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A systematic review of the aetiology of tobacco disparities for sexual minorities
  1. John Blosnich1,
  2. Joseph G L Lee2,
  3. Kimberly Horn3
  1. 1Department of Psychiatry, University of Rochester, Rochester, New York, USA
  2. 2Department of Health Behavior & Health Education, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
  3. 3Department of Community Medicine, West Virginia University, Morgantown, West Virginia, USA
  1. Correspondence to Dr John Blosnich, Department of Psychiatry, University of Rochester, 300 Crittenden Blvd. Rochester, NY 14642, USA; john_blosnich{at}urmc.rochester.edu

Abstract

Objective To conduct a systematic review of the literature examining risk factors/correlates of cigarette smoking among lesbian, gay and bisexual (ie, sexual minority) populations.

Methods Sets of terms relevant to sexual minority populations and cigarette smoking were used in a simultaneous search of 10 databases through EBSCOhost. The search was limited to the peer-reviewed literature up to January 2011, using no geographic or language limits. For inclusion, the paper was required to: (1) have been written in English, (2) have sexual minorities (defined by either attraction, behaviour, or identity) included in the study population and (3) have examined some form of magnitude of association for risk factors/correlates of any definition of cigarette smoking. A total of 386 abstracts were reviewed independently, with 26 papers meeting all inclusion criteria. Abstracts were reviewed and coded independently by authors JB and JGLL using nine codes derived from the inclusion/exclusion criteria.

Results Studies used various measures of sexual orientation and of smoking. Risk factors that could be considered unique to sexual minorities included internalised homophobia and reactions to disclosure of sexual orientation. Some studies also indicated common smoking risk factors experienced at higher rates among sexual minorities, including stress, depression, alcohol use and victimisation.

Conclusions This review identified risks that were associated with sexual minority status and common to the general population but experienced at potentially higher rates by sexual minorities. Government and foundation funds should be directed towards research on the origins of this disparity.

  • Disparities
  • priority/special populations
  • advocacy
  • public policy
  • prevention
  • cessation
  • youth
  • young adults
  • adolescent

http://dx.doi.org/10.1136/tobaccocontrol-2011-050181

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    Introduction

    Cigarette smoking remains a major public health priority, contributing to over 10 million premature deaths since the US Surgeon General first published the hazards of smoking over 50 years ago.1 Additionally, the costs from smoking due to healthcare expenditures and productivity losses reach nearly US$200 billion annually.2 Evidence is unequivocal that the burden of tobacco-related morbidity and mortality is not shared equally across different population groups. These include changes in risk for smoking by geography, gender, poverty and racial/ethnic identity. Recently, evidence has emerged that there are also significant disparities by sexual orientation, at least in the USA.3 The risk factors driving this disparity among sexual minorities remain largely unknown.

    Although studies on smoking among lesbian, gay and bisexual (ie, sexual minority) populations first identified inequalities in smoking prevalence through convenience samples,4–12 a growing number of probability-based studies confirm the disparity.13–24 These inequalities appear to exist internationally, albeit with limited research, with studies from around the world, including Australia,25 Mexico,26 Switzerland,27 Taiwan,28 Canada,29 ,30 and China.31 Some Irish32 and Canadian33 studies, however, show no evidence of an inequality in smoking prevalence, suggesting the need for confirmatory studies and additional efforts to identify the causes of health equality. Nonetheless, these studies construct a narrative through various methodologies and geography across time to show that sexual minority populations have 1.5 to 2 times the odds of smoking as their heterosexual peers.3

    While the ability to gauge the damage of cigarette smoking to sexual minority health is hampered by the paucity of morbidity and mortality data containing sexual minority measures, a few studies have found that disproportionate prevalence of smoking is associated with correspondingly disproportionate odds of illness. Blosnich and colleagues found that a sample of sexual minority college students had higher prevalence of acute respiratory illnesses (eg, bronchitis, sinus infection, strep throat) than their heterosexual peers, and that smoking mediated some of the association between sexual orientation and respiratory outcomes.34 Using data from the National Health Interview Survey, Heck and Jacobson found that respondents in same-sex relationships had significantly higher prevalence of current smoking, men in same-sex relationships had increased odds of ever having a diagnosis of asthma and women in same-sex relationships had increased odds of current asthma diagnoses.35 Additionally, Case et al suggested that lesbians may have increased risk of cardiovascular disease due to a constellation of elevated risk factors, including smoking.6

    The demonstration of high smoking prevalence and the potential concomitant health effects has led to burgeoning efforts to address this disparity. Most recently, the Institute of Medicine issued a consensus report confirming deficits in knowledge about sexual minority health and urging sexual and gender minority demographics be collected in federally-funded surveillance.36 Specific to tobacco use, the American Lung Association published a special lesbian, gay, bisexual and transgender (LGBT) report in their Disparities in Lung Health Series, recommending targeted anti-smoking messages as well as interventions sensitive to sexual minority populations.37 However, interventions with sexual minorities remain relatively scant,38 ,39 and the reasons for the disparity are not fully understood.

    While this systematic review focuses on the synthesis of empirical results and not a synthesis of theories, frameworks, or models applied to sexual minority smoking, there is a common theoretical underpinning to much of sexual minority health disparities research. The minority stress model, prominently used as a guiding conceptual framework for the Institute of Medicine report,36 posits that negative experiences (eg, discrimination, stigma, violence victimisation) and hegemonic devaluation endured by a minority group contributes to poor mental health.40 ,41 More specifically, minority stressors differ from general stressors, in three principal ways: (1) they are unique in that they increase stress above general, common stressors experienced by the average person; (2) they are chronic in that they stem from cultural and social paradigms that largely stay intact, even in spite of advancements of minorities (eg, the Civil Rights Act was passed in 1964, yet racism persists); and (3) they are socially based since they are rooted in culturally constructed conventions, as opposed to other stressors that are at the personal level (eg, biological or genetic stressors).42 In addition to associations between minority stress and mental health outcomes such as distress,41 depression,43 anxiety,44 studies document relationships between minority stress and increased health risk behaviours, including smoking.26 ,45 ,46

    In addition to theoretical frameworks of enhanced individual-level risk, sexual minority persons may experience community-level risk factors in the forms of targeted tobacco industry advertising and the reliance on gay bars as safe spaces for socialising. There is robust evidence, through independent research47–49 and tobacco industry-authored documents,50 ,51 that sexual minority populations have been specifically marketed to by tobacco companies. Additionally, gay bars are steeped in LGBT history as places of advocacy and socialisation within a safe space.52 Unfortunately, the positive aspects of the gay bar as an institution also come with some risks inherent to many bar settings, such as smoking and exposure to environmental tobacco smoke. It is unclear whether there is empirical evidence examining if either socialisation at bars or targeted marketing bear significantly on the epidemic of tobacco use among sexual minority populations.

    Understanding of mutable risk factors that drive health disparities provides critical information for the design and implementation of interventions. This is especially the case when there are smoking risk factors that are either (1) unique to sexual minority populations (eg, internalised homophobia) or (2) common among the general population but experienced at disparately higher rates among sexual minorities (eg, depression). More generally, although prevalence studies of smoking are numerous,3 ,53 ,54 the breadth of research about potential reasons for elevated smoking among sexual minorities lacks summary and synthesis. The purpose of this paper was to conduct a systematic review of the peer-reviewed literature, summarising current knowledge about determinants of smoking among sexual minority populations in order to answer the following research question: ‘In the face of demonstrated disparity, what are known, empirically-tested risk factors for smoking among sexual minority persons?’

    Methods

    Systematic reviews have gained prominence across disciplines as a helpful—if not vital—methodology in assessing what is known about specific topics. Pettigrew and Roberts explain that the systematic review differs from a normal literature review in that it ‘strives to comprehensively identify, appraise and synthesise all the relevant studies on a given topic’.55 Specifically, the rigour of systematic reviews make large sums of studies intelligible; summarise consistencies and inconsistencies among studies; and are transparent, comparable and replicable—aspects not typical of ordinary literature reviews. Systematic reviews typically take one of two forms: (1) a narrative approach in summarising the extant literature (eg, research design, findings, biases), or (2) a statistical approach of combination and reanalysis of study findings (ie, meta-analysis).56

    The overall process for this project aligned with general guidelines and suggestions from Petticrew and Roberts for a narrative systematic review,55 which was chosen over a meta-analysis for two principle reasons. First, research with sexual minorities differs substantially from that of different minority groups given the variable ways in which researchers measure sexual minority status: behaviour, attraction and/or identity.57 For instance, a respondent may indicate that she is attracted to women, had a sexual experience with a woman, but does not identify as a lesbian. At best, a researcher who measures all three components of sexual orientation must navigate disparate responses across each category, and at worst, a researcher risks selection bias by measuring only one category. Thus, the variability in operationalising sexual minority status decreases the probability of having enough study samples similarly defined in a way to justify combining them. Second, research with sexual minority populations remains challenged by the limited number of studies available and by wide variations in quality.36 Much of the sexual minority literature has depended on convenience samples,58 and, compared to gender and racial/ethnic minority status, data collection about sexual minority status on population-based studies is limited due to lack of inclusion of sexual orientation measures in all but approximately 12 statewide surveillance systems.59

    To begin, a set of search terms was developed to capture studies relevant to the research question, using Boolean operators, truncation and exact match search criteria. The search term consisted of the following: ((homosexual* OR gay OR ‘sexual minority’ OR ‘sexual minorities’ OR lesbian* OR bisexual* OR queer OR ‘sexual orientation’ OR ‘men who have sex with men’ OR MSM OR ‘women who have sex with women’ OR WSW) AND (tobacco OR smok* OR cigarette OR nicotine)). Using EBSCOhost, a simultaneous search of 10 databases was conducted (Academic Search Elite, Alt HealthWatch, CAB Abstracts 1990–Present, CINAHL with Full Text, Health Source—Consumer Edition, Health Source: Nursing/Academic Edition, MEDLINE, PsycARTICLES, PsycINFO and Social Work Abstracts). Specific search parameters included reviewing only the peer-reviewed literature for articles up to January 2011. No geographic or language limits were used.

    The search results were downloaded to a reference managing software, which facilitated ease of screening for duplicate abstracts and organisation of the final set of abstracts (n=369). Additionally, 17 abstracts that were not in the search results, but potentially met the inclusion criteria were identified by the authors through citations, resulting in a total of 386 abstracts for review.

    For inclusion, the paper must have: (1) been written in English, (2) had sexual minorities (defined by either attraction, behaviour, or identity) as the entire study population or a component of the study population and (3) examined some form of magnitude of association for risk factors/correlates of any definition of cigarette smoking behaviours. Studies were excluded if they only reported differences in smoking prevalence or only discussed theoretical risk factors (ie, did not empirically investigate relationships among variables). Each abstract was reviewed and coded independently by authors JB and JGLL using nine codes derived from the inclusion/exclusion criteria. We also coded for related qualitative work, related commentaries and other reviews or systematic reviews for background information. When codes did not match, coders discussed each abstract to reach agreement of inclusion/exclusion. See figure 1 for results of initial abstract review.

    Figure 1
    Figure 1

    Final inclusion/exclusion of abstracts.

    Initially, 27 studies were flagged for inclusion, and each of the articles was reviewed with a data extraction form to pull key elements of information from the study (eg, measure of sexual minority status, measurement of smoking behaviour, key findings) by a single author (JB). Upon reviewing all of the initial 27 studies, 1 paper focused solely about prevalence differences60 and was excluded (ie, placed in the ‘no magnitude of association’ category), leaving a final analytic sample of 26 studies.

    Results

    The majority of the 26 included studies (61%) used non-probability samples, with fewer (31%) using probability-based sampling (see online table 1). One study used a combined sample that employed probability and non-probability methods,14 and one study used respondent-driven sampling methods involving complex network analysis that mathematically models probability of selection from an initial non-probability sample.61 Of the eight studies that used probability-sampling methods, two of them were based outside the US (Australia25 and Mexico26).

    Sexual orientation is most often conceptualised as having three domains: attraction (to whom a person feels physically/romantically attracted), behaviour (with whom a person engages with sexual activities) and identity (how a person affiliates with a wider community).57 There were variable uses of these measures across the included papers. Only one study measured all three domains, seven measured two domains and the remaining ascertained only one domain (see online table 1). The most used method of defining sexual orientation involved identity (73%), followed by behaviour (42%) and attraction (19%).

    Even more varied than the measures of sexual orientation were the outcome measures of smoking behaviours, which ranged from indicators of lifetime use, to the average number of cigarettes smoked per day, to smoking before age 14, to one study in which the authors did not define how smoking was assessed.62 Moreover, there were many terms and definitions used to discuss smoking status (eg, former smoker, ever smoker, current smoker, early onset of smoking, daily smoker), intensity (eg, number of cigarettes smoked in the past week, number of cigarettes per day in the past 3 months) and frequency (eg, smoking at all in the past 30 days, ever used cigarettes in the past year, smoked at least weekly). Only 1 study21 employed the federal definition of current smoker (ie, smoked at least 100 cigarettes in lifetime and currently smoke everyday or on some days).63

    Sociodemographic and common factors

    Several studies found associations between demographic correlates of smoking that are similar to characteristics identified in the general population, including younger age30 ,64 ,65 and lower educational attainment.8 ,14 ,21 ,31 ,65–67 Other common correlates with smoking were alcohol use14 ,31 ,65 ,68 and depression/depressive symptoms.30 ,65 ,69 One small study using a convenience sample found no associations between income and age with smoking.67

    Victimisation and discrimination factors

    Victimisation and discrimination have been posited to play a role in driving health disparities among sexual minority populations, often as part of the minority stress model. While these negative experiences have been linked to poor mental health outcomes,41 ,70 the evidence regarding smoking is inconclusive. The most consistent findings seem to be with adolescents. Among sexual minority adolescents, Bontempo and D'Augelli found that higher levels of victimisation are associated with smoking intensity.45 While Jun et al reported that exposure to physical or sexual childhood abuse mediated the associations between early onset adolescent smoking and smoking intensity with sexual orientation,71 another study found no association between childhood sexual abuse and cigarette use.72 Findings from a sample of Mexican adolescents showed that victimisation and discrimination mediated the relationships between some smoking behaviours and domains of sexual orientation.26 Finally, Willoughby and colleagues found a direct relationship between victimisation and harassment with smoking intensity.73

    Among adult samples, the evidence for victimisation and discrimination was less clear. Among a representative sample of Minnesotans, discrimination was associated with smoking, but it did not mediate the relationships between sexual orientation and smoking.16 In one sample of men who have sex with men (MSM), men experiencing intimate partner violence were not more likely to smoke than men who did not.74 Interestingly, this finding contrasts with studies showing an association between intimate partner violence victimisation and elevated rates of smoking, however this association has primarily been explored among heterosexual women victims.75–77

    Other factors

    Many studies examined risk factors that are unique to sexual minorities with inconclusive findings. Variables related to internalised homophobia (ie, having a negative self-concept by accepting negative societal beliefs about homosexuality)78 showed that less comfort with one's sexual identity (ie, higher levels of internalised homophobia) was associated with smoking,31 ,46 although one study found no association between them.73 Rosario et al did not find an association between gay-related stress and smoking,72 however, among the same sample, more negative reactions to disclosure of sexual orientation were associated with smoking.64 In contradiction with those findings, Willoughby and colleagues did not find an association between smoking and family rejection.73 An array of risks were examined, from religiosity being protective against smoking among heterosexual adolescents but not sexual minority adolescents,79 to bisexual women having greater odds of smoking for weight control than lesbian women,25 to differential associations of smoking among subcultures of sexual minority populations.67 ,80

    Qualitative, case study and tobacco-document evidence

    Though our criteria limited inclusion of studies to those using empirical analysis to test association/correlation, our systematic review flagged studies using alternative methodologies to explore reasons for smoking or to generate hypotheses about elevated smoking prevalence. These included case studies, tobacco industry document analyses on marketing and qualitative research. Based on interview data with adult lesbians, Gruskin and colleagues reported that major themes of affect, or emotional regulation and stress reduction surfaced and seemed to stem from minority stress and stigma.81 An additional theme of the social aspects of smoking (eg, bonding, ice breaker) also arose from the data. Remafedi interviewed a sample of sexual minority youth and adults who interacted with sexual minority youth, finding somewhat similar themes of stress and social relationships in addition to peer pressure, the need to fit in, having friends who smoked and going to venues where smoking was permitted.82

    Using tobacco industry documents, a number of researchers have identified targeted marketing by the tobacco industry.49–51 ,83 Surveys of the sexual minority press show high visibility of tobacco advertising and positive tobacco-related imagery.47 ,84 Such marketing is likely successful through increased exposure and receptivity to marketing.85 Offen and colleagues used qualitative interviews of sexual minority community leaders, identifying an ambivalence towards the tobacco epidemic.86 Smith and colleagues found similar themes in community focus groups and identified themes of appreciation for industry marketing as it recognises the existence of sexual minority communities.48

    Discussion

    Research examining risk factors and correlates for smoking among sexual minority populations is relatively new with the earliest included study from 1994. Although prevalence studies demonstrate higher rates of smoking among sexual minorities,3 the literature examining the potential reasons for smoking disparities appears discordant and somewhat fragmented in sampling, measuring sexual orientation and smoking, and selection of risk factors. Consequently, the current evidence base constructs an incomplete and challenging glimpse into the aetiology of smoking disparities among sexual minorities.

    However, this systematic review provides the most comprehensive look at the aetiology of such disparities to date and begins to show the outlines of patterns indicating two general sources of the disparity: (1) smoking risk factors unique to sexual minority populations or (2) common smoking risk factors experienced at higher rates among sexual minority populations. Risk factors identified in this review that could be considered unique to sexual minorities include internalised homophobia,46 reactions to disclosure of sexual orientation,87 and identity within sexual minority communities (eg, ‘goth’ identity or presentation of masculinity/femininity).67 ,80 Research conducted after the search time for the present review indicates some evidence for smoking risk based on presentation of masculinity or femininity,88 which is compatible with historical scholarship.89 The included studies also indicate common smoking risk factors experienced at higher rates among sexual minorities, including stress,64 ,72 depression,65 alcohol use,65 victimisation,26 ,45 ,71 and low socioeconomic status.31 ,65–67

    The findings of this review suggest that the minority stress model provides a compelling way of understanding the disparity. However, the aetiology of the disparity in smoking is not fully explained by the minority stress model. Certainly, a number of predictor variables (eg, negative reaction to disclosure of sexual orientation, victimisation and less accepting communities) are fully compatible with the minority stress model. Other theories may be needed to fully account for potential protective effects and other factors. While a full review of alternative theoretical approaches is outside the scope of this review, several examples can illustrate, in very general terms, the potential of other theoretical approaches for new directions in aetiological investigations. Social cognitive theory looks at behaviours learnt from the social environment and their intrapersonal processing90 and is thus relevant for investigating the ways smoking norms are reified and processed in sexual minority communities. Protection motivation theory posits that behaviour change is influenced by appraisals of the health threat, countermeasures and efficacy91; how these are influenced by competing health issues (eg, HIV) and by the accessibility of cessation services remains underinvestigated. These examples and other theoretical approaches to examining the aetiology of the disparity may provide new avenues and previously unmeasured constructs for advancing the field.

    Limited research on resiliency and protective factors

    It is important to note that while the preponderance of literature focused on risk, some findings noted protective characteristics. Several studies from the Add Health study have found that ‘exclusively’ homosexual youth are less likely to smoke than heterosexual youth.18 ,92 ,93 Our review identified very few studies addressing protective factors. Eisenberg and Wechsler reported that the availability of sexual minority resources was associated with less smoking among sexual minority women on college campuses.94 Stall and colleagues noted that healthy behaviours (eg, nutrition and exercise) were protective against smoking among a sample of urban men who have sex with men.14 A study published after our search found that community characteristics such as school-based gay straight alliance student organisations and the political environment are associated with a protective effect.95

    Addressing risks specific to sexual minority communities

    In terms of interventions specific to sexual minority communities, there is currently very little research of sexual minority-specific efforts in the literature.38 ,39 Burkhalter and colleagues reported that intentions to quit among a sample of LGBT smokers were fairly similar to those expressed among smokers in general, and that LGBT-specific stressors (eg, stigma) were not associated with intent to quit,96 although one study found that sexual minority smokers have significantly lower intentions of ever using quitline services.97 Despite a lack of published efficacy trials of tailored programmes, there is some evidence that shows support within the sexual minority community for tailored or culturally sensitive programmes.37 ,98 ,99

    Addressing common tobacco-related risk factors experienced at higher rates by sexual minorities

    Regarding interventions, we are unaware of evidence that population-wide efforts to address smoking are more or less effective among sexual minorities. However, evidence is growing that policies protecting and/or affirming sexual minorities have a protective impact on mental health44 and, in a paper published after our search, are associated with reduced adolescent tobacco initiation among sexual minorities.95 Evidence-based strategies such as tobacco tax increases, advertising limits, integrated mass-media campaigns, point of sale restrictions and tobacco-free places and spaces continue to be important areas of intervention for researchers, practitioners and community leaders to consider. In fact, limited evidence from one study among HIV positive gay men in France suggests tobacco taxes may be more effective for gay men than for other HIV positive groups.62 Caution is necessary, however, as population-wide interventions when implemented without attention to inequality can exacerbate disparities even while improving the health of the population.100

    Although the literature contains many mentions of tobacco industry targeted marketing to LGBT populations,51 ,84 ,86 we did not find any empirical investigations that specifically tested whether targeted marketing explained smoking among sexual minority populations. That said, some studies report that sexual minorities have increased odds of being marketed to85 and exhibiting more receptivity to marketing,48 ,85 both of which have been linked to smoking uptake among adolescents.101

    There was little examination of differential exposure to social spaces where tobacco use may be normative, such as the gay or lesbian bar. Stall and colleagues found that MSM who attend gay bars more frequently had about 60% greater odds in being smokers,14 but Trocki et al noted that bar attendance (and a measure of sensation seeking) mediated the association between sexual minority status and smoking only among women in their sample.102 Qualitative and historical work suggests that the lesbian or gay bar, which has an important historical role in the LGBT civil rights movement,52 may promote smoking as a normative value.103 This also raises questions of whether sexual minorities may experience higher burdens of environmental tobacco smoke exposure and whether clean indoor air regulations may be a particularly effective intervention in limiting exposure to and use of cigarettes among sexual minority populations.

    Recommendations for future research

    In terms of statistical methods, mediating and moderating analyses are two strategies to help demonstrate how other factors explain the relationship between two variables.104 Even though some selected correlates were found to associate with smoking and mediate the relationship between sexual orientation and smoking,26 ,71 ,80 it is noteworthy that, of the studies that used a mediating approach, various other correlates of smoking (eg, familial smoking, sensation seeking, bar attendance) still did not explain the association between sexual orientation and smoking. For instance, while McKirnan and colleagues found that depression mediated smoking among a sample of MSM,65 a different study with a sample of adolescents found that depressive symptoms did not mediate smoking and sexual minority status.69 This discordance could be from artefacts of sampling bias, random chance, measurement error, or use of different survey measures. Regardless, further enquiry needs to replicate and build upon these findings in order to fully identify key factors in the aetiology of smoking disparity. Additionally, lack of significant mediation could stem from omitted variable bias, in that key mediating variables were not included in the model.

    Additionally, there is a need for research using statistical methods that can establish association between correlates and smoking among sexual minorities (eg, mediation, moderation, path analysis, hierarchical linear modelling and stratification by sexual orientation). For analyses that use sexual orientation to explain smoking (ie, use sexual orientation as an independent variable in a mediating/moderating model), there is caution in interpreting results, particularly when mediation or moderation is not achieved. In terms of the science, when mediation/moderation is not established, sexual orientation remains associated with smoking. In terms of the art, we are aware of no theoretical basis for sexual orientation, itself, to cause or confer risk of smoking. Rather, it is likely social environmental variables such as stress and victimisation, which some of the reviewed studies identified, that drive the disparity.

    Furthermore, we suggest several topics requiring future study to assess the issue of smoking among sexual minorities. First, the field is in need of investigations that explicitly test association between marketing exposure and receptivity with smoking behaviours among sexual minorities. Second, there may be cohort effects in prevalence and aetiology of smoking among sexual minorities. Ideally, longitudinal studies are strongly suited to gain evidence of causation, however only two studies used longitudinal data. Third, resiliency (eg, supportive family environment) and protective factors are understudied areas of sexual minority research and may be of key importance since, even though sexual minorities have higher smoking prevalence than heterosexuals, the majority of sexual minority persons do not smoke.95 ,105 Fourth, additional theoretical approaches beyond minority stress may yield new insights. Fifth, limited research shows that racial/ethnic smoking disparities exist within sexual minority populations,106 and additional efforts are needed to explore heterogeneity within sexual minority populations.

    Limitations

    There are several limitations to be considered in light of these findings. Relevant abstracts may have been overlooked due to language bias since the inclusion criteria was limited to articles written in English. Publication bias may have impacted the search itself in that studies finding non-statistically significant associations among risk factors for smoking among sexual minorities may have downplayed, or not published, non-significant findings. We did not search the grey literature and thus may have missed technical reports that were not published. Nor did we rate studies by quality or identify if studies were adequately powered. We did not systematically assess the theoretical framework used by each study or its appropriateness. Finally, a meta-analytic approach would have provided different information (eg, new estimates of associations) in regards to how explanatory variables relate with smoking outcomes across studies, although we judged such an approach to be unfeasible at this time given the variability of study designs and measures.

    Conclusions

    While the burgeoning evidence on aetiology of smoking disparity provides suggestions and directions for further research, it does not provide conclusive evidence on the origins of the tobacco epidemic in sexual minority communities. Data limitations about the US sexual minority population continue to challenge researchers' abilities to better assess the breadth of health and wellness issues among this population.36 The exclusion of sexual orientation and gender identity data in large national surveillance studies remains, in general, a major shortcoming in public health research and, more specifically, a massive impediment to tobacco prevention and control research. Integration into routine surveillance is especially important given the cost of doing independent probability-based sampling to gather sexual minorities is prohibitively high.107 As sexual minority and gender minority health inequity issues gain ground as national health imperatives,108 a major step to address disparities is knowing where disparities exist; a clearly tautological statement, but one that perhaps bears repeating in order to substantiate inclusion of sexual and gender minority-specific information in national health surveillance.

    What this paper adds

    • This review suggests that risk factors contributing to smoking disparities among sexual minority populations can be conceptualised as risk factors uniquely associated with sexual minority status and risk factors common to the general population but experienced at higher rates among sexual minorities.

    • Sexual minority status, itself, is not an independent risk factor for smoking, rather the mutable risk factors for smoking likely are tied to social environmental factors associated with sexual minority status (eg, homophobia).

    • Collection of sexual orientation measures in national health surveillance projects are needed in order to further investigate potential causes for smoking disparities.

    Acknowledgments

    JB thanks his dissertation committee members Robert Anderson, Steven Branstetter, Geri Dino and Cindy Tworek for their comments on previous drafts. Additionally, JB thanks Ilan Meyer for his mentorship through the Fenway Institute.

    References

    1. ↵
      U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion et al . The Health Consequences of Smoking: A Report of the Surgeon General. Washington, DC: US GPO, 2004.
    2. ↵
      1. Adhikari B,
      2. Malarcher A,
      3. Pechacek T
      . Smoking-attributable mortality, years of potential life lost, and productivity losses - United States, 2000-2004. MMWR Morb Mortal Wkly Rep 2008;57:1226–8.
      OpenUrlPubMed
    3. ↵
      1. Lee JG,
      2. Griffin GK,
      3. Melvin CL
      . Tobacco use among sexual minorities in the USA, 1987 to May 2007: a systematic review. Tob Control 2009;18:275–82.
      OpenUrlAbstract/FREE Full Text
    4. ↵
      1. Kelly BC,
      2. Weiser JD,
      3. Parsons JT
      . Smoking and attitudes on smoke-free air laws among club-going young adults. Soc Work Public Health 2009;24:446–53.
      OpenUrlCrossRefPubMedWeb of Science
    5. ↵
      1. Hyde Z,
      2. Comfort J,
      3. McManus A,
      4. et al
      . Alcohol, tobacco and illicit drug use amongst same-sex attracted women: results from the Western Australian Lesbian and Bisexual Women's Health and Well-Being Survey. BMC Public Health 2009;9:317.
      OpenUrlCrossRefPubMed
    6. ↵
      1. Case P,
      2. Austin SB,
      3. Hunter DJ,
      4. et al
      . Sexual orientation, health risk factors, and physical functioning in the Nurses' Health Study II. J Womens Health (Larchmt) 2004;13:1033–47.
      OpenUrlCrossRefPubMed
    7. ↵
      1. Aaron DJ,
      2. Markovic N,
      3. Danielson ME,
      4. et al
      . Behavioral risk factors for disease and preventive health practices among lesbians. Am J Public Health 2001;91:972–5.
      OpenUrlPubMedWeb of Science
    8. ↵
      1. Skinner WF
      . The prevalence and demographic predictors of illicit and licit drug use among lesbians and gay men. Am J Public Health 1994;84:1307–10.
      OpenUrlPubMedWeb of Science
    9. ↵
      1. Herrick AL,
      2. Matthews AK,
      3. Garofalo R
      . Health risk behaviors in an urban sample of young women who have sex with women. J Lesbian Stud 2010;14:80–92.
      OpenUrlCrossRefPubMed
    10. ↵
      1. Remafedi G,
      2. Jurek AM,
      3. Oakes JM
      . Sexual identity and tobacco use in a venue-based sample of adolescents and young adults. Am J Prev Med 2008;35(6 Suppl 1):S463–70.
      OpenUrlCrossRefPubMed
    11. ↵
      1. Rosario M,
      2. Hunter J,
      3. Gwadz M
      . Exploration of substance use among lesbian, gay, and bisexual youth. J Adolesc Res 1997;12:454–76.
      OpenUrlAbstract
    12. ↵
      1. Sanchez JP,
      2. Meacher P,
      3. Beil R,
      4. et al
      . Cigarette smoking and lesbian and bisexual women in the Bronx. J Community Health 2005;30:23–37.
      OpenUrlCrossRefPubMedWeb of Science
    13. ↵
      1. Dilley JA,
      2. Simmons KW,
      3. Boysun MJ,
      4. et al
      . Demonstrating the importance and feasibility of including sexual orientation in public health surveys: health disparities in the Pacific Northwest. Am J Public Health 2010;100:460–7.
      OpenUrlCrossRefPubMedWeb of Science
    14. ↵
      1. Stall RD,
      2. Greenwood GL,
      3. Acree M,
      4. et al
      . Cigarette smoking among gay and bisexual men. Am J Public Health 1999;89:1875–8.
      OpenUrlCrossRefPubMedWeb of Science
    15. ↵
      1. Rhodes SD,
      2. McCoy TP,
      3. Wilkin AM,
      4. et al
      . Behavioral risk disparities in a random sample of self-identifying gay and non-gay male university students. J Homosex 2009;56:1083–100.
      OpenUrlCrossRefPubMedWeb of Science
    16. ↵
      1. Burgess D,
      2. Lee R,
      3. Tran A,
      4. et al
      . Effects of perceived discrimination on mental health and mental health services utilization among gay, lesbian, bisexual and transgender persons. J LGBT Health Res 2007;3:1–14.
      OpenUrlCrossRefPubMed
    17. ↵
      1. Burgard SA,
      2. Cochran SD,
      3. Mays VM
      . Alcohol and tobacco use patterns among heterosexually and homosexually experienced California women. Drug Alcohol Depend 2005;77:61–70.
      OpenUrlCrossRefPubMedWeb of Science
    18. ↵
      1. Easton A,
      2. Jackson K,
      3. Mowery P,
      4. et al
      . Adolescent same-sex and both-sex romantic attractions and relationships: implications for smoking. Am J Public Health 2008;98:462–7.
      OpenUrlCrossRefPubMedWeb of Science
    19. ↵
      1. Diamant AL,
      2. Wold C,
      3. Spritzer K,
      4. et al
      . Health behaviors, health status, and access to and use of health care: a population-based study of lesbian, bisexual, and heterosexual women. Arch Fam Med 2000;9:1043–51.
      OpenUrlCrossRefPubMedWeb of Science
    20. ↵
      1. Gruskin EP,
      2. Greenwood GL,
      3. Matevia M,
      4. et al
      . Disparities in smoking between the lesbian, gay, and bisexual population and the general population in California. Am J Public Health 2007;97:1496–502.
      OpenUrlCrossRefPubMedWeb of Science
    21. ↵
      1. Tang H,
      2. Greenwood GL,
      3. Cowling DW,
      4. et al
      . Cigarette smoking among lesbians, gays, and bisexuals: how serious a problem? (United States). Cancer Causes Control 2004;15:797–803.
      OpenUrlCrossRefPubMedWeb of Science
    22. ↵
      1. Ridner SL,
      2. Frost K,
      3. LaJoie AS
      . Health information and risk behaviors among lesbian, gay, and bisexual college students. J Am Acad Nurse Pract 2006;18:374–8.
      OpenUrlCrossRefPubMedWeb of Science
    23. ↵
      1. Garofalo R,
      2. Wolf R,
      3. Kessel S,
      4. et al
      . The association between health risk behaviors and sexual orientation among a school-based sample of adolescents. Pediatrics 1998;101:895–902.
      OpenUrlAbstract/FREE Full Text
    24. ↵
      1. Conron KJ,
      2. Mimiaga MJ,
      3. Landers SJ
      . A population-based study of sexual orientation identity and gender differences in adult health. Am J Public Health 2010;100:1953–60.
      OpenUrlCrossRefPubMedWeb of Science
    25. ↵
      1. Polimeni AM,
      2. Austin SB,
      3. Kavanagh AM
      . Sexual orientation and weight, body image, and weight control practices among young australian women. J Womens Health (Larchmt) 2009;18:355–62.
      OpenUrlCrossRefPubMedWeb of Science
    26. ↵
      1. Ortiz-Hernandez L,
      2. Tello BL,
      3. Valdes J
      . The association of sexual orientation with self-rated health, and cigarette and alcohol use in Mexican adolescents and youths. Soc Sci Med 2009;69:85–93.
      OpenUrlCrossRefPubMed
    27. ↵
      1. Wang J,
      2. Häusermann M,
      3. Vounatsou P,
      4. et al
      . Health status, behavior, and care utilization in the Geneva Gay Men's Health Survey. Prev Med 2007;44:70–5.
      OpenUrlCrossRefPubMed
    28. ↵
      1. Kuang MF,
      2. Mathy RM,
      3. Carol HM,
      4. et al
      . The Effects of Sexual Orientation, Gender Identity, and Gender Role on the Mental Health of Women in Taiwan's T-Po Lesbian Community. J Psychol 2003;15:163–84.
      OpenUrl
    29. ↵
      1. Steele LS,
      2. Ross LE,
      3. Dobinson C,
      4. et al
      . Women's sexual orientation and health: results from a Canadian population-based survey. Women Health 2009;49:353–67.
      OpenUrlCrossRef
    30. ↵
      1. Lampinen TM,
      2. Bonner SJ,
      3. Rusch M,
      4. et al
      . High prevalence of smoking among urban-dwelling Canadian men who have sex with men. J Urban Health 2006;83:1143–50.
      OpenUrlCrossRefPubMedWeb of Science
    31. ↵
      1. Berg CJ,
      2. Nehl EJ,
      3. Wong FY,
      4. et al
      . Prevalence and correlates of tobacco use among a sample of MSM in Shanghai, China. Nicotine Tob Res 2011;13:22–8.
      OpenUrlAbstract/FREE Full Text
    32. ↵
      1. Kabir Z,
      2. Keogan S,
      3. Clarke V,
      4. et al
      . Smoking profile among the gay and lesbian community in Ireland. Ir J Med Sci 2010;179:423–6.
      OpenUrlCrossRefPubMed
    33. ↵
      1. Brennan DJ,
      2. Ross LE,
      3. Dobinson C,
      4. et al
      . Men's sexual orientation and health in Canada. Can J Public Health 2010;101:255–8.
      OpenUrlPubMedWeb of Science
    34. ↵
      1. Blosnich J,
      2. Jarrett T,
      3. Horn K
      . Disparities in smoking and acute respiratory illnesses among sexual minority young adults. Lung 2010;188:401–7.
      OpenUrlCrossRefPubMedWeb of Science
    35. ↵
      1. Heck JE,
      2. Jacobson JS
      . Asthma diagnosis among individuals in same-sex relationships. J Asthma 2006;43:579–84.
      OpenUrlCrossRefPubMedWeb of Science
    36. ↵
      Institute of Medicine. The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding. Washington, DC: Institute of Medicine, 2011.
    37. ↵
      American Lung Association. Smoking Out a Deadly Threat: Tobacco Use in the LGBT Community. Disparities in Lung Health Series. Washington, DC: American Lung Association, 2010.
    38. ↵
      1. Doolan DM,
      2. Froelicher ES
      . Efficacy of smoking cessation intervention among special populations: review of the literature from 2000 to 2005. Nurs Res 2006;55(4 Suppl):S29–37.
      OpenUrlCrossRefPubMedWeb of Science
    39. ↵
      1. Fiore MC,
      2. Jaen CR,
      3. Baker TB,
      4. et al
      . Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. Rockville, MD: US Dept. of Health and Human Services, Public Health Service, 2008.
    40. ↵
      1. Brooks VR
      . Minority Stress and Lesbian Women. Lexington, MA: Lexington Books, 1981.
    41. ↵
      1. Meyer IH
      . Minority stress and mental health in gay men. J Health Soc Behav 1995;36:38–56.
      OpenUrlCrossRefPubMedWeb of Science
    42. ↵
      1. Meyer IH,
      2. Northridge ME
      . Prejudice and discrimination as social stressors. In: Meyer IH, Northridge ME , eds. The Health of Sexual Minorities: Public Health Perspectives on Lesbian, Gay, Bisexual, and Transgender Populations. New York, NY: Springer Science + Business Media, 2007:242–67.
    43. ↵
      1. Friedman MS,
      2. Marshal MP,
      3. Stall R,
      4. et al
      . Gay-related development, early abuse and adult health outcomes among gay males. AIDS Behav 2008;12:891–902.
      OpenUrlCrossRefPubMedWeb of Science
    44. ↵
      1. Hatzenbuehler ML,
      2. Keyes KM,
      3. Hasin DS
      . State-level policies and psychiatric morbidity in lesbian, gay, and bisexual populations. Am J Public Health 2009;99:2275–81.
      OpenUrlCrossRefPubMedWeb of Science
    45. ↵
      1. Bontempo DE,
      2. D'Augelli AR
      . Effects of at-school victimization and sexual orientation on lesbian, gay, or bisexual youths' health risk behavior. J Adolesc Health 2002;30:364–74.
      OpenUrlCrossRefPubMedWeb of Science
    46. ↵
      1. Amadio DM,
      2. Chung YB
      . Internalized homophobia and substance use among lesbian, gay, and bisexual persons. Journal of Gay and Lesbian Social Services 2004;17:83–101.
      OpenUrlCrossRef
    47. ↵
      1. Smith EA,
      2. Offen N,
      3. Malone RE
      . Pictures worth a thousand words: noncommercial tobacco content in the lesbian, gay, and bisexual press. J Health Commun 2006;11:635–49.
      OpenUrlCrossRefPubMedWeb of Science
    48. ↵
      1. Smith EA,
      2. Thomson K,
      3. Offen N,
      4. et al
      . “If you know you exist, it's just marketing poison”: meanings of tobacco industry targeting in the lesbian, gay, bisexual, and transgender community. Am J Public Health 2008;98:996–1003.
      OpenUrlCrossRefPubMedWeb of Science
    49. ↵
      1. Smith EA,
      2. Malone RE
      . The outing of Philip Morris: advertising tobacco to gay men. Am J Public Health 2003;93:988–93.
      OpenUrlPubMedWeb of Science
    50. ↵
      1. Stevens P,
      2. Carlson LM,
      3. Hinman JM
      . An analysis of tobacco industry marketing to lesbian, gay, bisexual, and transgender (LGBT) populations: strategies for mainstream tobacco control and prevention. Health Promot Pract 2004;5(3 Suppl):129S–34S.
      OpenUrlAbstract/FREE Full Text
    51. ↵
      1. Washington HA
      . Burning Love: big tobacco takes aim at LGBT youths. Am J Public Health 2002;92:1086–95.
      OpenUrlCrossRefPubMedWeb of Science
    52. ↵
      1. Achilles N
      . The development of the homosexual bar as an institution. In: Nardi PM, Schneider BE , eds. Social Perspectives in Lesbian and Gay Studies: A Reader. New York, NY: Routledge, 1998:175–82.
    53. ↵
      1. Ryan H,
      2. Wortley P,
      3. Easton A,
      4. et al
      . Smoking among lesbians, gays, and bisexuals: a review of the literature. Am J Prev Med 2001;21:142–9.
      OpenUrlCrossRefPubMedWeb of Science
    54. ↵
      1. Hughes TL,
      2. Jacobson KM
      . Sexual orientation and women's smoking. Curr Womens Health Rep 2003;3:254–61.
      OpenUrlPubMed
    55. ↵
      1. Petticrew M,
      2. Roberts H
      . Systematic Reviews in the Social Sciences: A Practical Guide. Malden, MA: Wiley-Blackwell, 2006.
    56. ↵
      1. Mulrow CD
      . Rationale for systematic reviews. In: Chalmers I, Altman DG , eds. Systematic Reviews. London, UK: BMJ Publishing Group, 1995.
    57. ↵
      1. Sell RL
      . Defining and measuring sexual orientation: a review. Arch Sex Behav 1997;26:643–58.
      OpenUrlCrossRefPubMedWeb of Science
    58. ↵
      1. Meyer IH,
      2. Colten ME
      . Sampling gay men: random digit dialing versus sources in the gay community. J Homosex 1999;37:99–110.
      OpenUrlCrossRefPubMedWeb of Science
    59. ↵
      1. Lee JG
      . Social ecology of tobacco surveillance data for sexual and gender minority populations. Nicotine Tob Res 2009;11:908–9.
      OpenUrlFREE Full Text
    60. ↵
      1. Hogg RS,
      2. Craib KJP,
      3. Willoughby B,
      4. et al
      . Sociodemographic correlates for risk-taking behaviour among HIV seronegative homosexual men. Can J Public Health 1993;84:423–6.
      OpenUrlPubMedWeb of Science
    61. ↵
      1. Heckathorn DD
      . Respondent-driven sampling: a new approach to the study of hidden populations. Social Problems 1997;44:174–99.
      OpenUrlAbstract/FREE Full Text
    62. ↵
      1. Peretti-Watel P,
      2. Villes V,
      3. Duval X,
      4. et al
      . How do HIV-infected smokers react to cigarette price increases? Evidence from the APROCO-COPILOTE-ANRS CO8 Cohort. Curr HIV Res 2009;7:462–7.
      OpenUrlCrossRefPubMedWeb of Science
    63. ↵
      1. Dube SR,
      2. McClave A,
      3. Caraballo R,
      4. et al
      . Vital signs: current cigarette smoking among adults aged =18 years — United States, 2009. MMWR Morb Mortal Wkly Rep 2010;59:1135–40.
      OpenUrlPubMed
    64. ↵
      1. Rosario M,
      2. Schrimshaw EW,
      3. Hunter J
      . Cigarette smoking as a coping strategy: negative implications for subsequent psychological distress among lesbian, gay, and bisexual youths. J Pediatr Psychol 2011;36:731–42.
      OpenUrlAbstract/FREE Full Text
    65. ↵
      1. McKirnan DJ,
      2. Tolou-Shams M,
      3. Turner L,
      4. et al
      . Elevated risk for tobacco use among men who have sex with men is mediated by demographic and psychosocial variables. Subst Use Misuse 2006;41:1197–208.
      OpenUrlCrossRefPubMedWeb of Science
    66. ↵
      1. Hughes TL,
      2. Johnson TP,
      3. Matthews AK
      . Sexual orientation and smoking: results from a multisite women's health study. Subst Use Misuse 2008;43:1218–39.
      OpenUrlCrossRefPubMedWeb of Science
    67. ↵
      1. Willoughby BLB,
      2. Lai BS,
      3. Doty ND,
      4. et al
      . Peer crowd affiliations of adult gay men: Linkages with health risk behaviors. Psychology of Men & Masculinity 2008;9:235–47.
      OpenUrlCrossRefWeb of Science
    68. ↵
      1. Lombardi E,
      2. Silvestre AJ,
      3. Janosky JE,
      4. et al
      . Impact of early sexual debut on gay men's tobacco use. Nicotine Tob Res 2008;10:1591–5.
      OpenUrlAbstract/FREE Full Text
    69. ↵
      1. Austin SB,
      2. Ziyadeh N,
      3. Fisher LB,
      4. et al
      . Sexual orientation and tobacco use in a cohort study of US adolescent girls and boys. Arch Pediatr Adolesc Med 2004;158:317–22.
      OpenUrlCrossRefPubMedWeb of Science
    70. ↵
      1. Mays VM,
      2. Cochran SD
      . Mental health correlates of perceived discrimination among lesbian, gay, and bisexual adults in the United States. Am J Public Health 2001;91:1869–76.
      OpenUrlCrossRefPubMedWeb of Science
    71. ↵
      1. Jun HJ,
      2. Austin SB,
      3. Wylie SA,
      4. et al
      . The mediating effect of childhood abuse in sexual orientation disparities in tobacco and alcohol use during adolescence: results from the Nurses' Health Study II. Cancer Causes Control 2010;21:1817–28.
      OpenUrlCrossRefPubMedWeb of Science
    72. ↵
      1. Rosario M,
      2. Schrimshaw EW,
      3. Hunter J
      . Predictors of substance use over time among gay, lesbian, and bisexual youths: an examination of three hypotheses. Addict Behav 2004;29:1623–31.
      OpenUrlCrossRefPubMedWeb of Science
    73. ↵
      1. Willoughby BLB,
      2. Doty ND,
      3. Malik NM
      . Victimization, family rejection, and outcomes of gay, lesbian, and bisexual young people: The role of negative GLB identity. Journal of GLBT Family Studies 2010;6:403–24.
      OpenUrlCrossRef
    74. ↵
      1. Houston E,
      2. McKirnan DJ
      . Intimate partner abuse among gay and bisexual men: risk correlates and health outcomes. J Urban Health 2007;84:681–90.
      OpenUrlCrossRefPubMedWeb of Science
    75. ↵
      1. Jun HJ,
      2. Rich-Edwards JW,
      3. Boynton-Jarrett R,
      4. et al
      . Intimate partner violence and cigarette smoking: association between smoking risk and psychological abuse with and without co-occurrence of physical and sexual abuse. Am J Public Health 2008;98:527–35.
      OpenUrlCrossRefPubMedWeb of Science
    76. ↵
      1. Lemon SC,
      2. Verhoek-Oftedahl W,
      3. Donnelly EF
      . Preventive healthcare use, smoking, and alcohol use among Rhode Island women experiencing intimate partner violence. J Womens Health Gend Based Med 2002;11:555–62.
      OpenUrlCrossRefPubMedWeb of Science
    77. ↵
      1. Vest JR,
      2. Catlin TK,
      3. Chen JJ,
      4. et al
      . Multistate analysis of factors associated with intimate partner violence. Am J Prev Med 2002;22:156–64.
      OpenUrlCrossRefPubMedWeb of Science
    78. ↵
      1. Herek G,
      2. Gillis J,
      3. Cogan J
      . Internalized stigma among sexual minority adults: insights from a social psychological perspective. J Couns Psychol 2009;56:32–43.
      OpenUrlCrossRef
    79. ↵
      1. Rostosky SS,
      2. Danner F,
      3. Riggle ED
      . Is religiosity a protective factor against substance use in young adulthood? Only if you're straight! J Adolesc Health 2007;40:440–7.
      OpenUrlCrossRefPubMedWeb of Science
    80. ↵
      1. Rosario M,
      2. Schrimshaw EW,
      3. Hunter J
      . Butch/Femme differences in substance use and abuse among young lesbian and bisexual women: examination and potential explanations. Subst Use Misuse 2008;43:1002–15.
      OpenUrlCrossRefPubMedWeb of Science
    81. ↵
      1. Gruskin EP,
      2. Byrne KM,
      3. Altschuler A,
      4. et al
      . Smoking it all away: influences of stress, negative emotions, and stigma on lesbian tobacco use. J LGBT Health Res 2008;4:167–79.
      OpenUrlPubMed
    82. ↵
      1. Remafedi G
      . Lesbian, gay, bisexual, and transgender youths: who smokes, and why? Nicotine Tob Res 2007;9(Suppl 1):S65–71.
      OpenUrlAbstract/FREE Full Text
    83. ↵
      1. Yamey G
      . Gay tobacco ads come out of the closet. BMJ 2003;327:296.
      OpenUrlFREE Full Text
    84. ↵
      1. Smith EA,
      2. Offen N,
      3. Malone RE
      . What makes an ad a cigarette ad? Commercial tobacco imagery in the lesbian, gay, and bisexual press. J Epidemiol Community Health 2005;59:1086–91.
      OpenUrlAbstract/FREE Full Text
    85. ↵
      1. Dilley JA,
      2. Spigner C,
      3. Boysun MJ,
      4. et al
      . Does tobacco industry marketing excessively impact lesbian, gay and bisexual communities? Tob Control 2008;17:385–90.
      OpenUrlAbstract/FREE Full Text
    86. ↵
      1. Offen N,
      2. Smith EA,
      3. Malone RE
      . Is tobacco a gay issue? Interviews with leaders of the lesbian, gay, bisexual and transgender community. Cult Health Sex 2008;10:143–57.
      OpenUrlCrossRefPubMedWeb of Science
    87. ↵
      1. Rosario M,
      2. Schrimshaw EW,
      3. Hunter J
      . Disclosure of sexual orientation and subsequent substance use and abuse among lesbian, gay, and bisexual youths: Critical role of disclosure reactions. Psychol Addict Behav 2009;23:175–84.
      OpenUrlCrossRefPubMedWeb of Science
    88. ↵
      1. Pachankis JE,
      2. Westmaas JL,
      3. Dougherty LR
      . The influence of sexual orientation and masculinity on young men's tobacco smoking. J Consult Clin Psychol 2011;79:142–52.
      OpenUrlCrossRefPubMed
    89. ↵
      SFLGHP. “She even chewed tobacco”: a pictoral narrative of passing women in America. In: Duberman MB, Vicinus M, Chauncey G , eds. Hidden From History: Reclaiming the Gay and Lesbian Past. New York, NY: New American Library, 1989:183–94.
    90. ↵
      1. Bandura A
      . Health promotion by social cognitive means. Health Educ Behav 2004;31:143–64.
      OpenUrlAbstract/FREE Full Text
    91. ↵
      1. Maddux JE,
      2. Rogers RW
      . Protection motivation and self-efficacy: a revised theory of fear appeals and attitude change. J Exp Soc Psychol 1983;19:469–79.
      OpenUrlCrossRefWeb of Science
    92. ↵
      1. Russell ST,
      2. Driscoll AK,
      3. Truong N
      . Adolescent same-sex romantic attractions and relationships: implications for substance use and abuse. Am J Public Health 2002;92:198–202.
      OpenUrlCrossRefPubMedWeb of Science
    93. ↵
      1. Udry JR,
      2. Chantala K
      . Risk assessment of adolescents with same-sex relationships. J Adolesc Health 2002;31:84–92.
      OpenUrlCrossRefPubMedWeb of Science
    94. ↵
      1. Eisenberg ME,
      2. Wechsler H
      . Social influences on substance-use behaviors of gay, lesbian, and bisexual college students: findings from a national study. Soc Sci Med 2003;57:1913–23.
      OpenUrlCrossRefPubMedWeb of Science
    95. ↵
      1. Hatzenbuehler ML,
      2. Wieringa NF,
      3. Keyes KM
      . Community-level determinants of tobacco use disparities in lesbian, gay, and bisexual youth: results from a population-based study. Arch Pediatr Adolesc Med 2011;165:527–32.
      OpenUrlCrossRefPubMedWeb of Science
    96. ↵
      1. Burkhalter JE,
      2. Warren B,
      3. Shuk E,
      4. et al
      . Intention to quit smoking among lesbian, gay, bisexual, and transgender smokers. Nicotine Tob Res 2009;11:1312–20.
      OpenUrlAbstract/FREE Full Text
    97. ↵
      1. Burns EK,
      2. Deaton EA,
      3. Levinson AH
      . Rates and reasons: disparities in low intentions to use a state smoking cessation quitline. Am J Health Promot 2011;25(5 Suppl):S59–65.
      OpenUrlCrossRefPubMedWeb of Science
    98. ↵
      1. Schwappach DL
      . Smoking behavior, intention to quit, and preferences toward cessation programs among gay men in Zurich, Switzerland. Nicotine Tob Res 2008;10:1783–7.
      OpenUrlAbstract/FREE Full Text
    99. ↵
      1. Harding R,
      2. Bensley J,
      3. Corrigan N
      . Targeting smoking cessation to high prevalence communities: outcomes from a pilot intervention for gay men. BMC Public Health 2004;4:43–5.
      OpenUrlCrossRefPubMed
    100. ↵
      1. Frohlich KL,
      2. Potvin L
      . Transcending the known in public health practice: the inequality paradox: the population approach and vulnerable populations. Am J Public Health 2008;98:216–21.
      OpenUrlCrossRefPubMedWeb of Science
    101. ↵
      1. Lovato C,
      2. Linn G,
      3. Stead LF,
      4. et al
      . Impact of tobacco advertising and promotion on increasing adolescent smoking behaviours. Cochrane Database Syst Rev 2003;(4):CD003439.
    102. ↵
      1. Trocki KF,
      2. Drabble LA,
      3. Midanik LT
      . Tobacco, marijuana, and sensation seeking: comparisons across gay, lesbian, bisexual, and heterosexual groups. Psychol Addict Behav 2009;23:620–31.
      OpenUrlCrossRefPubMedWeb of Science
    103. ↵
      1. Gruskin E,
      2. Byrne K,
      3. Kools S,
      4. et al
      . Consequences of frequenting the lesbian bar. Women Health 2006;44:103–20.
      OpenUrl
    104. ↵
      1. Baron RM,
      2. Kenny DA
      . The moderator-mediator variable distinction in social psychological research: conceptual, strategic, and statistical considerations. J Pers Soc Psychol 1986;51:1173–82.
      OpenUrlCrossRefPubMedWeb of Science
    105. ↵
      1. Ryan C,
      2. Russell ST,
      3. Huebner D,
      4. et al
      . Family Acceptance in Adolescence and the Health of LGBT Young Adults. J Child Adolesc Psychiatr Nurs 2010;23:205–13.
      OpenUrlCrossRefPubMed
    106. ↵
      1. Blosnich JR,
      2. Jarrett T,
      3. Horn K
      . Racial and ethnic differences in current use of cigarettes, cigars, and hookahs among lesbian, gay, and bisexual young adults. Nicotine Tob Res 2011;13:487–91.
      OpenUrlAbstract/FREE Full Text
    107. ↵
      1. Meyer IH,
      2. Wilson PA
      . Sampling lesbian, gay, and bisexual populations. J Couns Psychol 2009;56:23–31.
      OpenUrlCrossRefWeb of Science
    108. ↵
      US Department of Health and Human Services. 2020 topics & objectives; lesbian, gay, bisexual, and transgender health. http://www.healthypeople.gov/2020/topicsobjectives2020/overview.aspx?topicid=25 (accessed 1 Aug 2011).

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    Footnotes

    • Funding This work was supported by a dissertation training grant to JB through the National Institute on Drug Abuse (Award 1R36DA030589-01). This paper is solely the responsibility of the authors and does not necessarily represent the official views of the authors' respective institutional affiliations, the National Institute on Drug Abuse, or the National Institutes of Health.

    • Competing interests None.

    • Provenance and peer review Not commissioned; externally peer reviewed.