AJPH LETTERS AND RESPONSES A STRATEGIC APPROACH TO ELIMINATING SEXUAL ORIENTATION–RELATED HEALTH DISPARITIES

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ax et al.,1 investigating changes in self-reported tobacco use and household secondhand smoke (SHS) exposure in California, recently found good news: a reduction in SHS exposure over time, although lesbian, gay, and bisexual (LGB) nonsmokers remained at greater risk for SHS exposure than similar heterosexuals. As we reported in 2013,2 SHS exposure is elevated among nonsmoking LGB individuals nationally. Using information from the National Health and Nutrition Examination Survey, which measured both self-report and serum cotinine levels, we observed greater risk of both household and workplace SHS exposure among nonsmoking LGB individuals compared with heterosexuals. However, this varied by gender and sexual orientation identity, underscoring both the diversity of health risks that affect sexual minorities and the need for well-targeted interventions. While clearly national and state specific pictures may differ, research can benefit from building on previous studies. In this instance, our work offered some additional variables Letters to the editor referring to a recent AJPH article are encouraged up to 3 months after the article’s appearance. By submitting a letter to the editor, the author gives permission for its publication in AJPH. Letters should not duplicate material being published or submitted elsewhere. The editors reserve the right to edit and abridge letters and to publish responses. Text is limited to 400 words and 7 references. Submit online at www. editorialmanager.com/ajph. Queries should be addressed to the Editor-inChief, Alfredo Morabia, MD, PhD, at [email protected]

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Letters and Responses



Cochran and Mays

of interest for California’s tobacco control efforts, including household composition, which may be a significant moderator in SHS exposure for nonsmoking sexual minority men, many of whom live alone. We agree with the call by Max et al. for an intersectionality approach to LGB health research. We would like to advance this idea further using perspectives drawn from work by Thomas et al.3 and Kilbourne et al.4 They argued, using a four-generation health equity framework that racial/ethnic health disparities research must find a way to eliminate disparities. From their view, the first generation of work is to document that disparities exist; sexual orientation researchers have been doing this now for several years.5 The second generation of studies seeks to identify factors that contribute to disparities. Here, an emerging body of sexual orientation research has begun to do just that—calls to intersectionality foci and documenting the impact of minority stress6 are examples. The third generation, which as yet lies mostly over the horizon for sexual orientation research, is to propose and test interventions targeted at a specific disparity. And the fourth is to eliminate the risk of health disparities by removing their fundamental cause—in this case, likely social marginalization and stigmatization of LGB individuals. While research on LGB populations is still in its infancy compared with research on racial/ethnic minorities, the ability to move the field forward and achieve health equity will only come, as it does generally in science, through building on findings generated by previous research. Susan D. Cochran, PhD, MS Vickie M. Mays, PhD, MSPH ABOUT THE AUTHORS Susan D. Cochran is with the departments of Epidemiology and Statistics, University of California, Los Angeles (UCLA) Fielding School of Public Health, Los Angeles. Vickie M. Mays is with the departments of Psychology and Health Policy and Management, UCLA. Both authors are also with the UCLA Center for Bridging Research Innovation, Training and Education for Minority Health Disparities Solutions, Los Angeles.

Correspondence should be sent to Susan D. Cochran, Department of Epidemiology, UCLA Fielding School of Public Health, Box 951772, Los Angeles, CA 90095-1772 (e-mail: [email protected]). Reprints can be ordered at http:// www.ajph.org by clicking the “Reprints” link. This letter was accepted May 13, 2016. doi: 10.2105/AJPH.2016.303271

CONTRIBUTORS Both authors contributed equally to this letter.

REFERENCES 1. Max WB, Stark B, Sung HY, Offen N. Sexual identity disparities in smoking and secondhand smoke exposure in California: 2003–2013. Am J Public Health. 2016;106(6): 1136–1142. 2. Cochran SD, Bandiera FC, Mays VM. Sexual orientation-related differences in tobacco use and secondhand smoke exposure among US adults aged 20 to 59 years: 2003–2010 National Health and Nutrition Examination Surveys. Am J Public Health. 2013;103(10): 1837–1844. 3. Thomas SB, Quinn SC, Butler J, Fryer CS, Garza MA. Toward a fourth generation of disparities research to achieve health equity. Annu Rev Public Health. 2011;32: 399–416. 4. Kilbourne AM, Switzer G, Hyman K, CrowleyMatoka M, Fine MJ. Advancing health disparities research within the health care system: a conceptual framework. Am J Public Health. 2006; 96(12):2113–2121. 5. Stall R, Matthews DD, Friedman MR, et al. The continuing development of health disparities research on lesbian, gay, bisexual, and transgender individuals. Am J Public Health. 2016;106(5):787–789. 6. Meyer IH. Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: conceptual issues and research evidence. Psychol Bull. 2003;129(5): 674–697.

MAX ET AL. RESPOND

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e thank Cochran et al. for their thoughtful comments regarding the needed research to eliminate health disparities, in this case, related to tobacco use and secondhand smoke (SHS) exposure in the lesbian, gay, and bisexual (LGB) community. As we reported in our study, both tobacco use and SHS exposure have fallen over time for sexual minority as well as heterosexual adults in California, although both prevalence rates remain higher for the former. A number of explanations have been suggested to explain the greater rates of tobacco use and SHS exposure in the LGB community, including

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AJPH LETTERS AND RESPONSES

a bar-focused subculture, targeted tobacco industry efforts, stress, and structural stigma and discrimination commonly perceived by LGB adults. Cochran et al. suggest that another factor that might be considered as moderating SHS exposure is household composition, which they define as living alone or with others.1 Other measures of household composition could include living with a spouse and the presence of absence of children in the home. The four-generation framework proposed by Thomas et al.2 is indeed a useful one for evaluating our progress toward eliminating sexual identity disparities in smoking and SHS exposure. To this framework, we would add documenting the impact of these disparities. There is a growing literature that reports greater rates of illness, including asthma, cancer, cardiovascular disease, and diabetes among sexual minorities, particularly women,3–6 and tobacco use is cited by several of these studies as a potential causal factor. Determining the health-related economic burden that results from tobacco use and exposure in LGB adults is an additional way to measure the impact of tobacco use on sexual-identity health disparities. Documenting the impact of disparities helps motivate the development of interventions to reduce them. The LGB community proved to be extremely adept at organizing to bring attention to an earlier threat to health— that of HIV/AIDS. Estimates of the health care and other costs that tobacco imposes on the LGB community will be very useful for rallying the developing networks of LGB tobacco control advocates7 as well as the public health community at large to redouble efforts toward reducing the impact of tobacco on this highly vulnerable community.

Correspondence should be sent to Wendy Max, Professor of Health Economics and Director, Institute for Health & Aging, University of California, San Francisco, 3333 California Street, Suite 340, San Francisco, CA 94118 (e-mail: [email protected] ucsf.edu). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link. This letter was accepted May 13, 2016. doi: 10.2105/AJPH.2016.303272

CONTRIBUTORS All authors contributed equally to this letter.

REFERENCES 1. Cochran SD, Bandiera FC, Mays VM. Sexual orientation-related differences in tobacco use and secondhand smoke exposure among US adults aged 20 to 59 years: 2003-2010 National Health and Nutrition Examination Surveys. Am J Public Health. 2013;103(10): 1837–1844. 2. Thomas SB, Quinn SC, Butler J, Fryer CS, Garza MA. Toward a fourth generation of disparities research to achieve health equity. Annu Rev Public Health. 2011;32: 399–416. 3. Lick DJ, Durso LE, Johnson KL. Minority stress and physical health among sexual minorities. Perspect Psychol Sci. 2013;8(5):521–548. 4. Blosnich JR, Lee JG, Bossarte R, Silenzio VM. Asthma disparities and within-group differences in a national, probability sample of same-sex partnered adults. Am J Public Health. 2013;103(9):e83–e87. 5. Heck JE, Jacobson JS. Asthma diagnosis among individuals in same-sex relationships. J Asthma. 2006;43(8): 579–584. 6. Farmer GW, Jabson JM, Bucholz KK, Bowen DJ. A population-based study of cardiovascular disease risk in sexual-minority women. Am J Public Health. 2013; 103(10):1845–1850. 7. Offen N, Smith EA, Malone RE. Is tobacco a gay issue? Interviews with leaders of the lesbian, gay, bisexual and transgender community. Cult Health Sex. 2008;10(2): 143–157.

Wendy Max, PhD Brad Stark, BA Hai-Yen Sung, PhD Naphtali Offen, BS ABOUT THE AUTHORS Wendy Max and Hai-Yen Sung are with the Institute for Health & Aging and the Department of Social and Behavioral Sciences in the School of Nursing, University of California, San Francisco. Brad Stark is with the Institute for Health & Aging, School of Nursing, University of California, San Francisco. Naphtali Offen is with the Department of Social and Behavioral Sciences, School of Nursing, University of California, San Francisco.

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Max et al. Respond.

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