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Article

Cigarette Smoking Disparities Between Sexual Minority and Heterosexual Youth

Jessica N. Fish, Blair Turner, Gregory Phillips and Stephen T. Russell
Pediatrics April 2019, 143 (4) e20181671; DOI: https://doi.org/10.1542/peds.2018-1671
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Abstract

BACKGROUND: Using a population-based sample of youth, we examined rates of cigarette use and trends in cigarette use disparities between heterosexual youth and 3 subgroups of sexual minority youth (SMY) (ie, lesbian or gay, bisexual, and unsure) from 2005 to 2015.

METHODS: Data are from 6 cohorts of the Youth Risk Behavior Survey, a national, biennial, school-based survey of ninth- to 12th-grade students in the United States (n = 404 583). Sex-stratified analyses conducted in 2017 examined trends in 2 cigarette-related behaviors: lifetime cigarette use and heavy cigarette use (20+ days in the past 30).

RESULTS: Disparities in lifetime cigarette use between lesbian and heterosexual girls were statistically smaller in 2015 relative to 2005 (adjusted odds ratio [aOR] 0.29; 95% confidence interval [CI] 0.12–0.75; P = .011). Sexual orientation disparities in heavy use were narrower for bisexual boys in 2015 compared with 2005 (aOR 0.39; 95% CI 0.17–0.90; P = .028). Girls and boys unsure of their sexual identity had wider disparities in heavy use in 2015 (aOR 3.85; 95% CI 1.39–11.10; P = .009) relative to 2005 (aOR 2.44; 95% CI 1.22–5.00; P = .012).

CONCLUSIONS: SMY remain at greater risk for cigarette-related behaviors despite greater acceptance of lesbian, gay, and bisexual people in the United States. Focused policies and programs aimed at reducing rates of SMY cigarette use are warranted, particularly for youth questioning their sexual identity.

  • Abbreviations:
    aOR —
    adjusted odds ratio
    CDC —
    Centers for Disease Control and Prevention
    CI —
    confidence interval
    LGB —
    lesbian, gay, and bisexual
    OR —
    odds ratio
    SMY —
    sexual minority youth
    YRBS —
    Youth Risk Behavior Survey

    • What’s Known on This Subject:

    Elevated rates of cigarette use among sexual minorities are largely attributed to experiences of stigma. Data limitations have prevented research on whether sexual orientation disparities in cigarette use have changed amid growing social acceptance of lesbian, gay, and bisexual people.

    What This Study Adds:

    Adolescent cigarette use declined for heterosexual, lesbian, gay, and bisexual youth from 2005 to 2015. Sexual orientation identity disparities between heterosexual and sexual minority youth have largely remained unchanged and for questioning youth have widened since 2005.

    Tobacco use is a leading preventable cause of death in the United States.1,2 Although adolescent cigarette use has declined in recent decades,3,4 a substantial body of research documents sexual orientation disparities in cigarette use among youth and adults.5,6 Sexual minority (eg, lesbian, gay, and bisexual [LGB]) youth are >3 times as likely as heterosexual youth to indicate lifetime cigarette use and >1.5 times more likely to report smoking cigarettes in the past 30 days.7 Prospective studies also indicate that sexual minority youth (SMY), particularly sexual minority relative to heterosexual girls, demonstrate an acceleration in the frequency of cigarette use during the transition to adulthood.8 These early experiences with cigarette use, along with increased use over time, leave sexual minority adults vulnerable to smoking-related morbidity and mortality across the life course.9,10 Early intervention therefore has long-term consequences, particularly for LGB population health.

    A growing body of literature links structural (ie, laws and policies)11 and interpersonal (ie, discrimination and victimization)12 stigma to sexual orientation–related disparities in tobacco use. For example, SMY who live in states with lower levels of structural stigma (operationalized by density of same-sex–headed households, presence of gay-straight alliances, and protective policies) are less likely to report cigarette smoking than SMY who live in high-stigma states.11 Although structural and interpersonal factors that perpetuate anti-LGB stigma remain, there have been extraordinarily swift changes to the political and social climate as it relates to the rights and protections of LGB people. The visibility surrounding these changes was also accompanied by notable increases in favorable attitudes toward LGB people in the United States. In 1999, for example, 62% of United States adults opposed same-sex marriage compared to 34% in 2017.13 Similarly, 57% of adults in 2015 report that they would not be upset if their child told them that they were gay or lesbian compared to 23% of adults in 2000.14 Recent data also indicate that younger cohorts are more accepting of LGB people than previous generations.13 As of 2017, 56% of baby boomers (born 1946–1964) favor same-sex marriage compared to 65% of generation X (born 1965–1980) and 74% of millennials (born 1981–2004), which suggests that contemporary SMY are coming of age in peer cohorts that are increasingly more accepting of LGB people. Considering the link between anti-LGB attitudes and elevated rates of substance use among SMY and sexual minority adults,15–18 there has been emerging interest in whether health disparities between heterosexual and LGB youth have diminished as social attitudes toward LGB people have improved.19–21

    Despite public discourse emphasizing the benefits of growing up LGB in the most recent decade, there has been limited empirical research explicitly examining whether sexual identity disparities in health, including substance use, have changed during this time. Until recently, national surveys of youth have excluded measures of sexual identity, attractions, or behaviors (exclusions that have stymied efforts to understand the health and well-being of SMY at the population level). Given recent advancements in the inclusion of sexual identity measures in population-based studies of youth (such as the Youth Risk Behavior Survey [YRBS]) and data management efforts to pool these data, we are able to test whether tobacco use disparities between heterosexual youth and subgroups of SMY have changed amid the backdrop of increasing public acceptance of LGB people. Specifically, we use data from 6 administrations of the YRBS from 2005 to 2015 to examine trends in the prevalence of 2 cigarette-related behaviors among heterosexual and SMY: lifetime use (ie, any) and heavy use (ie, 20 or more days in the past month). We then assessed within-year sexual identity differences in cigarette-related behaviors between heterosexual youth and 3 subgroups of SMY: (1) lesbian or gay, (2) bisexual, and (3) youth unsure of their sexual identity. Finally, we tested whether the degree to which heterosexual youth and SMY differ in cigarette-related behaviors has changed from 2005 to 2015.

    Methods

    Data Source

    The YRBS is a biennial national survey that has been conducted by the Centers for Disease Control and Prevention (CDC) since 1991 to collect health data on students in grades 9 to 12.22 The YRBS monitors priority health-related behaviors among youth, such as alcohol use, experiences with violence, and sexual behaviors, among others.23 For this study, we used data from local versions of the YRBS, which are administered at the state, large urban school district, or county level; in this implementation, jurisdictions use a 2-stage cluster sample design to identify a sample of students.22 In the first stage, schools are selected with a probability proportional to their enrollment; in the second stage, classes are randomly selected, and all students within these classes are eligible to participate. A new sample or cohort is selected each year that the survey is administered; the same students are not tracked over time.

    Analytic Sample

    Local YRBS data were pooled across multiple jurisdictions (city and state) and years (biennially from 2005 to 2015). The entire data set consists of 47 jurisdictions across 6 time points and 541 410 students (see Supplemental Table 5). There were a total of 114 jurisdiction-years (distinct surveys administered by a particular jurisdiction in a specific year) that assessed sexual identity (419 694 students). This data set includes the largest sample of SMY of its kind. For the present analysis, students were excluded if they were missing data on sexual identity (see Supplemental Table 6 for missing by survey year) and any of the primary demographic variables of interest (race and/or ethnicity: 3.11%; sex: 0.67%; and age: 0.32%; not mutually exclusive), resulting in a final sample of 404 583 students.

    Measures

    Sexual Identity

    Sexual identity was assessed with the following question: “Which of the following best describes you?” Response options were “heterosexual (straight),” “gay or lesbian,” “bisexual,” and “unsure.”

    Lifetime Cigarette Use

    Participants were asked, “Have you ever tried cigarette smoking, even 1 or 2 puffs?” The response options were “yes” or “no.”

    Heavy Cigarette Use

    Participants were asked, “During the past 30 days, on how many days did you smoke cigarettes?” Potential response options were “0 days,” “1 or 2 days,” “3 to 5 days,” “6 to 9 days,” “10 to 19 days,” and “20 to 29 days.” Responses were recoded to reflect as “<20 days” and “20 or more days” per the CDC’s 2015 YRBS data users guide.24

    Demographics

    Race and/or Ethnicity

    Participants were asked if they identified as Hispanic or Latino. Additionally, participants could select all races that applied from the list of “American Indian or Alaska Native,” “Asian,” “Black or African American,” “Native Hawaiian or Other Pacific Islander,” and “White.” By using the CDC’s classification, these variables were combined into the following racial and/or ethnic groups: (1) “American Indian or Alaskan Native,” (2) “Asian,” (3) “Black or African American,” (4) “Native Hawaiian and/or other Pacific Islander,” (5) “White,” (6) “Hispanic and/or Latino,” and (7) “multiracial, non-Hispanic.”

    Sex

    Participants were asked to identify their sex with the item “What is your sex?” Response options were “female” and “male.”

    Age

    Participants were asked, “How old are you?” The response options ranged from ≤12 years old to ≥18 years old. Items were recoded to reflect youth “14 years old or younger,” “15 years old,” “16 years old,” “17 years old,” and “18 years old and older.”

    Statistical Analysis

    All data management was conducted in SAS version 9.4 (SAS Institute, Inc, Cary, NC). Analyses were conducted by using SAS-Callable SUDAAN version 11.0.1 (RTI International, Research Triangle Park, NC) to appropriately weight estimates and to account for the complex sampling design of the YRBS. The YRBS data weights adjust for student nonresponse and the distribution of students by grade, sex, and race and/or ethnicity in each jurisdiction.22

    Descriptive analyses were conducted to determine the prevalence of cigarette use behaviors by sex and sexual identity at each time point. Then, trends in cigarette use behaviors by sex and sexual identity from 2005 to 2015 were assessed by using the CDC’s recommended approach to trend analysis; time was modeled as a continuous variable by using orthogonal coefficients to reflect the biennial spacing of the surveys.25,26 The linear time component was significant at P < .05. These analyses were stratified by sex, controlled for age and race and/or ethnicity, and assessed linear, quadratic, and cubic trends. Linear trends test for significant linear increases or decreases over time, whereas quadratic and cubic trends test for significant nonlinear changes over time. Next, we tested whether SMY differed from heterosexual youth in the prevalence of each cigarette-use behavior within each data collection year stratified by sex and adjusted for age and race and/or ethnicity.

    Finally, we used logistic regression with year–by–sexual-identity interactions terms to test whether disparities between heterosexual youth and SMY changed (ie, widened, narrowed, or maintained) from 2005 to 2015. Given that odds ratios (ORs) cannot be compared directly across different samples,27 the use of an interaction term between survey year and sexual identity in a logistic regression framework allows us to test whether disparities change over time. The year–by–sexual-identity interaction term calculates a ratio of the OR that compares adjusted odds ratios (aORs) for a cigarette use behavior (eg, ever smoked) for a particular subgroup (eg, lesbian girls) relative to the referent group (heterosexual girls) in a given year (eg, 2005) to the odds of those with the same identity in 2015. For ease of interpretation, we inverted estimated interaction ORs to reflect changes from past to present. Therefore, an OR for the interaction term >1 indicates a widening disparity from the comparison year to 2015, and an OR <1 indicates a narrowing disparity. A more detailed explanation of this approach is available elsewhere.19,20 Data analyses were conducted in 2017.

    Results

    Sex-stratified prevalence of sexual identity subgroups and tobacco-related outcomes by survey year are presented in Table 1.

    View this table:
    TABLE 1

    Frequency and Prevalence of Sexual Identity and Cigarette Smoking Behaviors, YRBS 2005–2015

    Prevalence and Trends by Sexual Identity

    Results from adjusted linear trend comparisons by sexual identity revealed that rates of cigarette-related behaviors have significantly declined from 2005 to 2015 for all youth, regardless of sex or sexual identity, with the exception of heavy use among boys unsure of their sexual identity (see Table 2, Figs 1 and 2). Unadjusted prevalence rates reflected in figures are available in Supplemental Table 7.

    View this table:
    TABLE 2

    Linear Trend Comparison of the Prevalence of Lifetime, Past-30-Day, and Heavy Use by Sexual Identity From 2005 to 2015

    FIGURE 1
    FIGURE 1

    Unadjusted prevalence and trend comparisons of cigarette-related outcomes among girls by sexual identity from 2005 to 2015.

    FIGURE 2
    FIGURE 2

    Unadjusted prevalence and trend comparisons of cigarette-related outcomes among boys by sexual identity from 2005 to 2015.

    Cigarette Use Disparities Between SMY and Heterosexual Youth Over Time

    Within-year sexual identity disparities in cigarette use are displayed in Table 3. Rates of lifetime use were elevated for all sexual minority girls, with the exception of unsure girls in 2007. Sexual identity disparities in heavy cigarette use systematically increased from 2005 to 2015, with all sexual minority girl subgroups reporting higher odds of heavy use than heterosexual girls from 2011 to 2015.

    View this table:
    TABLE 3

    Sexual Identity Disparities in Cigarette-Related Outcomes Within the Year

    Sexual identity disparities in cigarette use were more idiosyncratic across years for boys. Bisexual boys showed consistently higher odds of lifetime cigarette use compared with heterosexual boys for all survey years; gay boys indicated greater odds of lifetime use in 2007, 2011, 2013, and 2015. Unsure boys did not statistically differ in lifetime use relative to heterosexual boys in any 1 year. Compared with heterosexual boys, rates of heavy use were elevated among gay and bisexual boys across all survey years, with the exception of gay boys in 2015 and bisexual boys in 2009. Unsure boys had greater odds of heavy use than heterosexual boys in 2007, 2011, 2013, and 2015.

    Trends in Cigarette Use Disparities Over Time

    Sexual-identity–by–year interactions testing differences in the size of sexual orientation disparities in cigarette smoking behavior largely indicated statistically stable differences between heterosexual youth and subgroups of SMY (see Table 4). In other words, smoking behaviors among specific populations of LGB youth, with few exceptions, were largely the same in 2015 as they were in 2005. Recall that ORs >1.00 indicate a wider disparity in 2015 relative to 2005, whereas ORs <1.00 indicate a narrower disparity. Lifetime use disparities between heterosexual and lesbian girls were narrower in 2015 relative to 2005 (aOR 0.29; 95% confidence interval [CI] 0.12–0.75; P = .011). The difference in heavy use between heterosexual and bisexual boys also narrowed in 2015 relative to 2005 (aOR 0.39; 95% CI 0.17–0.90; P = .028). Both girls and boys unsure of their sexual identity demonstrated wider sexual orientation disparities in heavy use in 2015 relative to unsure youth in 2005 (aOR 3.85 [95% CI 1.39–11.10; P = .009] and aOR 2.44 [95% CI 1.22–5.00; P = .012] for girls and boys, respectively).

    View this table:
    TABLE 4

    Adjusted Trends in Cigarette-Related Disparities From 2005 to 2015

    Discussion

    Although studies have consistently documented cigarette-related disparities between heterosexual youth and SMY,6,7,28,29 data limitations have stymied understanding of whether sexual identity–related health disparities in the United States have narrowed, concurrent with pro-LGB social and structural changes. Similar to those in previous studies, our results reveal that the prevalence of lifetime and heavy cigarette use is decreasing among youth, including SMY.4,19 Boys unsure of their sexual identity, however, indicated slower rates of decline in lifetime use and no statistical decline in heavy use. Ultimately, results testing differences in disparities over time suggest that the size of sexual identity–related disparities in cigarette use have remained relatively stable from 2005 to 2015, with few exceptions; sexual identity disparities in heavy use and lifetime use were narrower for bisexual boys and lesbian girls, respectively, in 2015 relative to 2005. Unsure girls and boys in 2015 showed wider disparities in heavy use than unsure girls and boys in 2005, suggesting unique risk for cigarette use among youth who are unsure of their sexual identity.

    Sexual minority health disparities are theoretically driven by experiences with anti-LGB stigma and discrimination,30,31 and a growing body of empirical work supports that these experiences affect the health and well-being of SMY and sexual minority adults.16,32 Thus, given improved social attitudes and policies for LGB people, we anticipated that these social changes would attenuate health disparities between heterosexual youth and SMY in more recent samples of youth. Our results, however, do not support this hypothesis. Why might this be? Recent work suggests that there may be a developmental explanation; amid the backdrop of improved pro-LGB attitudes in the United States, research demonstrates a steady decline in the age at which SMY first disclose their sexual identities.33,34 Young adolescents, however, are more likely to assert prejudicial attitudes, engage in homophobic behavior, and regulate the sexuality and gender expression of peers.35,36 This leaves youth who adopt and assert sexual minority identities earlier in the life course vulnerable to social exclusion and victimization from peers.37 Therefore, despite macrosystemic changes in the acceptance of LGB people, youth may remain vulnerable to interpersonal experiences of prejudice and victimization and associated health outcomes.16,30,33

    Our findings regarding the persistence of sexual identity disparities in cigarette use may be explained by recent research that documents school-based victimization among SMY. A recent meta-analytic review,38 for example, noted that SMY experience moderately higher levels of school-based harassment and victimization than their heterosexual peers and that the association between sexual minority status and school-based victimization was stronger in more recent years; in other words, there are larger sexual orientation disparities in school-based harassment today than in the past. These findings, coupled with additional studies that indicate that general and anti-LGB victimization are among the strongest predictors for substance use among SMY,16 suggest that focused policies and programs that eliminate school-based victimization for SMY could help to mitigate sexual identity disparities in cigarette use and other negative outcomes.

    Still, there may be other competing or compounding explanations for why sexual orientation–related disparities in tobacco use have remained largely unchanged since 2005. For example, there are several intrapersonal and interpersonal factors that have been shown to shape substance use among sexual minorities, including positive expectations of alcohol use and drinking to conform.39,40 Furthermore, studies continue to reveal that tobacco companies persist in targeting LGB people and communities.41 Still, continued risk for depression and other mental health symptomology may leave SMY vulnerable to cigarette use. Such factors may complicate the association between changing sociocultural contexts and substance use among sexual minority populations. Ultimately, more research is needed to understand the compounding nature of stress and substance use in the context of these other known mechanisms.

    Despite documented differences in sexual orientation–related health disparities by sex and sexual identity,7,8,20,23,33 it is notable that we observed declines in lifetime and heavy tobacco use for both girls and boys as well as LGB youth. We did, however, find sex and sexual identity differences when assessing change in disparities over time. That is, sexual orientation differences in lifetime use for lesbian girls and heavy use for bisexual boys were statistically smaller in 2015 relative to 2005. These findings suggest that lesbian girls in 2015 were less likely to try cigarettes than in the past but demonstrated the same degree of elevated risk for heavy use as their lesbian peers in 2005. Conversely, bisexual boys were no more or less likely to try cigarettes in 2015 than in 2005 but had lower odds of heavy use in 2015. These findings are in line with research that documents more robust sexual orientation–related substance use and abuse disparities among sexual minority girls and women than sexual minority boys and men.7,8,20,42 More research is needed to understand the mechanisms that are driving these differences both concurrently and over sociohistorical time. It could be, for example, that girls are more susceptible to substance use as the result of peer victimization and thus more likely to use at higher rates.43,44 Studies of adults support this supposition.45

    The increase in risk among youth who are unsure of their sexual identity also deserves attention. Other preliminary evidence suggests elevated risk among youth questioning their identity,15 particularly those youth who experience homophobic victimization. Interestingly, although unsure youth were at greater risk for tobacco use than heterosexual youth, their overall levels of risk were lower than those of LGB youth (see within-year comparisons). It may be that unsure youth are less likely to experience homophobic victimization and harassment than their LGB-identified peers. Indeed, studies indicate that youth who are “out” about their sexual identity are more susceptible to victimization.37 Together, findings suggest that youth who are unsure of or questioning their sexual orientation may be uniquely vulnerable to cigarette and other substance use and could benefit from focused research attention.

    Our findings must be considered in light of limitations. The YRBS is a crucial source of data on the health of adolescents in the United States, but there has been inconsistent inclusion of sexual identity measures. These analyses cover a wide range of the nation but are not strictly population representative. The YRBS data are also school based; therefore, youth not enrolled or absent are not included in the data. This is important considering that SMY are often overrepresented in groups of youth who experience homelessness, school pushout, or absence because of safety concerns.46–48 Such limitations would suggest, however, that the results presented in this article are likely underestimated because youth who are likely to be most vulnerable are excluded.

    Conclusions

    Broadly, our findings indicate that cigarette use has declined among youth in the United States. Yet, sexual identity disparities in cigarette use persist. Such results support the conclusion that SMY health disparities remain a significant public health concern. Researchers should continue to explore how SMY health and health disparities have changed or remain unchanged in light of social changes. However, this work can only be done with the continued inclusion of sexual identity measures in large-scale studies of youth. In the interim, the development and application of policies and programs that seek to reduce SMY cigarette use are needed.

    Footnotes

      • Accepted January 7, 2019.
    • Address correspondence to Jessica N. Fish, PhD, Department of Family Science, School of Public Health, University of Maryland, 4200 Valley Dr, Suite 1142, College Park, MD 20742. E-mail: jnfish{at}umd.edu

    • FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.

    • FUNDING: Supported by the National Institute on Alcohol Abuse and Alcoholism (F32AA023138 to Dr Fish; R01AA024409 to Dr Phillips and Ms Turner) and the Eunice Kennedy Shriver National Institute of Child Health and Human Development (P2CHD042849 to Drs Fish and Russell; P2CHD041041 to Dr Fish). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. Funded by the National Institutes of Health (NIH).

    • POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

    References

    1. ↵
      1. Rostron BL,
      2. Chang CM,
      3. Pechacek TF
      . Estimation of cigarette smoking-attributable morbidity in the United States. JAMA Intern Med. 2014;174(12):1922–1928pmid:25317719
      OpenUrlCrossRefPubMed
    2. ↵
      1. Centers for Disease Control and Prevention (CDC)
      . Cigarette smoking-attributable morbidity—United States, 2000. MMWR Morb Mortal Wkly Rep. 2003;52(35):842–844pmid:12966360
      OpenUrlPubMed
    3. ↵
      1. Miech RA,
      2. Johnston LD,
      3. O’Malley PM,
      4. Bachman JG,
      5. Schulenberg JE,
      6. Patrick ME
      . Monitoring the Future National Survey Results on Drug Use, 1975–2016: Volume I, Secondary School Students. Ann Arbor, MI: Institute for Social Research, University of Michigan; 2017
    4. ↵
      1. Centers for Disease Control and Prevention
      . Trends in the prevalence of tobacco use national YRBS: 1991-2015. 2018. Available at: https://www.cdc.gov/healthyyouth/data/yrbs/pdf/trends/2015_us_tobacco_trend_yrbs.pdf. Accessed March 12, 2018
    5. ↵
      1. Gruskin EP,
      2. Greenwood GL,
      3. Matevia M,
      4. Pollack LM,
      5. Bye LL
      . Disparities in smoking between the lesbian, gay, and bisexual population and the general population in California. Am J Public Health. 2007;97(8):1496–1502pmid:17600265
      OpenUrlCrossRefPubMed
    6. ↵
      1. Jamal A,
      2. Agaku IT,
      3. O’Connor E,
      4. King BA,
      5. Kenemer JB,
      6. Neff L
      . Current cigarette smoking among adults–United States, 2005-2013. MMWR Morb Mortal Wkly Rep. 2014;63(47):1108–1112pmid:25426653
      OpenUrlPubMed
    7. ↵
      1. Marshal MP,
      2. Friedman MS,
      3. Stall R, et al
      . Sexual orientation and adolescent substance use: a meta-analysis and methodological review. Addiction. 2008;103(4):546–556pmid:18339100
      OpenUrlCrossRefPubMed
    8. ↵
      1. Marshal MP,
      2. King KM,
      3. Stepp SD, et al
      . Trajectories of alcohol and cigarette use among sexual minority and heterosexual girls. J Adolesc Health. 2012;50(1):97–99pmid:22188841
      OpenUrlCrossRefPubMed
    9. ↵
      1. Goldberg S,
      2. Strutz KL,
      3. Herring AA,
      4. Halpern CT
      . Risk of substance abuse and dependence among young adult sexual minority groups using a multidimensional measure of sexual orientation. Public Health Rep. 2013;128(3):144–152pmid:23633729
      OpenUrlCrossRefPubMed
    10. ↵
      1. Fredriksen-Goldsen KI,
      2. Kim HJ,
      3. Barkan SE,
      4. Muraco A,
      5. Hoy-Ellis CP
      . Health disparities among lesbian, gay, and bisexual older adults: results from a population-based study. Am J Public Health. 2013;103(10):1802–1809pmid:23763391
      OpenUrlCrossRefPubMed
    11. ↵
      1. Hatzenbuehler ML,
      2. Jun HJ,
      3. Corliss HL,
      4. Austin SB
      . Structural stigma and cigarette smoking in a prospective cohort study of sexual minority and heterosexual youth. Ann Behav Med. 2014;47(1):48–56pmid:24136092
      OpenUrlCrossRefPubMed
    12. ↵
      1. Katz-Wise SL,
      2. Hyde JS
      . Victimization experiences of lesbian, gay, and bisexual individuals: a meta-analysis. J Sex Res. 2012;49(2–3):142–167pmid:22380586
      OpenUrlCrossRefPubMed
    13. ↵
      1. Pew Research Center
      . Changing attitudes on gay marriage. 2017. Available at: www.pewforum.org/2016/05/12/changing-attitudes-on-gay-marriage/. Accessed March 17, 2017
    14. ↵
      1. Gao G; Pew Research Center
      . Most Americans now say learning their child is gay wouldn’t upset them. 2015. Available at: www.pewresearch.org/fact-tank/2015/06/29/most-americans-now-say-learning-their-child-is-gay-wouldnt-upset-them/. Accessed October 12, 2018
    15. ↵
      1. Birkett M,
      2. Espelage DL,
      3. Koenig B
      . LGB and questioning students in schools: the moderating effects of homophobic bullying and school climate on negative outcomes. J Youth Adolesc. 2009;38(7):989–1000pmid:19636741
      OpenUrlCrossRefPubMed
    16. ↵
      1. Goldbach JT,
      2. Tanner-Smith EE,
      3. Bagwell M,
      4. Dunlap S
      . Minority stress and substance use in sexual minority adolescents: a meta-analysis. Prev Sci. 2014;15(3):350–363pmid:23605479
      OpenUrlCrossRefPubMed
      1. Pachankis JE,
      2. Hatzenbuehler ML,
      3. Starks TJ
      . The influence of structural stigma and rejection sensitivity on young sexual minority men’s daily tobacco and alcohol use. Soc Sci Med. 2014;103:67–75pmid:24507912
      OpenUrlCrossRefPubMed
    18. ↵
      1. Hatzenbuehler ML,
      2. Flores AR,
      3. Gates GJ
      . Social attitudes regarding same-sex marriage and LGBT health disparities: results from a national probability sample. J Soc Issues. 2017;73(3):508–528
      OpenUrl
    19. ↵
      1. Homma Y,
      2. Saewyc E,
      3. Zumbo BD
      . Is it getting better? An analytical method to test trends in health disparities, with tobacco use among sexual minority vs. heterosexual youth as an example. Int J Equity Health. 2016;15:79pmid:27215223
      OpenUrlPubMed
    20. ↵
      1. Fish JN,
      2. Watson RJ,
      3. Porta CM,
      4. Russell ST,
      5. Saewyc EM
      . Are alcohol-related disparities between sexual minority and heterosexual youth decreasing? Addiction. 2017;112(11):1931–1941pmid:28678415
      OpenUrlPubMed
    21. ↵
      1. Goodenow C,
      2. Watson RJ,
      3. Adjei J,
      4. Homma Y,
      5. Saewyc E
      . Sexual orientation trends and disparities in school bullying and violence-related experiences, 1999-2013. Psychol Sex Orientat Gend Divers. 2016;3(4):386–396pmid:29322064
      OpenUrlPubMed
    22. ↵
      1. Brener ND,
      2. Kann L,
      3. Shanklin S, et al; Centers for Disease Control and Prevention (CDC)
      . Methodology of the youth risk behavior surveillance system–2013. MMWR Recomm Rep. 2013;62(RR-1):1–20
      OpenUrlPubMed
    23. ↵
      1. Kann L,
      2. Olsen EO,
      3. McManus T, et al
      . Sexual identity, sex of sexual contacts, and health-related behaviors among students in grades 9-12 - United States and selected sites, 2015. MMWR Surveill Summ. 2016;65(9):1–202
      OpenUrlCrossRefPubMed
    24. ↵
      1. Centers for Disease Control and Prevention
      . 2015 YRBS National, State, and District Combined Datasets User’s Guide. Atlanta, GA: Centers for Disease Control and Prevention; 2016
    25. ↵
      1. Esser MB,
      2. Clayton H,
      3. Demissie Z,
      4. Kanny D,
      5. Brewer RD
      . Current and binge drinking among high school students - United States, 1991-2015. MMWR Morb Mortal Wkly Rep. 2017;66(18):474–478pmid:28493857
      OpenUrlPubMed
    26. ↵
      1. Centers for Disease Control and Prevention
      . Conducting trend analyses of YRBS data. 2018. Available at: https://www.cdc.gov/healthyyouth/data/yrbs/pdf/2017/2017_YRBS_Conducting_Trend_Analyses.pdf. Accessed March 18, 2018
    27. ↵
      1. Altman DG,
      2. Bland JM
      . Interaction revisited: the difference between two estimates. BMJ. 2003;326(7382):219pmid:12543843
      OpenUrlFREE Full Text
    28. ↵
      1. Rosario M,
      2. Corliss HL,
      3. Everett BG,
      4. Russell ST,
      5. Buchting FO,
      6. Birkett MA
      . Mediation by peer violence victimization of sexual orientation disparities in cancer-related tobacco, alcohol, and sexual risk behaviors: pooled youth risk behavior surveys. Am J Public Health. 2014;104(6):1113–1123pmid:24825215
      OpenUrlCrossRefPubMed
    29. ↵
      1. Gruskin EP,
      2. Hart S,
      3. Gordon N,
      4. Ackerson L
      . Patterns of cigarette smoking and alcohol use among lesbians and bisexual women enrolled in a large health maintenance organization. Am J Public Health. 2001;91(6):976–979pmid:11392944
      OpenUrlCrossRefPubMed
    30. ↵
      1. Meyer IH
      . Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: conceptual issues and research evidence. Psychol Bull. 2003;129(5):674–697pmid:12956539
      OpenUrlCrossRefPubMed
    31. ↵
      1. Hatzenbuehler ML
      . How does sexual minority stigma “get under the skin”? A psychological mediation framework. Psychol Bull. 2009;135(5):707–730pmid:19702379
      OpenUrlCrossRefPubMed
    32. ↵
      1. Lick DJ,
      2. Durso LE,
      3. Johnson KL
      . Minority stress and physical health among sexual minorities. Perspect Psychol Sci. 2013;8(5):521–548pmid:26173210
      OpenUrlCrossRefPubMed
    33. ↵
      1. Russell ST,
      2. Fish JN
      . Mental health in lesbian, gay, bisexual, and transgender (LGBT) youth. Annu Rev Clin Psychol. 2016;12:465–487pmid:26772206
      OpenUrlPubMed
    34. ↵
      1. Floyd FJ,
      2. Bakeman R
      . Coming-out across the life course: implications of age and historical context. Arch Sex Behav. 2006;35(3):287–296pmid:16804747
      OpenUrlCrossRefPubMed
    35. ↵
      1. Mulvey KL,
      2. Killen M
      . Challenging gender stereotypes: resistance and exclusion. Child Dev. 2015;86(3):681–694pmid:25382748
      OpenUrlPubMed
    36. ↵
      1. Poteat VP,
      2. Anderson CJ
      . Developmental changes in sexual prejudice from early to late adolescence: the effects of gender, race, and ideology on different patterns of change. Dev Psychol. 2012;48(5):1403–1415pmid:22250998
      OpenUrlPubMed
    37. ↵
      1. Russell ST,
      2. Toomey RB,
      3. Ryan C,
      4. Diaz RM
      . Being out at school: the implications for school victimization and young adult adjustment. Am J Orthopsychiatry. 2014;84(6):635–643pmid:25545431
      OpenUrlCrossRefPubMed
    38. ↵
      1. Toomey RB,
      2. Russell ST
      . The role of sexual orientation in school-based victimization: a meta-analysis. Youth Soc. 2016;48(2):176–201pmid:26997680
      OpenUrlCrossRefPubMed
    39. ↵
      1. Fish JN,
      2. Hughes TL
      . Alcohol expectancies, heavy drinking, and indicators of alcohol use disorders in a community-based sample of lesbian and bisexual women. LGBT Health. 2018;5(2):105–111pmid:29297753
      OpenUrlPubMed
    40. ↵
      1. Hatzenbuehler ML,
      2. Corbin WR,
      3. Fromme K
      . Discrimination and alcohol-related problems among college students: a prospective examination of mediating effects. Drug Alcohol Depend. 2011;115(3):213–220pmid:21145669
      OpenUrlCrossRefPubMed
    41. ↵
      1. Dilley JA,
      2. Spigner C,
      3. Boysun MJ,
      4. Dent CW,
      5. Pizacani BA
      . Does tobacco industry marketing excessively impact lesbian, gay and bisexual communities? Tob Control. 2008;17(6):385–390
      OpenUrlAbstract/FREE Full Text
    42. ↵
      1. Hughes TL,
      2. Wilsnack SC,
      3. Kantor LW
      . The influence of gender and sexual orientation on alcohol use and alcohol-related problems: toward a global perspective. Alcohol Res. 2016;38(1):121–132pmid:27159819
      OpenUrlPubMed
    43. ↵
      1. Fish JN,
      2. Schulenberg JE,
      3. Russell ST
      . Sexual minority youth report high-intensity binge drinking: the critical role of school victimization. J Adolesc Health. 2019;64(2):186–193
      OpenUrl
    44. ↵
      1. Phillips G II,
      2. Turner B,
      3. Salamanca P, et al
      . Victimization as a mediator of alcohol use disparities between sexual minority subgroups and sexual majority youth using the 2015 National Youth Risk Behavior Survey. Drug Alcohol Depend. 2017;178:355–362pmid:28692946
      OpenUrlPubMed
    45. ↵
      1. Mereish EH,
      2. O’Cleirigh C,
      3. Bradford JB
      . Interrelationships between LGBT-based victimization, suicide, and substance use problems in a diverse sample of sexual and gender minorities. Psychol Health Med. 2014;19(1):1–13pmid:23535038
      OpenUrlPubMed
    46. ↵
      1. Durso LE,
      2. Gates GJ
      . Serving our youth: findings from a national survey of services providers working with lesbian, gay, bisexual and transgender youth who are homeless or at risk of becoming homeless. 2012. Available at: http://escholarship.org/uc/item/80x75033. Accessed June 21, 2016
      1. Baams L,
      2. Talmage CA,
      3. Russell ST
      . Economic costs of bias-based bullying. Sch Psychol Q. 2017;32(3):422–433pmid:28661165
      OpenUrlPubMed
    48. ↵
      1. Snapp SD,
      2. Hoenig JM,
      3. Fields A,
      4. Russell ST
      . Messy, butch, and queer LGBTQ youth and the school-to-prison pipeline. J Adolesc Res. 2015;30:57–82
      OpenUrlCrossRef
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    Pediatrics
    Vol. 143, Issue 4
    1 Apr 2019
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    Cigarette Smoking Disparities Between Sexual Minority and Heterosexual Youth
    Jessica N. Fish, Blair Turner, Gregory Phillips, Stephen T. Russell
    Pediatrics Apr 2019, 143 (4) e20181671; DOI: 10.1542/peds.2018-1671
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