 28.42 (26.90, 30.00) 0.141
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Note. Analyses included weighted estimates. Current established cigarette smokers were those who reported smoking ≥ 100 cigarettes in their lifetime and also reported currently using cigarettes somedays or every day. Current experimental cigarette smokers were those who have smoked < 100 cigarettes in their lifetime, but reported currently using cigarettes somedays or every day. Former established cigarette smokers were those who smoked ≥ 100 cigarettes in their lifetime and did not report smoking in the past year or no current smoking. Former experimental cigarette smokers were those who have smoked < 100 cigarettes in their lifetime and did not report smoking in the past year or no current smoking.

a

= asked of ever smokers.

b

= asked of ever smokers who reported ever smoking fairly regularly.

c

= asked of past 30-day smokers.

Table 2 shows results from multivariable logistic regression analyses. Controlling for relevant covariates, among those who reported ever smoking, sexual minority females were more likely than heterosexual females to report initiating with a menthol cigarette (aOR = 1.27, 95% CI: 1.05,1.54) and past 30-day smoking (aOR = 1.36, 95%CI: 1.14,1.62). Among past 30-day smokers, sexual minority females were more likely than heterosexual females to report using menthol cigarettes (aOR = 1.24, 95%CI: 1.01,1.51).

Table 2.

Weighted Multivariate Logistic Regression Models of the Association between Sexual Identify and Initiation with a Menthol Cigarette, Past 30-day Cigarette Smoking, and Past 30-Day Menthol Cigarette Smoking.

Initiation with Menthol Cigarettea Past 30-Day Cigarette Usea Past 30-Day Menthol Cigarette Useb
aOR (95% CI) aOR (95% CI) aOR (95% CI)
Sexual identity
Straight Reference Reference Reference
Lesbian/gay/bisexual 1.27 (1.05, 1.54) 1.36 (1.14, 1.62) 1.24 (1.01, 1.51)
Age
18–24 Reference Reference Reference
25–34 0.88 (0.76, 1.02) 1.21 (1.06, 1.37) 0.91 (0.75, 1.10)
35–44 0.58 (0.48, 0.69) 1.21 (1.03, 1.43) 0.61 (0.47, 0.79)
45–54 0.67 (0.55, 0.80) 0.99 (0.84, 1.16) 0.37 (0.30, 0.47)
55–64 0.63 (0.54, 0.74) 0.64 (0.54, 0.76) 0.44 (0.35, 0.56)
65 or older 0.45 (0.37, 0.55) 0.22 (0.18, 0.27) 0.36 (0.25, 0.52)
Race
White Reference – Reference
Black 2.89 (2.36, 3.55) – 4.15 (3.24, 5.31)
Other 1.19 (0.95, 1.50) – 1.23 (0.97, 1.55)
Ethnicity
Non-Hispanic Reference Reference Reference
Hispanic 1.49 (1.25, 1.78) 0.52 (0.44, 0.61) 1.57 (1.22, 2.02)
Household annual income
<$10,000 – Reference –
$10,000–$24,999 – 0.58 (0.50, 0.68) –
$25,000–$49,999 – 0.38 (0.32, 0.45) –
$50,000–$99,999 – 0.20 (0.17, 0.24) –
$100,000 or more – 0.09 (0.07, 0.12) –
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Note. Analyses included weighted estimates. aOR = adjusted odds ratio; CI = confidence interval. Only covariates significantly associated with the outcome variable were retained for the analyses. “-“ indicates variable not retained in final model. Items in bold are significantly different at p<.05.

a

= asked of ever smokers.

b

= asked of past 30-day smokers.

4. Discussion

This study used a large nationally representative sample to examine differences in smoking characteristics, including menthol cigarette use and initiation, among sexual minority and heterosexual female adult ever smokers. Over 12% of participants identified as a sexual minority, which is higher than rates in the U.S. population of sexual and gender minority individuals (6.4%; Jones, 2021). This may be attributed to the oversampling of tobacco users for the PATH Study (Hyland et al., 2017) and the higher tobacco use rates among sexual minority adults (Li et al., 2020). Sexual minority females in the current sample were also younger than heterosexual women which is consistent with population trends (Jones, 2021), and may provide one explanation for why they were less likely to be former smokers. That is, they may have been smoking for fewer years. Consistent with prior research, the current study revealed that sexual minority females were more likely to be current smokers (Hoffman, Delahanty, Johnson, & Zhao, 2018; Schuler & Collins, 2020) and to report past 30-day menthol cigarette use (Fallin, Goodin, & King, 2015; Ganz & Delnevo, 2021; Johnson et al., 2016), compared to heterosexual females. Importantly, these findings remained significant even when controlling for covariates that are commonly associated with menthol smoking such as race and ethnicity (Cohn, Johnson, Hair, Rath, & Villanti, 2016; Delnevo, Ganz, & Goodwin, 2020a; Weinberger et al., 2019). The higher prevalence of smoking among sexual minority females could be a result of targeted tobacco industry marketing to the sexual minority community (Dilley, Spigner, Boysun, Dent, & Pizacani, 2008; Smith & Malone, 2003); however, there is an absence of research on targeted marketing of menthol cigarettes among sexual minorities. Additionally, sexual minority females may experience minority stressors related to their sexual identity (Meyer, 2003). Consequently, they may use cigarettes to cope with these minority stressors.

This was the first study to find that sexual minority female smokers are more likely to initiate with a menthol cigarette compared with heterosexual females. Initiating with a menthol cigarette is associated with progression to regular smoking, compared to initiating with a nonmenthol cigarette (Villanti, Collins, Niaura, Gagosian, & Abrams, 2017). Our findings also revealed that sexual minority females began smoking regularly at an earlier age than heterosexual females. A possible explanation for the earlier progression to regular cigarette use could be attributed to peer influence. Qualitative research among sexual minority women revealed that smoking is perceived as an ingrained part of the sexual and gender minority culture (Youatt, Johns, Pingel, Soler, & Bauermeister, 2015). Perhaps sexual minority females begin smoking to form social connections with other sexual minority individuals as a way to mitigate the psychological distress from experiencing sexual minority stressors. The positive sensory characteristics of menthol, coupled with the social norms of smoking within the sexual minority community and minority stress experiences may increase the likelihood of progression to regular smoking among sexual minority females.

It is worth noting that sexual minority females in the current analysis reported lower overall smoking intensity (i.e., smoked fewer cigarettes per day) compared to heterosexual females. Furthermore, there were no differences in cigarette dependence. The fact that sexual minority females had similar levels of cigarette dependence, even though they were more likely to be menthol smokers and smoked fewer cigarettes per day, further underscores the notion that menthol may be linked to greater nicotine ingestion (Hymowitz, Mouton, & Edkholdt, 1995; Jarvik, Tashkin, Caskey, McCarthy, & Rosenblatt, 1994; Wickham, 2015). Sexual minority females may smoke their cigarettes more intensely or for longer periods of time than heterosexual females. However, to date, no laboratory studies have been conducted to examine differences in smoking topography (e.g., puff volume, puff duration) among sexual minority and heterosexual females.

The Food and Drug Administration recently announced it intends to ban menthol flavoring in cigarettes (Kaplan, 2021) which may positively impact public health, particularly by decreasing disparities in cigarette smoking among vulnerable groups. However, even with a ban on menthol cigarettes, it will be important for comprehensive terminology to be included in the legislation to prevent menthol cigarettes from being marketed and sold under a different descriptor. Also, additional intervention support (e.g., nicotine replacement therapy, cessation counseling) that is free and easily accessed for sexual minority females, and other populations with disproportionately high rates of menthol cigarette smoking, will be important under a menthol ban. Without targeted cessation support, current menthol smokers may use other tobacco products as a substitute (Kingsbury et al., 2020; O’Connor, Bansal-Travers, Carter, & Cummings, 2012) which may negate any positive effects of the menthol ban. Further, sexual minority females were less likely than heterosexual females to be former smokers suggesting a particular challenge for smoking cessation among this group of adults, possibly due to their high use of menthol cigarettes. Menthol smoking has been associated with greater nicotine dependence (Villanti et al., 2017), a factor that negatively impacts successful cessation and likelihood of being a former smoker. Because sexual minority females were more likely than heterosexual females to initiate smoking with a menthol cigarette, a menthol cigarette ban could also help deter uptake among those who have not yet tried cigarettes, but who may be interested in using.

This study had several limitations. Due to restrictions with the public use data file, analyses between subgroups of sexual minority females (i. e., lesbian vs. bisexual) were not examined. Participants were primarily White, limiting the ability to examine results from an intersectionality approach (e.g., sexual minority females of color). While we proposed that minority stress, targeted tobacco company marketing of menthol cigarettes, and subjective response to smoking may be mechanisms implicated in the association of menthol use among sexual minority females, these factors were not examined in the current study because these items are not queried in the PATH Survey.

Even after controlling for robust correlates of menthol use (e.g., race) sexual minority status still emerged as a significant correlate of menthol initiation and past 30-day menthol smoking. Proposed regulations on menthol flavoring could improve the overall health outcomes of sexual minority females. Further, cessation programs specific for sexual minority females should be developed to reduce tobacco use rates among this high-risk group.

Footnotes

Author CRediT Statement

Sarah J. Ehlke: Conceptualization, Writing – original draft, Writing – review & editing. Ollie Ganz: Conceptualization, Formal analysis, Writing – review & editing. Darla E. Kendzor: Conceptualization, Writing – review & editing. Amy M. Cohn: Conceptualization, Writing – review & editing.

Declaration of Competing Interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

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