Coming out as bisexual associated with increased risk of smoking: BU study

For many years, lesbian, gay, bisexual, and other non-heterosexual (LGB+) folks have been known to be more likely to smoke than their straight counterparts.

But a new, first-of-its-kind Boston University School of Public Health (BUSPH) study paints a more precise picture by looking at LGB+ identities separately and over time, finding that bisexuality is the identity most associated with smoking, especially around the time of coming out.

Published in the journal JAMA Pediatrics, the nationally-representative cohort study followed 7,843 youth and young adults over three years, finding that those who came out as bisexual were twice as likely as consistently-heterosexual participants to start smoking. Coming out as lesbian, gay, or another non-heterosexual identity, or having a consistent LG+ identity, was not associated with being more likely to smoke.

The study “highlights the importance of moving beyond static measures of sexual identity towards more dynamic measures that capture critical periods of vulnerability,” says Dr. Andrew Stokes, assistant professor of global health at BUSPH and the study’s corresponding author.

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“This approach turned out to be really important, because it revealed disparities that would have otherwise been missed if we measured identity at one time point, or grouped all LGB+ identities together,” says study lead author Alyssa Harlow, a doctoral candidate at BUSPH.

“Bisexual young people may face unique forms of discrimination and stigma that increase their risk for smoking or other substance use behaviors,” she says. “For example, they may experience stigma from heterosexual individuals as well as from within the LGB+ community. There’s also prior research that shows that bisexual populations have worse mental health outcomes than LG+ populations.

‘The findings point to a need for public health interventions specifically designed to address the unique needs, experiences, and stressors associated with coming out and identifying as bisexual,” Harlow says.

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For the study, the researchers used data from the first four waves of the nationwide Population Assessment of Tobacco and Health (PATH) study, which surveyed the same 14-29-year-olds three times between 2013 and 2018. (There were too few transgender respondents in this sample for the researchers to include gender identity in their analysis.) The researchers adjusted for other variables including sex, age, race/ethnicity, education level (for participants over 18) and parents’ education level (for participants under 18), and where participants lived (urban/nonurban, and region of the U.S.).

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By the third wave, 14% of the respondents had smoked at some point, and 6% were current smokers. The researchers found that the same sexual identity patterns held true both for having smoked at any point in the study period and for being a current smoker.

The researchers found that, compared to a consistent heterosexual identity, coming out as bisexual was associated with being more than twice as likely to smoke. Participants with LG+ identities in the first wave who shifted to a bisexual identity, or vice versa, were twice as likely to smoke.

On the other hand, participants with a consistent LG+ identity throughout the three waves of the study and participants who started out identifying as heterosexual and came out as LG+ were not more likely to smoke than those with a consistent heterosexual identity–while those with a consistent bisexual identity were slightly more likely to smoke.

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The researchers say that the study’s unique approach to LGB+ identities–separated and over time–could provide valuable insights for other issues that disproportionately affect the community, including mental health issues and substance use.

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But to make that possible, more national surveys need to ask youth about their sexual orientation and gender identity, says study co-author Dielle Lundberg, a research fellow at BUSPH.

“The PATH study is unique because it asks youth about their sexual orientation and gender identity. Most national surveys do not,” Lundberg says.

“We must advocate for better data. Whenever national surveys fail to ask about sexual orientation and gender identity, they are directly contributing to health inequities for LGBTQ+ populations.”


Boston University School of Medicine

Journal Reference

Association of Coming Out as Lesbian, Gay, and Bisexual+ and Risk of Cigarette Smoking in a Nationally Representative Sample of Youth and Young Adults

Importance Coming out as lesbian, gay, bisexual, or other identities besides heterosexual (LGB+) may represent a susceptible period for cigarette smoking initiation in youth and young adults.

Objective To assess whether young people who change their sexual identity have higher risk of cigarette smoking initiation and current smoking compared with those with consistent sexual identities.

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Design, Setting, and Participants This cohort study used data from the nationally representative Population Assessment of Tobacco and Health study (wave 1, 2013-2014; wave 2, 2014-2015; wave 3, 2015-2016; wave 4, 2016-2018). Youth and young adults aged 14 to 29 years who were never smokers at wave 1 were included in this study. Analysis began October 2018 and ended June 2020.

Exposures Consistent sexual identity (consistently heterosexual, consistently LGB+) vs changing sexual identity (coming out as LGB+, other LGB+ patterns) based on 4 waves of sexual identity data. Identities were further classified by distinguishing between bisexual and lesbian, gay, and other nonheterosexual identities.

Main Outcomes and Measures Smoking initiation and current cigarette smoking at wave 4.

Results Among 7843 individuals who never smoked at wave 1, 6991 (90.7%) reported a consistent sexual identity, and 852 (9.3%) changed sexual identity across waves. The mean (SE) baseline age of participants who reported consistent heterosexuality was 20.1 (0.8) years; consistently LGB+, 20.0 (3.7) years; coming out as LGB+, 18.0 (2.9) years, and other LGB+ pattern, 20.3 (3.8) years. A total of 14.1% (weighted) initiated smoking, and 6.3% were current smokers at wave 4. Compared with consistently heterosexual identities, coming out as LGB+ (23% vs 13%; odds ratio [OR], 1.72; 95% CI, 1.34-2.20), consistently LGB+ identities (17% vs 13%; OR, 1.45; 95% CI, 1.03-2.04), and other LGB+ patterns (17% vs 13%; OR, 1.47; 95% CI, 1.04-2.08) were positively associated with smoking initiation by wave 4. Compared with consistently heterosexual identities, ORs for smoking initiation were 2.24 (28% vs 13%; 95% CI, 1.72-2.92) for coming out as bisexual, 1.99 (23% vs 13%; 95% CI, 1.20-3.29) for consistently LGB+ with change to/from bisexual, and 2.20 (23% vs 13%; 95% CI, 1.40-3.46) for other LGB+ patterns with change to/from bisexual identity. Current smoking estimates were similar to those for smoking initiation.

Conclusions and Relevance Compared with consistently heterosexual identities, changing sexual identity over follow-up was associated with smoking initiation and current smoking. The risk associated with changing sexual identities was concentrated among participants coming out as bisexual or reporting other changes in their identity to/from being bisexual. More research is needed on mechanisms underlying the association between changing sexual identity and smoking initiation to inform tailored prevention programs and tobacco regulations.

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