Journal of Homosexuality, 62:604–620, 2015 Copyright © Taylor & Francis Group, LLC ISSN: 0091-8369 print/1540-3602 online DOI: 10.1080/00918369.2014.987569
Smoking and Intention to Quit Among a Large Sample of Black Sexual and Gender Minorities JENNA N. JORDAN, MPH and KEVIN D. EVERETT, PhD Department of Family & Community Medicine, University of Missouri, Columbia, Missouri, USA
BIN GE, MD, MA Department of Medical Research, University of Missouri, Columbia, Missouri, USA
JANE A. MCELROY, PhD Department of Family & Community Medicine, University of Missouri, Columbia, Missouri, USA
The purpose of this study is to more completely quantify smoking and intention to quit from a sample of sexual and gender minority (SGM) Black individuals ( N = 639) through analysis of data collected at Pride festivals and online. Frequencies described demographic characteristics; chi-square analyses were used to compare tobacco-related variables. Black SGM smokers were more likely to be trying to quit smoking than White SGM smokers. However, Black SGM individuals were less likely than White SGM individuals to become former smokers. The results of this study indicate that smoking behaviors may be heavily influenced by race after accounting for SGM status. KEYWORDS African American, black, LGBT, sexual minority, smoking, cessation
Studying the fundamental determinants of tobacco use, such as race, sexual orientation, and gender identity, is critical to inform targeted public health interventions. Tobacco use is a widespread problem among sexual and gender minorities (SGM; also referred to as lesbian, gay, bisexual, Address correspondence to Jane A. McElroy, Department of Family & Community Medicine, University of Missouri, MA306 Medical Sciences Bldg., Columbia, MO 65212, USA. E-mail: [email protected] 604
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transgender, transsexual, and queer or questioning). Tobacco use has been shown to be more prevalent among SGM adults than the general population (Aaron et al., 2001; Archer, Hoff, & Snook, 2005; Diamant et al., 2000; Dilley et al., 2005; Gruskin et al., 2007; Lee, Griffin, & Melvin, 2009; McCabe, Hughes, Bostwick, & Boyd, 2005; McElroy, Everett, & Zaniletti, 2011; Pizacani et al., 2009; Stall et al., 1999; Tang et al., 2004; Valanis et al., 2000). For example, a study by the National Coalition for LGBT Health found that lesbian, gay, bisexual, and transgender subgroups range from 40%–70% more likely to smoke than the non-LGBT population (Hitchcock & Hitchcock, 2005). Among SGM subgroups in the Pacific Northwest, a study found smoking prevalence to be 31.7% gay men, 35.9% bisexual men, 29.5% lesbian women, and 35.9% bisexual women compared to 20.3% heterosexual men and 17.3% heterosexual women (Pizacani et al., 2009). In a California study, the smoking prevalence by SGM subgroups were 22.2% gay/lesbian, 22.6% bisexual, and 29.7% men who have sex with men/women who have sex with women compared to 9.1% in the general population (Gruskin et al., 2007). Missourians’ smoking prevalence were found to be 40% or higher for bisexual females, transgender/genderqueer, and transsexual individuals (McElroy, Everett, & Zaniletti 2011) compared to 23% for Missourians (Missouri Department of Health and Senior Services, 2007a). Only a few studies have collected information on attitudes about tobacco use by selfidentified lesbians, gays, bisexuals, transgendered, or transsexual people (Pizacani et al., 2009). Among sexual and gender minorities in Missouri, 40% believe LGBT organizations should not accept money from tobacco companies, 54% support smoke-free policies in workplaces (including bars and restaurants), and 61% do not allow smoking in the home (McElroy, Everett, & Zaniletti, 2011). A survey in Washington and Oregon that included 2,106 SGM participants found 53% of lesbians, 29% of gay men, and 38% of bisexuals supported banning smoking in bars (Pizacani et al., 2009). While smoking rates are comparable in the general population between adult White and Black Americans (20.6% vs. 19.4%, respectively; Centers for Disease Control and Prevention [CDC], 2012), a review of smoking cessation data found that Whites were significantly more likely than African Americans to be former smokers (King, Polednak, Bendel, Vilsaint, & Nahata, 2004). A few studies have examined smoking behaviors and cessation programs in self-identified SGM Black individuals (Lee, Griffin, & Melvin, 2009). In a study of urban women, African American lesbians were more likely to smoke than both African American heterosexual women and White lesbians (Hughes, Johnson, & Matthews, 2008). Masini and Matthews reported that men who have sex with men are more entrenched in their smoking attitudes, and they argued that smoking is influenced by many factors such as race/ethnicity, age, educational attainment, income, stress associated with homophobia and discrimination, higher alcohol rates, social norms that support smoking, and targeted marketing to the SGM communities by tobacco companies (Masini
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& Matthews, 2007). As suggested by Masini and Matthews, Black individuals who identify as SGM represent a minority within a minority, and they are subject to multiple minority stress due to experiences with both racism and heterosexism (Balsam, Molina, Beadnell, Simoni, & Walters, 2011; Wheeler, 2003). In the context of the social–ecological model, health behaviors (such as smoking) and taking action to improve one’s health (such as or quitting smoking) are determined by multiple influences at the individual, relationship, community, and society levels (CDC, 2009). With regard to health and access to resources to improve one’s health, sexual and gender minorities are a disenfranchised group that experience discrimination, stigma, and prejudice, all of which are social determinants of health (CDC, 2011; Healthy People 2020, 2013; Meyer, 2003). Moreover, the resulting psychological distress experienced by SGM people as a result of discrimination and stigma may be heightened among African American sexual and gender minorities (Cochran & Mays, 1994). Within SGM communities, people of color may experience racism (Balsam et al., 2011), be excluded from LGBT events and spaces (Kudler, 2007), and perceive LGBT organizations to predominately serve White populations (Ward, 2008). The complex intersection of sexual orientation, gender identity, and race compound the marginalization of Black sexual and gender minorities at multiple levels of the social–ecological model, potentially leading to tobacco-related disparities (CDC, 2009; Wheeler, 2003). A recent study of community-based smoking cessation for LGBT smokers found benefits to offering LGBT-tailored treatment (32% self-reported quit rate) but did not include tailoring for Black LGBT smokers (Matthews, Li, Kuhns, Tasker, & Cesario, 2013). As a result, the purpose of this study is to more completely quantify tobacco use and intention to quit from a sample of self-identified SGM Black individuals through analysis of Out, Proud, and Healthy survey data collected at five Missouri Pride Festivals and online during 2011. Information obtained from this assessment can be used to bridge the gap and develop accessible interventions for SGM Black individuals to reduce tobacco use.
METHODS Project Recruitment The primary recruitment method involved asking attendees at five Pride Festivals in Missouri (St. Louis, Kansas City, Springfield, Columbia, and the Black Pride Festival in St. Louis) during the summer of 2011 to complete a 36-item paper survey. The second method used Internet-based recruitment of participants who then completed the survey online. Compensation was not provided, but Pride Festival attendees were offered bubbles, Out, Proud,
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and Healthy stickers, and ice water. Participant eligibility included being age 18 or older and able to read English. The participants identifying as heterosexual were included in the study to provide a more thorough description of the Pride Festival sample and to serve as a comparison group.
Pride Festival Data Collection The University of Missouri Health Sciences Institutional Review Board approved the Out, Proud, and Healthy study. Research staff received training in study protocols. A booth was rented at each Pride Festival to serve as a base from which attendees were approached and invited to complete, anonymously, a 36-item paper survey on health, including tobacco-related behaviors and attitudes. Basic demographic and health information were also collected. The survey took approximately 10 minutes to complete.
Web-Based Survey Data Collection The Out, Proud, and Healthy advisory board, using formal and informal networks, assisted in posting the Web-based survey on several SGM sites, including a statewide electronic SGM newspaper, the statewide SGM organization, and SGM urban communities centers, as well as Listservs that focus on SGM issues. The Web-based anonymous survey contained the same 36 items found on the Pride Festival surveys. A screening question eliminated participants less than 18 years old and those who had completed the survey at any of the five Pride Festivals in 2011. The survey was posted for 6 weeks. E-mail reminders were sent twice to SGM organizations and community center Listservs encouraging people to participate.
Measurement The survey included demographics (race, age, ethnicity, and education), gender identity and sexual orientation, tobacco and alcohol use, and questions targeting beliefs and preferences related to tobacco use as well as other health-related behavior. The Behavioral Risk Factor Surveillance System Questionnaire (CDC, 2007) was used as a guide for developing questions about tobacco use histories, rules for tobacco use in households and vehicles, and other health-risk and health-related behaviors.
Categorizing Gender and Sexual Minority (SGM) Status Individuals were classified into only one category (lesbian, gay, bisexual male, bisexual female, heterosexual, transgender/ transsexual, or other SGM) based on their response to the following questions, “Do you consider yourself to be: (lesbian; gay; bisexual; straight/heterosexual; other/please
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specify; or don’t know/not sure),” “Do you identify as transgender or transsexual: (Yes, transgender; Yes, transsexual; or No),” and “Are you a man or a woman? (Circle one).” “Other/please specify” and “don’t know/not sure” responses for the sexual orientation questions were combined and labeled “other SGM” as a separate SGM category. Heterosexual status was defined as indicating straight/heterosexual on the sexual orientation question and indicating either male or female (not transgender or transsexual). The participants were also classified into two overall categories: heterosexual or sexual and gender minorities (SGM).
Categorizing Race and Ethnicity Participants were first asked, “Are you Hispanic/Latino/a?: (Yes or No).” Participants were then asked, “Which category most closely describes your race? Check all that apply: (Black/African American; Asian; White; American Indian or Alaska Native; Native Hawaiian or Other Pacific Islander).” Participants were classified as White if they responded “No” to being Hispanic/Latino and if they only marked “Yes” for White. Participants were considered Black/African American if they responded “No” to being Hispanic/Latino and if they only marked “Yes” for Black/African American. Due to small sample sizes, participants in other racial and ethnic categories were excluded from analysis, and this study specifically examined nonHispanic White (referred to as White) and non-Hispanic Black (referred to as Black) participants.
Categorizing Smoking Status and Intention to Quit Current smokers were defined as those who had smoked at least 100 cigarettes in their lifetimes and reported currently smoking some days or every day. Former smokers were defined as those who had smoked at least 100 cigarettes in their lifetimes and reported not currently smoking. Never smokers were defined as having not smoked 100 cigarettes in their lifetimes. Intention to quit status was determined by asking “Which statement best describes you now?” The four options were (1) “I am trying to quit,” (2) “I plan to quit smoking tobacco (within the next month),” (3) “I think about quitting smoking tobacco some time in the future (in the next 6 months),” and (4) “I don’t think about quitting smoking tobacco.”
Analytic Plan A series of analyses examined differences between Black and White participants by SGM status on variables related to tobacco use in SGM
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communities. Frequencies were calculated to describe items measuring demographic characteristics, smoking status, and issues concerning public and personal smoke-free policies. Chi-square analyses were used to compare all variables other than age and mean cigarettes smoked per day. t tests were used to compare differences in mean age between the groups, and Wilcoxon two-sample tests were used to compare differences in mean cigarettes smoked per day between the groups. Analysis was conducted using SAS 9.3 statistical software (Cary, NC).
RESULTS Sample Description: Total Sample Comparisons by Race and SGM Subgroup A total of 4,363 adults participated in the study; however, 155 participants were excluded because they were missing data for smoking status, race, or SGM status. There was no statistical difference between those who were excluded for missing race and sexual orientation data compared to the overall sample in terms of smoking status. An additional 521 participants who did not identify as non-Hispanic Black or non-Hispanic White were excluded from the analysis. Of the remaining 3,687 surveys, 639 (17.3%) participants were Black and 3,048 (82.7%) were White. The Black sample was represented by 218 lesbian (34.1%), 176 gay (27.5%), 87 bisexual (13.6%), 20 transgender/transsexual (3.1%), and 42 other sexual and gender minorities (6.6%), comprising 84.9% of the Black sample. Heterosexuals comprised 15.1% of the Black sample. The White sample was represented by 821 lesbian (26.9%), 1,003 gay (32.9%), 339 bisexual (11.1%), 118 transgender/ transsexual (3.9%), and 162 other sexual and gender minorities (5.3%); comprising 80.1% of the White sample. Heterosexuals comprised 19.9% of the White sample. The mean age for the Black SGM sample was 30.0 years. Education distribution for the Black SGM sample was 29.3% with a high school diploma, GED, or less, 48.1% with some college or technical school, and 22.7% with a college degree or more. Among the Black SGM sample: 58.6% were never smokers, 5.2% were former smokers, and 36.3% were current smokers (Table 1). The mean age for the White SGM sample was 33.7 years. Education distribution for the White SGM sample was 17.5% with a high school diploma, GED, or less, 38.4% with some college or technical school, and 44.0% with a college degree or more. Among the White SGM sample, 47.3% were never smokers, 15.1% were former smokers, and 37.7% were current smokers (Table 1).
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TABLE 1 Comparing smoking status of Black and White participants and within SGM subgroups† Smoking Status
Black (n = 639)
Total Current Total Former∗∗∗ Total Never∗∗∗ Current Lesbian Gay Bisexual Men Bisexual Women Transgender/Transexual Other SGM Heterosexual Former Lesbian∗∗∗ Gay∗∗ Bisexual Men Bisexual Women Transgender/Transexual Other SGM Heterosexual Never Lesbian∗∗ Gay Bisexual Men Bisexual Women∗ Transgender/Transexual Other SGM Heterosexual
White (n = 3,048)
36.3% 5.2% 58.6%
37.7% 15.1% 47.3%
38.1% 35.8% 36.4% 30.8% 55% 28.6% 36.5%
47.2% 34.7% 38.6% 41.6% 36.4% 34.6% 32.6%
3.9% 6.8% 9.1% 3.1% 5% 4.8% 7.3%
14.9% 16.4% 5.7% 14.5% 11.9% 15.4% 15.2%
57.8% 57.4% 54.5% 66.2% 40% 66.7% 56.2%
44.8% 49.0% 55.7% 43.9% 51.7% 50.0% 52.2%
† Percentages
may not add to 100 due to rounding. at p < 0.05. ∗ Significant at p < 0.01. ∗∗ Significant at p < 0.001. ∗∗∗ Significant at p < 0.0001. Significant
Comparing Pride Festivals and Web-Based Participants Of the 3,687 surveys analyzed, 3,381 surveys were obtained from the five Pride Festivals and 306 were obtained from the Web-based survey. Statistical differences in responses to questions between the two modes of participation included race, educational attainment, and age. Specifically, a greater proportion of the Web-based sample compared to the Pride Festival sample self-identified as White (91.9% vs. 70.9%) (p < 0.0001), had a college education (72.4% vs. 50.0%; p < 0.0001) and had a significantly older average age (40.6 years vs. 31.6 years; p < 0.0001). There were no significant differences in smoking status (current, former, or never) between the Web-based and Pride Festival samples (data not shown).
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Comparing Smoking Status of Black SGM Respondents to White SGM Respondents Significantly more Black lesbian (p < 0.001), bisexual women (p < 0.01), and gay men (p < 0.05) were never smokers compared to their White SGM counterparts (Table 1). No racial differences were found in the proportion of bisexual men, transgender/transsexual, other SGM, or heterosexual respondents who were never smokers. In addition, significantly fewer Black lesbian (p < 0.0001), bisexual women (p < 0.05), gay (p < 0.001), and heterosexuals (p < 0.05) were former smokers compared to White lesbian, bisexual women, gay, and heterosexuals. No racial differences were found in the proportion of bisexual men, transgender/transsexual, or other SGM who were former smokers. No significant differences were found in the proportion of current smokers in each SGM subgroup by race (Table 1). Overall, significant differences were found in never and former smoking status between SGM Black and SGM White adults, but not in current smoking status. SGM Black adults were less likely to be former smokers compared to SGM White adults (p < 0.0001). SGM Black individuals were also significantly more likely to be never smokers compared to their White counterparts (p < 0.0001; data not shown).
Comparing SGM Black Current Smokers to SGM White Current Smokers Significant differences in age and education were found between Black SGM current smokers and White SGM current smokers. Black SGM smokers were younger (28.9 years) than White SGM smokers (32.4 years; p < 0.001). In addition, Black SGM smokers were less likely to have graduated college (p < 0.001; Table 2). Black SGM individuals smoked a mean of 10 cigarettes per day, while their White counterparts smoked a mean of 13 cigarettes per day (p < 0.0001). Black SGM smokers were more likely to be currently trying to quit or planning to quit smoking within the next month (p < 0.0001). On variables related to attitudes and beliefs about smoking, differences were found in household smoking rules. Black SGM smokers were much more likely to allow smoking in their homes compared to White SGM smokers (p < 0.001). Black SGM smokers did not significantly differ from their White counterparts in rules about smoking in the vehicle, having a partner that smoked, supporting smoke-free policies in all indoor workplaces (including restaurants and bars), being some day smokers, or being everyday smokers (Table 2). Black and White heterosexuals were examined to determine if differences in smoking behaviors by race existed regardless of SGM status.
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TABLE 2 Comparing characteristics of Black SGM current smokers and White SGM current smokers† Demographics and Smoking Characteristics Education High school graduate or less∗∗∗ Some college∗∗∗ College graduate or more∗∗∗ Every day or some days smoker Every day Some days Intention to quit Trying to quit∗∗ Plan to quit within month∗∗ Think about quitting in 6 months∗∗ Don’t think about quitting∗∗ Partner smokes Yes No Smoking rules in house Not allowed∗∗∗ Allowed∗∗∗ Smoking rules in vehicle Not allowed Allowed Support smoke-free policies Yes No Not sure Mean Age∗∗∗ Mean number of cigarettes smoked/day∗∗∗
Black SGM n = 197 33.5% 55.8% 10.7% n = 196 70.9% 29.1% n = 182 22.0% 24.2% 36.3% 17.6% n = 171 38.6% 61.4% n = 176 25.0% 75.0% n = 179 16.2% 83.8% n = 181 51.4% 36.5% 12.2% n = 197 28.9 n = 197 10
White SGM n = 920 25.2% 43.8% 31.0% n = 918 75.9% 24.1% n = 813 12.7% 18.9% 42.4% 26.0% n = 792 45.7% 54.3% n = 887 54.9% 45.1% n = 894 17.3% 82.7% n = 892 55.3% 36.4% 8.3% n = 921 32.4 n = 921 13
† Percentages
may not add to 100 due to rounding. ages 25 and older. ∗∗ Significant at p < 0.001. ∗∗∗ Significant at p < 0.0001. Participants
In evaluating differences between heterosexual Black and White participants, White smokers averaged 12 cigarettes per day, while Black smokers averaged 8 cigarettes per day (p < 0.05). No other differences were found between Black heterosexual smokers and White heterosexual smokers in any of the aforementioned categories (data not shown).
Comparing Black SGM Current Smokers and Black Heterosexual Current Smokers Black SGM smokers had an average age of 28.9 years and were younger on average than Black heterosexual smokers, who had an average of 34.2 years
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(p < 0.05). No differences were found between the two groups on the following variables: education level, smoking status, intention to quit, mean number of cigarettes smoked per day, rates of partner smoking, household smoking rules, vehicle smoking rules, and support for smoke-free policies (data not shown).
DISCUSSION This Out, Proud, and Healthy study is the first to look for differences in smoking status, intention to quit, and smoking-related attitudes between Black and White adults who self-identify as sexual and gender minorities, and it represents one of the largest and most diverse samples of the SGM communities in the published literature. The overall size and diversity of the sample allowed for comparisons within the SGM communities related to racial differences. This study provides new, important research on smoking behaviors regarding this minority within a minority population. Several important differences were found between Black and White sexual and gender minorities related to smoking. While Black SGM and White SGM had similar current smoking prevalence (36.3% vs. 37.7%), significantly more Black SGM were never smokers compared to White SGMs (58.6% vs. 47.3%). Among current smokers, Black SGM were significantly more likely to be trying to quit smoking (22.0% vs. 12.7%) or planning on quitting smoking within the month (24.2% vs. 18.9%) compared to White SGM. Some gender differences were also seen by race. Fewer Black lesbian and bisexual women were former smokers compared to their White counterparts. The same was true for gay men but not bisexual men. In addition, Black SGM smokers use significantly fewer cigarettes per day (CPD) on average than White SGM smokers (10 CPD vs. 13 CPD). With more Black SGM participants expressing a readiness to quit smoking than their White counterparts, cessation campaign messaging targeted to the Black community may be an effective tobacco control strategy. Additional research is needed to determine the factors creating the social context for Black SGM individuals to endorse a greater readiness to quit. In contrast, SGM Black individuals were significantly less likely than SGM White individuals to become former smokers (5.2% vs. 15.1%). This suggests fewer successful cessation attempts for Black SGM smokers, which may indicate barriers to Black SGM individuals, especially lesbian, bisexual women, and gay men, receiving evidence-based cessation services despite their higher readiness to quit. For example, Okuyemi et al. reported that Black light smokers at an inner city walk-in clinic were more likely to be ready to quit; paradoxically, they were also less likely to be asked about their smoking status or told to arrange a follow-up meeting for smoking cessation by their physicians than moderate or heavy smokers (Okuyemi,
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Ahluwalia, Richter, Mayo, & Resnicow, 2001). Similarly, numerous barriers to quitting were identified by low-income Black women that may resonate among the Black SGM community, including managing their lives in highly stressful environments, commonality of smoking in their community, and little knowledge about evidence-based cessation strategies, among other barriers (Manfredi, Balch, & Warnecke, 1993). In light of the social–ecological theory, while Black SGM smokers have higher motivation to quit than their White counterparts but lower prevalence of former smokers, community and societal influences (i.e., access to resources or referrals by physicians) may play a larger role in becoming a former smoker than individual level behavior (intention to quit). This pattern matters since fewer former smokers in the Black community compared to the White community may lead to worsening of health disparities due to the significant role of tobacco in producing health problems. Discrimination based on one’s racial identity or sexual orientation can lead to poor health outcomes such as anxiety, depression, drug use, and low self-esteem (Balsam et al., 2011; Landrine & Klonoff, 1996; Williams & Mohammed, 2009). African American men in particular experience serious health disparities compared to other racial and gender groups (Xanthos, Treadwell, & Holden, 2010). In line with the social–ecological theory, social and environmental factors, such as reduced access to education, employment, and quality health services, play a significant role in African American men’s health (Xanthos et al., 2010). Moreover, Copeland reported that compared with White individuals, Black individuals were less likely to have private or employment-based health insurance, were more likely to be covered by Medicaid or other publicly funded insurance, and were twice as likely to be uninsured (Copeland, 2005). As a result, the Black population may not have the same access to smoking cessation information, counseling, or nicotine replacement therapies. This disparity could also result from cessation treatments that are not tailored to maximize success being offered to Black SGM individuals more often than their White counterparts. There are important relationships between socioeconomic status (SES) and health, and Blacks experience poverty at two to three times the rate of Whites (U.S. Census Bureau, 2008), potentially accounting for disparities in smoking cessation and health. Research finds that among the socioeconomically disadvantaged, there is a higher smoking prevalence, and quit attempts are less likely to be successful (Hiscock, Bauld, Amos, Fidler, & Munafo, 2012). The same disparities in access to health care exist for sexual and gender minorities (Dilley, Simmons, Boysun, Pizacani, & Stark, 2010). Further, SES is a significant predictor of self-reported health among sexual and gender minorities (Thomeer, 2013). In this way, the lack of access and utilization of health care and smoking cessation services may be compounded among Black individuals who identify as SGM due to their multiple minority status (Balsam et al., 2011).
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Although we did not evaluate nicotine dependency or type of preferred cigarette, previous studies suggest that Black smokers may become more heavily dependent on nicotine than White smokers due to the high rates of mentholated cigarette smoking among Black individuals (Royce, Hymowitz, Corbett, Hartwell, & Orlandi, 1993). While menthol may not be an addictive substance itself, it is considered a non-nicotine component that provides reinforcing sensory stimulation during smoking, compounding the addictive effect of nicotine (Rose, 2006). A study by Okuyemi, Ebersole-Robinson, Nazir, and Ahluwalia found that approximately 80% of Black smokers choose menthol cigarettes, compared to about 20% of White smokers, potentially contributing to the racial differences in rates of former smokers among SGM (Okuyemi, Ebersole-Robinson, Nazir, & Ahluwalia, 2004). Other variables identified in the study that may play a role in this difference include education level, age, and smoking in the home. It should be noted that education is protective against smoking (de Walque, 2007), and in our sample three times as many White SGM current smokers graduated college as Black SGM current smokers, indicating societal-level inequalities for this double minority group. Wetter et al. found that education level contributes to the prediction of smoking abstinence even after accounting for demographic, environmental, tobacco dependence, readiness to change, and job-related variables (Wetter et al., 2005). Furthermore, the average age of our SGM Black sample was 28.9 years, which was significantly younger than White SGM smokers at 32.4 years. The lower proportion of former smokers in the SGM Black sample may be partially due to their younger average age and having had less time in which to make quit attempts compared to the slightly older SGM White sample. In addition, significantly more SGM Black individuals allowed smoking in some or all places in their homes than their White counterparts. Acceptance of smoking in the home in the SGM Black population may also reduce successful quit attempts. A growing number of smoking cessation programs recognize the importance of being culturally sensitive to reach the intended audience, such as sexual and gender minorities. Beyond identifying SGM status, effective cessation programs must address the unique needs and culture of SGM Black individuals, which differ from those of SGM White individuals (Wheeler, 2003). Studies have found that efforts to encourage smoking cessation among Black populations are most successful if they use media that reach Black audiences, if they tailor their print materials to address their specific needs, and if Black communities networks are utilized (Stotts, Glynn, & Baquet, 1991). Although the effectiveness for culturally tailored programs for Black SGM individuals is still unknown, it is possible that these same strategies could be implemented within the SGM communities to effectively target Black SGM smokers. A limitation of this study is the scope of the survey (36 items). This survey did not encompass several variables related to tobacco use, such a type
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of cigarette smoked, brand, or tobacco dependency scale. Of proxy characteristics for socioeconomic status, only educational status was obtained. Also, due to the relatively young age of this sample (mean of 28.9 years for SGM Black current smokers and 32.4 years for SGM White current smokers), these findings may not extend to older SGM smokers. Since recruitment of the majority of these participants occurred at Pride Festivals, it is likely that the social environments of self-identified heterosexuals could be similar to that of the sexual and gender minority groups, thus accounting for the high level of heterosexual current smoking compared to Missouri’s adult smoking rate (34.5% versus 23.2%; Missouri Department of Health and Senior Services, 2007a). Similarly, in this sample heterosexual attitudes about smoke-free policies tended to mirror SGM attitudes. For example, in a probabilistic county-level study of behavioral risk factors, Missouri residents were more supportive of a smoke-free restaurant law (63.5%; Missouri Department of Health and Senior Services, 2007b) compared to either the heterosexual (49.8%) or SGM (53.4%) study participants. Finally, although this study has a relatively large sample size of over 600 self-identified SGM Black and over 3,000 SGM White participants, the participants were a nonprobabilistic convenience sample of Pride Festival and Web-based participants. In conclusion, significant differences were found between Black SGM smokers and White SGM smokers but not between Black SGM smokers and Black heterosexual smokers or between Black and White heterosexual current smokers. The results of this study indicate that smoking status and intention to quit may be heavily influenced by race after accounting for sexual and gender minority status. A larger proportion of Black SGM participants never start smoking, and more current Black SGM smokers were ready to quit compared to White SGM participants; however, significantly fewer Black SGM smokers are able to successfully achieve cessation compared to Whites. This suggests that community and societal influences play a larger role in becoming a former smoker than individual level behavior (intention to quit). By having lower quit rates compared to Whites, Black SGM communities are at increased risk for the many health problems associated with tobacco use and a worsening of health disparities. Future research should further explore the relationship between multiple minority status and tobacco use, attitudes and behaviors, and societal inequalities. Smoking cessation and educational campaigns that account for both race and SGM status may more effectively reach the intended audience.
ACKNOWLEDGMENTS The authors gratefully the contribution of Kitty Jerome, PhD, Scout, PhD, and the National LGBT Tobacco Control Network for resource information, Angela Bunge, Jeremy Lombardo, and Ashton Day for data entry, and Dean Andersen for project management.
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FUNDING This work has been supported by grants from the Missouri Foundation for Health and St. Louis County Department of Health.
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Smoking and Intention to Quit Among a Large Sample of Black Sexual and Gender Minorities JENNA N. JORDAN, MPH and KEVIN D. EVERETT, PhD Department of Family & Community Medicine, University of Missouri, Columbia, Missouri, USA
BIN GE, MD, MA Department of Medical Research, University of Missouri, Columbia, Missouri, USA
JANE A. MCELROY, PhD Department of Family & Community Medicine, University of Missouri, Columbia, Missouri, USA
The purpose of this study is to more completely quantify smoking and intention to quit from a sample of sexual and gender minority (SGM) Black individuals ( N = 639) through analysis of data collected at Pride festivals and online. Frequencies described demographic characteristics; chi-square analyses were used to compare tobacco-related variables. Black SGM smokers were more likely to be trying to quit smoking than White SGM smokers. However, Black SGM individuals were less likely than White SGM individuals to become former smokers. The results of this study indicate that smoking behaviors may be heavily influenced by race after accounting for SGM status. KEYWORDS African American, black, LGBT, sexual minority, smoking, cessation
Studying the fundamental determinants of tobacco use, such as race, sexual orientation, and gender identity, is critical to inform targeted public health interventions. Tobacco use is a widespread problem among sexual and gender minorities (SGM; also referred to as lesbian, gay, bisexual, Address correspondence to Jane A. McElroy, Department of Family & Community Medicine, University of Missouri, MA306 Medical Sciences Bldg., Columbia, MO 65212, USA. E-mail: [email protected] 604
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transgender, transsexual, and queer or questioning). Tobacco use has been shown to be more prevalent among SGM adults than the general population (Aaron et al., 2001; Archer, Hoff, & Snook, 2005; Diamant et al., 2000; Dilley et al., 2005; Gruskin et al., 2007; Lee, Griffin, & Melvin, 2009; McCabe, Hughes, Bostwick, & Boyd, 2005; McElroy, Everett, & Zaniletti, 2011; Pizacani et al., 2009; Stall et al., 1999; Tang et al., 2004; Valanis et al., 2000). For example, a study by the National Coalition for LGBT Health found that lesbian, gay, bisexual, and transgender subgroups range from 40%–70% more likely to smoke than the non-LGBT population (Hitchcock & Hitchcock, 2005). Among SGM subgroups in the Pacific Northwest, a study found smoking prevalence to be 31.7% gay men, 35.9% bisexual men, 29.5% lesbian women, and 35.9% bisexual women compared to 20.3% heterosexual men and 17.3% heterosexual women (Pizacani et al., 2009). In a California study, the smoking prevalence by SGM subgroups were 22.2% gay/lesbian, 22.6% bisexual, and 29.7% men who have sex with men/women who have sex with women compared to 9.1% in the general population (Gruskin et al., 2007). Missourians’ smoking prevalence were found to be 40% or higher for bisexual females, transgender/genderqueer, and transsexual individuals (McElroy, Everett, & Zaniletti 2011) compared to 23% for Missourians (Missouri Department of Health and Senior Services, 2007a). Only a few studies have collected information on attitudes about tobacco use by selfidentified lesbians, gays, bisexuals, transgendered, or transsexual people (Pizacani et al., 2009). Among sexual and gender minorities in Missouri, 40% believe LGBT organizations should not accept money from tobacco companies, 54% support smoke-free policies in workplaces (including bars and restaurants), and 61% do not allow smoking in the home (McElroy, Everett, & Zaniletti, 2011). A survey in Washington and Oregon that included 2,106 SGM participants found 53% of lesbians, 29% of gay men, and 38% of bisexuals supported banning smoking in bars (Pizacani et al., 2009). While smoking rates are comparable in the general population between adult White and Black Americans (20.6% vs. 19.4%, respectively; Centers for Disease Control and Prevention [CDC], 2012), a review of smoking cessation data found that Whites were significantly more likely than African Americans to be former smokers (King, Polednak, Bendel, Vilsaint, & Nahata, 2004). A few studies have examined smoking behaviors and cessation programs in self-identified SGM Black individuals (Lee, Griffin, & Melvin, 2009). In a study of urban women, African American lesbians were more likely to smoke than both African American heterosexual women and White lesbians (Hughes, Johnson, & Matthews, 2008). Masini and Matthews reported that men who have sex with men are more entrenched in their smoking attitudes, and they argued that smoking is influenced by many factors such as race/ethnicity, age, educational attainment, income, stress associated with homophobia and discrimination, higher alcohol rates, social norms that support smoking, and targeted marketing to the SGM communities by tobacco companies (Masini
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& Matthews, 2007). As suggested by Masini and Matthews, Black individuals who identify as SGM represent a minority within a minority, and they are subject to multiple minority stress due to experiences with both racism and heterosexism (Balsam, Molina, Beadnell, Simoni, & Walters, 2011; Wheeler, 2003). In the context of the social–ecological model, health behaviors (such as smoking) and taking action to improve one’s health (such as or quitting smoking) are determined by multiple influences at the individual, relationship, community, and society levels (CDC, 2009). With regard to health and access to resources to improve one’s health, sexual and gender minorities are a disenfranchised group that experience discrimination, stigma, and prejudice, all of which are social determinants of health (CDC, 2011; Healthy People 2020, 2013; Meyer, 2003). Moreover, the resulting psychological distress experienced by SGM people as a result of discrimination and stigma may be heightened among African American sexual and gender minorities (Cochran & Mays, 1994). Within SGM communities, people of color may experience racism (Balsam et al., 2011), be excluded from LGBT events and spaces (Kudler, 2007), and perceive LGBT organizations to predominately serve White populations (Ward, 2008). The complex intersection of sexual orientation, gender identity, and race compound the marginalization of Black sexual and gender minorities at multiple levels of the social–ecological model, potentially leading to tobacco-related disparities (CDC, 2009; Wheeler, 2003). A recent study of community-based smoking cessation for LGBT smokers found benefits to offering LGBT-tailored treatment (32% self-reported quit rate) but did not include tailoring for Black LGBT smokers (Matthews, Li, Kuhns, Tasker, & Cesario, 2013). As a result, the purpose of this study is to more completely quantify tobacco use and intention to quit from a sample of self-identified SGM Black individuals through analysis of Out, Proud, and Healthy survey data collected at five Missouri Pride Festivals and online during 2011. Information obtained from this assessment can be used to bridge the gap and develop accessible interventions for SGM Black individuals to reduce tobacco use.
METHODS Project Recruitment The primary recruitment method involved asking attendees at five Pride Festivals in Missouri (St. Louis, Kansas City, Springfield, Columbia, and the Black Pride Festival in St. Louis) during the summer of 2011 to complete a 36-item paper survey. The second method used Internet-based recruitment of participants who then completed the survey online. Compensation was not provided, but Pride Festival attendees were offered bubbles, Out, Proud,
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and Healthy stickers, and ice water. Participant eligibility included being age 18 or older and able to read English. The participants identifying as heterosexual were included in the study to provide a more thorough description of the Pride Festival sample and to serve as a comparison group.
Pride Festival Data Collection The University of Missouri Health Sciences Institutional Review Board approved the Out, Proud, and Healthy study. Research staff received training in study protocols. A booth was rented at each Pride Festival to serve as a base from which attendees were approached and invited to complete, anonymously, a 36-item paper survey on health, including tobacco-related behaviors and attitudes. Basic demographic and health information were also collected. The survey took approximately 10 minutes to complete.
Web-Based Survey Data Collection The Out, Proud, and Healthy advisory board, using formal and informal networks, assisted in posting the Web-based survey on several SGM sites, including a statewide electronic SGM newspaper, the statewide SGM organization, and SGM urban communities centers, as well as Listservs that focus on SGM issues. The Web-based anonymous survey contained the same 36 items found on the Pride Festival surveys. A screening question eliminated participants less than 18 years old and those who had completed the survey at any of the five Pride Festivals in 2011. The survey was posted for 6 weeks. E-mail reminders were sent twice to SGM organizations and community center Listservs encouraging people to participate.
Measurement The survey included demographics (race, age, ethnicity, and education), gender identity and sexual orientation, tobacco and alcohol use, and questions targeting beliefs and preferences related to tobacco use as well as other health-related behavior. The Behavioral Risk Factor Surveillance System Questionnaire (CDC, 2007) was used as a guide for developing questions about tobacco use histories, rules for tobacco use in households and vehicles, and other health-risk and health-related behaviors.
Categorizing Gender and Sexual Minority (SGM) Status Individuals were classified into only one category (lesbian, gay, bisexual male, bisexual female, heterosexual, transgender/ transsexual, or other SGM) based on their response to the following questions, “Do you consider yourself to be: (lesbian; gay; bisexual; straight/heterosexual; other/please
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specify; or don’t know/not sure),” “Do you identify as transgender or transsexual: (Yes, transgender; Yes, transsexual; or No),” and “Are you a man or a woman? (Circle one).” “Other/please specify” and “don’t know/not sure” responses for the sexual orientation questions were combined and labeled “other SGM” as a separate SGM category. Heterosexual status was defined as indicating straight/heterosexual on the sexual orientation question and indicating either male or female (not transgender or transsexual). The participants were also classified into two overall categories: heterosexual or sexual and gender minorities (SGM).
Categorizing Race and Ethnicity Participants were first asked, “Are you Hispanic/Latino/a?: (Yes or No).” Participants were then asked, “Which category most closely describes your race? Check all that apply: (Black/African American; Asian; White; American Indian or Alaska Native; Native Hawaiian or Other Pacific Islander).” Participants were classified as White if they responded “No” to being Hispanic/Latino and if they only marked “Yes” for White. Participants were considered Black/African American if they responded “No” to being Hispanic/Latino and if they only marked “Yes” for Black/African American. Due to small sample sizes, participants in other racial and ethnic categories were excluded from analysis, and this study specifically examined nonHispanic White (referred to as White) and non-Hispanic Black (referred to as Black) participants.
Categorizing Smoking Status and Intention to Quit Current smokers were defined as those who had smoked at least 100 cigarettes in their lifetimes and reported currently smoking some days or every day. Former smokers were defined as those who had smoked at least 100 cigarettes in their lifetimes and reported not currently smoking. Never smokers were defined as having not smoked 100 cigarettes in their lifetimes. Intention to quit status was determined by asking “Which statement best describes you now?” The four options were (1) “I am trying to quit,” (2) “I plan to quit smoking tobacco (within the next month),” (3) “I think about quitting smoking tobacco some time in the future (in the next 6 months),” and (4) “I don’t think about quitting smoking tobacco.”
Analytic Plan A series of analyses examined differences between Black and White participants by SGM status on variables related to tobacco use in SGM
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communities. Frequencies were calculated to describe items measuring demographic characteristics, smoking status, and issues concerning public and personal smoke-free policies. Chi-square analyses were used to compare all variables other than age and mean cigarettes smoked per day. t tests were used to compare differences in mean age between the groups, and Wilcoxon two-sample tests were used to compare differences in mean cigarettes smoked per day between the groups. Analysis was conducted using SAS 9.3 statistical software (Cary, NC).
RESULTS Sample Description: Total Sample Comparisons by Race and SGM Subgroup A total of 4,363 adults participated in the study; however, 155 participants were excluded because they were missing data for smoking status, race, or SGM status. There was no statistical difference between those who were excluded for missing race and sexual orientation data compared to the overall sample in terms of smoking status. An additional 521 participants who did not identify as non-Hispanic Black or non-Hispanic White were excluded from the analysis. Of the remaining 3,687 surveys, 639 (17.3%) participants were Black and 3,048 (82.7%) were White. The Black sample was represented by 218 lesbian (34.1%), 176 gay (27.5%), 87 bisexual (13.6%), 20 transgender/transsexual (3.1%), and 42 other sexual and gender minorities (6.6%), comprising 84.9% of the Black sample. Heterosexuals comprised 15.1% of the Black sample. The White sample was represented by 821 lesbian (26.9%), 1,003 gay (32.9%), 339 bisexual (11.1%), 118 transgender/ transsexual (3.9%), and 162 other sexual and gender minorities (5.3%); comprising 80.1% of the White sample. Heterosexuals comprised 19.9% of the White sample. The mean age for the Black SGM sample was 30.0 years. Education distribution for the Black SGM sample was 29.3% with a high school diploma, GED, or less, 48.1% with some college or technical school, and 22.7% with a college degree or more. Among the Black SGM sample: 58.6% were never smokers, 5.2% were former smokers, and 36.3% were current smokers (Table 1). The mean age for the White SGM sample was 33.7 years. Education distribution for the White SGM sample was 17.5% with a high school diploma, GED, or less, 38.4% with some college or technical school, and 44.0% with a college degree or more. Among the White SGM sample, 47.3% were never smokers, 15.1% were former smokers, and 37.7% were current smokers (Table 1).
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TABLE 1 Comparing smoking status of Black and White participants and within SGM subgroups† Smoking Status
Black (n = 639)
Total Current Total Former∗∗∗ Total Never∗∗∗ Current Lesbian Gay Bisexual Men Bisexual Women Transgender/Transexual Other SGM Heterosexual Former Lesbian∗∗∗ Gay∗∗ Bisexual Men Bisexual Women Transgender/Transexual Other SGM Heterosexual Never Lesbian∗∗ Gay Bisexual Men Bisexual Women∗ Transgender/Transexual Other SGM Heterosexual
White (n = 3,048)
36.3% 5.2% 58.6%
37.7% 15.1% 47.3%
38.1% 35.8% 36.4% 30.8% 55% 28.6% 36.5%
47.2% 34.7% 38.6% 41.6% 36.4% 34.6% 32.6%
3.9% 6.8% 9.1% 3.1% 5% 4.8% 7.3%
14.9% 16.4% 5.7% 14.5% 11.9% 15.4% 15.2%
57.8% 57.4% 54.5% 66.2% 40% 66.7% 56.2%
44.8% 49.0% 55.7% 43.9% 51.7% 50.0% 52.2%
† Percentages
may not add to 100 due to rounding. at p < 0.05. ∗ Significant at p < 0.01. ∗∗ Significant at p < 0.001. ∗∗∗ Significant at p < 0.0001. Significant
Comparing Pride Festivals and Web-Based Participants Of the 3,687 surveys analyzed, 3,381 surveys were obtained from the five Pride Festivals and 306 were obtained from the Web-based survey. Statistical differences in responses to questions between the two modes of participation included race, educational attainment, and age. Specifically, a greater proportion of the Web-based sample compared to the Pride Festival sample self-identified as White (91.9% vs. 70.9%) (p < 0.0001), had a college education (72.4% vs. 50.0%; p < 0.0001) and had a significantly older average age (40.6 years vs. 31.6 years; p < 0.0001). There were no significant differences in smoking status (current, former, or never) between the Web-based and Pride Festival samples (data not shown).
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Comparing Smoking Status of Black SGM Respondents to White SGM Respondents Significantly more Black lesbian (p < 0.001), bisexual women (p < 0.01), and gay men (p < 0.05) were never smokers compared to their White SGM counterparts (Table 1). No racial differences were found in the proportion of bisexual men, transgender/transsexual, other SGM, or heterosexual respondents who were never smokers. In addition, significantly fewer Black lesbian (p < 0.0001), bisexual women (p < 0.05), gay (p < 0.001), and heterosexuals (p < 0.05) were former smokers compared to White lesbian, bisexual women, gay, and heterosexuals. No racial differences were found in the proportion of bisexual men, transgender/transsexual, or other SGM who were former smokers. No significant differences were found in the proportion of current smokers in each SGM subgroup by race (Table 1). Overall, significant differences were found in never and former smoking status between SGM Black and SGM White adults, but not in current smoking status. SGM Black adults were less likely to be former smokers compared to SGM White adults (p < 0.0001). SGM Black individuals were also significantly more likely to be never smokers compared to their White counterparts (p < 0.0001; data not shown).
Comparing SGM Black Current Smokers to SGM White Current Smokers Significant differences in age and education were found between Black SGM current smokers and White SGM current smokers. Black SGM smokers were younger (28.9 years) than White SGM smokers (32.4 years; p < 0.001). In addition, Black SGM smokers were less likely to have graduated college (p < 0.001; Table 2). Black SGM individuals smoked a mean of 10 cigarettes per day, while their White counterparts smoked a mean of 13 cigarettes per day (p < 0.0001). Black SGM smokers were more likely to be currently trying to quit or planning to quit smoking within the next month (p < 0.0001). On variables related to attitudes and beliefs about smoking, differences were found in household smoking rules. Black SGM smokers were much more likely to allow smoking in their homes compared to White SGM smokers (p < 0.001). Black SGM smokers did not significantly differ from their White counterparts in rules about smoking in the vehicle, having a partner that smoked, supporting smoke-free policies in all indoor workplaces (including restaurants and bars), being some day smokers, or being everyday smokers (Table 2). Black and White heterosexuals were examined to determine if differences in smoking behaviors by race existed regardless of SGM status.
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TABLE 2 Comparing characteristics of Black SGM current smokers and White SGM current smokers† Demographics and Smoking Characteristics Education High school graduate or less∗∗∗ Some college∗∗∗ College graduate or more∗∗∗ Every day or some days smoker Every day Some days Intention to quit Trying to quit∗∗ Plan to quit within month∗∗ Think about quitting in 6 months∗∗ Don’t think about quitting∗∗ Partner smokes Yes No Smoking rules in house Not allowed∗∗∗ Allowed∗∗∗ Smoking rules in vehicle Not allowed Allowed Support smoke-free policies Yes No Not sure Mean Age∗∗∗ Mean number of cigarettes smoked/day∗∗∗
Black SGM n = 197 33.5% 55.8% 10.7% n = 196 70.9% 29.1% n = 182 22.0% 24.2% 36.3% 17.6% n = 171 38.6% 61.4% n = 176 25.0% 75.0% n = 179 16.2% 83.8% n = 181 51.4% 36.5% 12.2% n = 197 28.9 n = 197 10
White SGM n = 920 25.2% 43.8% 31.0% n = 918 75.9% 24.1% n = 813 12.7% 18.9% 42.4% 26.0% n = 792 45.7% 54.3% n = 887 54.9% 45.1% n = 894 17.3% 82.7% n = 892 55.3% 36.4% 8.3% n = 921 32.4 n = 921 13
† Percentages
may not add to 100 due to rounding. ages 25 and older. ∗∗ Significant at p < 0.001. ∗∗∗ Significant at p < 0.0001. Participants
In evaluating differences between heterosexual Black and White participants, White smokers averaged 12 cigarettes per day, while Black smokers averaged 8 cigarettes per day (p < 0.05). No other differences were found between Black heterosexual smokers and White heterosexual smokers in any of the aforementioned categories (data not shown).
Comparing Black SGM Current Smokers and Black Heterosexual Current Smokers Black SGM smokers had an average age of 28.9 years and were younger on average than Black heterosexual smokers, who had an average of 34.2 years
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(p < 0.05). No differences were found between the two groups on the following variables: education level, smoking status, intention to quit, mean number of cigarettes smoked per day, rates of partner smoking, household smoking rules, vehicle smoking rules, and support for smoke-free policies (data not shown).
DISCUSSION This Out, Proud, and Healthy study is the first to look for differences in smoking status, intention to quit, and smoking-related attitudes between Black and White adults who self-identify as sexual and gender minorities, and it represents one of the largest and most diverse samples of the SGM communities in the published literature. The overall size and diversity of the sample allowed for comparisons within the SGM communities related to racial differences. This study provides new, important research on smoking behaviors regarding this minority within a minority population. Several important differences were found between Black and White sexual and gender minorities related to smoking. While Black SGM and White SGM had similar current smoking prevalence (36.3% vs. 37.7%), significantly more Black SGM were never smokers compared to White SGMs (58.6% vs. 47.3%). Among current smokers, Black SGM were significantly more likely to be trying to quit smoking (22.0% vs. 12.7%) or planning on quitting smoking within the month (24.2% vs. 18.9%) compared to White SGM. Some gender differences were also seen by race. Fewer Black lesbian and bisexual women were former smokers compared to their White counterparts. The same was true for gay men but not bisexual men. In addition, Black SGM smokers use significantly fewer cigarettes per day (CPD) on average than White SGM smokers (10 CPD vs. 13 CPD). With more Black SGM participants expressing a readiness to quit smoking than their White counterparts, cessation campaign messaging targeted to the Black community may be an effective tobacco control strategy. Additional research is needed to determine the factors creating the social context for Black SGM individuals to endorse a greater readiness to quit. In contrast, SGM Black individuals were significantly less likely than SGM White individuals to become former smokers (5.2% vs. 15.1%). This suggests fewer successful cessation attempts for Black SGM smokers, which may indicate barriers to Black SGM individuals, especially lesbian, bisexual women, and gay men, receiving evidence-based cessation services despite their higher readiness to quit. For example, Okuyemi et al. reported that Black light smokers at an inner city walk-in clinic were more likely to be ready to quit; paradoxically, they were also less likely to be asked about their smoking status or told to arrange a follow-up meeting for smoking cessation by their physicians than moderate or heavy smokers (Okuyemi,
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Ahluwalia, Richter, Mayo, & Resnicow, 2001). Similarly, numerous barriers to quitting were identified by low-income Black women that may resonate among the Black SGM community, including managing their lives in highly stressful environments, commonality of smoking in their community, and little knowledge about evidence-based cessation strategies, among other barriers (Manfredi, Balch, & Warnecke, 1993). In light of the social–ecological theory, while Black SGM smokers have higher motivation to quit than their White counterparts but lower prevalence of former smokers, community and societal influences (i.e., access to resources or referrals by physicians) may play a larger role in becoming a former smoker than individual level behavior (intention to quit). This pattern matters since fewer former smokers in the Black community compared to the White community may lead to worsening of health disparities due to the significant role of tobacco in producing health problems. Discrimination based on one’s racial identity or sexual orientation can lead to poor health outcomes such as anxiety, depression, drug use, and low self-esteem (Balsam et al., 2011; Landrine & Klonoff, 1996; Williams & Mohammed, 2009). African American men in particular experience serious health disparities compared to other racial and gender groups (Xanthos, Treadwell, & Holden, 2010). In line with the social–ecological theory, social and environmental factors, such as reduced access to education, employment, and quality health services, play a significant role in African American men’s health (Xanthos et al., 2010). Moreover, Copeland reported that compared with White individuals, Black individuals were less likely to have private or employment-based health insurance, were more likely to be covered by Medicaid or other publicly funded insurance, and were twice as likely to be uninsured (Copeland, 2005). As a result, the Black population may not have the same access to smoking cessation information, counseling, or nicotine replacement therapies. This disparity could also result from cessation treatments that are not tailored to maximize success being offered to Black SGM individuals more often than their White counterparts. There are important relationships between socioeconomic status (SES) and health, and Blacks experience poverty at two to three times the rate of Whites (U.S. Census Bureau, 2008), potentially accounting for disparities in smoking cessation and health. Research finds that among the socioeconomically disadvantaged, there is a higher smoking prevalence, and quit attempts are less likely to be successful (Hiscock, Bauld, Amos, Fidler, & Munafo, 2012). The same disparities in access to health care exist for sexual and gender minorities (Dilley, Simmons, Boysun, Pizacani, & Stark, 2010). Further, SES is a significant predictor of self-reported health among sexual and gender minorities (Thomeer, 2013). In this way, the lack of access and utilization of health care and smoking cessation services may be compounded among Black individuals who identify as SGM due to their multiple minority status (Balsam et al., 2011).
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Although we did not evaluate nicotine dependency or type of preferred cigarette, previous studies suggest that Black smokers may become more heavily dependent on nicotine than White smokers due to the high rates of mentholated cigarette smoking among Black individuals (Royce, Hymowitz, Corbett, Hartwell, & Orlandi, 1993). While menthol may not be an addictive substance itself, it is considered a non-nicotine component that provides reinforcing sensory stimulation during smoking, compounding the addictive effect of nicotine (Rose, 2006). A study by Okuyemi, Ebersole-Robinson, Nazir, and Ahluwalia found that approximately 80% of Black smokers choose menthol cigarettes, compared to about 20% of White smokers, potentially contributing to the racial differences in rates of former smokers among SGM (Okuyemi, Ebersole-Robinson, Nazir, & Ahluwalia, 2004). Other variables identified in the study that may play a role in this difference include education level, age, and smoking in the home. It should be noted that education is protective against smoking (de Walque, 2007), and in our sample three times as many White SGM current smokers graduated college as Black SGM current smokers, indicating societal-level inequalities for this double minority group. Wetter et al. found that education level contributes to the prediction of smoking abstinence even after accounting for demographic, environmental, tobacco dependence, readiness to change, and job-related variables (Wetter et al., 2005). Furthermore, the average age of our SGM Black sample was 28.9 years, which was significantly younger than White SGM smokers at 32.4 years. The lower proportion of former smokers in the SGM Black sample may be partially due to their younger average age and having had less time in which to make quit attempts compared to the slightly older SGM White sample. In addition, significantly more SGM Black individuals allowed smoking in some or all places in their homes than their White counterparts. Acceptance of smoking in the home in the SGM Black population may also reduce successful quit attempts. A growing number of smoking cessation programs recognize the importance of being culturally sensitive to reach the intended audience, such as sexual and gender minorities. Beyond identifying SGM status, effective cessation programs must address the unique needs and culture of SGM Black individuals, which differ from those of SGM White individuals (Wheeler, 2003). Studies have found that efforts to encourage smoking cessation among Black populations are most successful if they use media that reach Black audiences, if they tailor their print materials to address their specific needs, and if Black communities networks are utilized (Stotts, Glynn, & Baquet, 1991). Although the effectiveness for culturally tailored programs for Black SGM individuals is still unknown, it is possible that these same strategies could be implemented within the SGM communities to effectively target Black SGM smokers. A limitation of this study is the scope of the survey (36 items). This survey did not encompass several variables related to tobacco use, such a type
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of cigarette smoked, brand, or tobacco dependency scale. Of proxy characteristics for socioeconomic status, only educational status was obtained. Also, due to the relatively young age of this sample (mean of 28.9 years for SGM Black current smokers and 32.4 years for SGM White current smokers), these findings may not extend to older SGM smokers. Since recruitment of the majority of these participants occurred at Pride Festivals, it is likely that the social environments of self-identified heterosexuals could be similar to that of the sexual and gender minority groups, thus accounting for the high level of heterosexual current smoking compared to Missouri’s adult smoking rate (34.5% versus 23.2%; Missouri Department of Health and Senior Services, 2007a). Similarly, in this sample heterosexual attitudes about smoke-free policies tended to mirror SGM attitudes. For example, in a probabilistic county-level study of behavioral risk factors, Missouri residents were more supportive of a smoke-free restaurant law (63.5%; Missouri Department of Health and Senior Services, 2007b) compared to either the heterosexual (49.8%) or SGM (53.4%) study participants. Finally, although this study has a relatively large sample size of over 600 self-identified SGM Black and over 3,000 SGM White participants, the participants were a nonprobabilistic convenience sample of Pride Festival and Web-based participants. In conclusion, significant differences were found between Black SGM smokers and White SGM smokers but not between Black SGM smokers and Black heterosexual smokers or between Black and White heterosexual current smokers. The results of this study indicate that smoking status and intention to quit may be heavily influenced by race after accounting for sexual and gender minority status. A larger proportion of Black SGM participants never start smoking, and more current Black SGM smokers were ready to quit compared to White SGM participants; however, significantly fewer Black SGM smokers are able to successfully achieve cessation compared to Whites. This suggests that community and societal influences play a larger role in becoming a former smoker than individual level behavior (intention to quit). By having lower quit rates compared to Whites, Black SGM communities are at increased risk for the many health problems associated with tobacco use and a worsening of health disparities. Future research should further explore the relationship between multiple minority status and tobacco use, attitudes and behaviors, and societal inequalities. Smoking cessation and educational campaigns that account for both race and SGM status may more effectively reach the intended audience.
ACKNOWLEDGMENTS The authors gratefully the contribution of Kitty Jerome, PhD, Scout, PhD, and the National LGBT Tobacco Control Network for resource information, Angela Bunge, Jeremy Lombardo, and Ashton Day for data entry, and Dean Andersen for project management.
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FUNDING This work has been supported by grants from the Missouri Foundation for Health and St. Louis County Department of Health.
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