LGBT+ young people smoke and vape at a higher prevalence than non-LGBT+ peers

New Truth Initiative® research finds that a higher proportion of lesbian, gay, bisexual, and transgender young people used cigarettes and e-cigarettes in 2021 compared to their non-LGBT+ peers, showing that disparities in tobacco use among LGBT+ young people persist and have crossed over to the e-cigarette products most popular with young people today. The findings build on long-established research that shows that lesbian, gay, bisexual, and transgender individuals use tobacco products more than their cisgender heterosexual peers. Disparities in tobacco use prevalence among this population are partly due to decades of tobacco industry targeted marketing.

A previous Truth Initiative analysis found higher rates of e-cigarette use among lesbian, gay, and bisexual (LGB) youth compared to heterosexual youth between 2020 and 2021. The new research finds that young people who identify as LGB continue to use tobacco at a consistently higher prevalence than their heterosexual peers across products, and contributes new data about transgender, nonbinary, and not-cisgender young people.

Research has shown that harassment and discrimination of LGBT+ individuals increases stress and leads to higher prevalence of tobacco use. The rising number of anti-LGBT+ policies in the last two years compounded with the ongoing youth mental health crisis puts this population at even greater risk of nicotine addiction and related mental health concerns.

Tobacco use is higher among LGBT+ young people compared to non-LGBT+ peers

Truth Initiative researchers examined data from 6,122 young people ages 15 to 31 surveyed between July 2021 and October 2021 as part of the ongoing Truth Longitudinal Cohort study. Young people were asked about their sexual orientation, gender identity, and use of cigarettes and e-cigarettes.

Participants identifying as lesbian or gay, bisexual, another identity, or questioning were considered “not heterosexual.” Respondents were also asked about their sex assigned at birth and their current gender identity (male, female, transgender, nonbinary, or a different identity). Individuals who had different responses for sex assigned at birth and their current gender identity were considered “not cisgender.” Any participant identifying as “not heterosexual” and/or “not cisgender” was considered LGBT+. Participants were asked if they had ever used a cigarette or e-cigarette or if they currently used the products in the past 30 days.

The analysis found that the ever or current use of cigarettes and e-cigarettes is higher among LGBT+ young people compared to their non-LGBT+ peers:

• Higher vaping prevalence: More LGBT+ young people have ever used e-cigarettes (49% vs. 39%) and currently use e-cigarettes (18% vs. 13%) compared to those who did not identify as LGBT+.
• Higher smoking prevalence: Young people who identity as LGBT+ more frequently report ever using cigarettes (34% vs. 26%) as well as currently using cigarettes (8% vs. 6%) compared to their non-LGBT+ peers.

Sexual orientation: Disparities among young people who do not identify as heterosexual

Across the board, young people who do not identify as heterosexual have ever or are currently using e-cigarettes and cigarettes to a greater extent than their heterosexual peers. Below are some of the notable disparities:

• Bisexual young people are using tobacco at the highest prevalence. Compared to heterosexual peers, bisexual young people reported higher prevalence of ever using cigarettes (41% vs 26%), currently using cigarettes (10% vs 6%), ever using e-cigarettes (57% vs 39%), and currently using e-cigarettes (22% vs 13%).
• Lesbian and gay young people report high tobacco use prevalence, with a greater proportion reporting cigarette use (33% vs 26%) and e-cigarette use (48% vs. 39%) compared to their heterosexual peers.
• Overall, all individuals who did not identify as heterosexual reported ever using both cigarettes (34% vs. 26%) and e-cigarettes (48% vs. 39%) at higher prevalence than their heterosexual peers.

Gender identity: High tobacco use rates for transgender and nonbinary young people

Tobacco use patterns are similar among young people who do not identify as cisgender, including transgender and nonbinary young people. This group generally uses cigarettes and e-cigarettes at higher prevalence than their cisgender peers.

• Nonbinary young people are using tobacco products at the highest prevalence. For example, nonbinary young people had the highest prevalence of ever using cigarettes (36% vs. 27%) and e-cigarettes (54% vs. 40%), and nearly twice as many nonbinary young people currently used cigarettes (11% vs. 6%) and e-cigarettes (17% vs. 14%) compared to cisgender peers. 
• Transgender individuals also report higher prevalence of ever using cigarettes (30% vs. 27%) and e-cigarettes (43% vs. 40%) compared with their cisgender peers.
• Overall, young people who are not cisgender reported ever using cigarettes (33% vs. 27%) and e-cigarettes (49% vs. 40%) at higher prevalence than cisgender peers.

The LGBT+ community has long faced high exposure to tobacco advertising

The tobacco industry has spent decades capitalizing on LGBT+ individuals, contributing to elevated tobacco use prevalence in the population. Historically, tobacco giant RJ Reynolds’ infamous 1995 SubCulture Urban Marketing campaign, “Project SCUM,” explicitly targeted LGBT+ populations in San Francisco’s Castro District.

More recently, tobacco companies have been leveraging social media to advertise e-cigarette products, and LGBT+ individuals are reporting significantly higher exposure to tobacco-related content on social media than their non-LGBT+ counterparts.

Higher tobacco product use attributed to greater stress

The new data confirm that tobacco use among LGBT+ individuals continues at a higher prevalence than their cisgender and heterosexual peers, a trend that researchers have noted since the early 2000s. Higher stress related to stigma, social disenfranchisement, and discrimination is a key factor in high tobacco use among this community, leading to higher product uptake and presenting barriers to quitting.

Mental health concerns are high for the LGBT+ community

Mental health among youth and young adults is understudied, however we know that LGBT+ individuals experience worse mental health outcomes compared to their cisgender peers. Truth Initiative data shows a significantly higher proportion of LGBT+ individuals reported a current diagnosis with a mental health disorder compared with those who are cisgender (44% vs. 20%) These mental health outcomes can be tied to stigma, social disenfranchisement, bullying, and discrimination.

Across the U.S., the introduction of bills that target the rights of LGBT+ individuals, particularly transgender and nonbinary people, has accelerated, exacerbating the existing stressors the community faces. Bills have been passed that restrict access to gender affirming care, limit the ability to update ID documentation, and undermine non-discrimination laws.

Seventy-one percent of LGBT+ youth have reported negative mental health impacts relating to state laws restricting their rights. Stress related to recent legislation can compound existing stress, with the potential to exacerbate health inequities such as tobacco use among members of the LGBT+ community, particularly among transgender and nonbinary individuals whom this legislation affects disproportionately.

More prevention efforts, quitting support, and research on tobacco use among LGBT+ individuals is needed

Persistently high prevalence of tobacco use among this population underscores the crucial need for prevention and intervention efforts specifically for LGBT+ young people. Truth Initiative recommends the following:

• Representation in health education campaigns. Because the LGBT+ community has higher exposure to tobacco advertising,4 public health education campaigns must work to counter this exposure.
• Addressing mental health concerns when quitting. LGBT+ young people could benefit from quitting support tailored to their needs. Quitting programs and interventions should explicitly address stress and mental health.
• More nuanced research on tobacco use by sexual orientation and gender identity. More survey research with accurate measurement of sexual orientation and gender identity is needed, particularly among young people. For example, many national surveillance surveys for young people don’t include the option to identify as nonbinary, a population that may represent at least half of non-cisgender young people and who report high prevalence of tobacco use. It is also important to note that some states have passed legislation that restricts how school surveys ask about sex and gender. These policies will inhibit the ability to monitor, and in turn advocate for, the health and wellness of transgender and nonbinary young people.

Tobacco use is higher among LGBT+ individuals, in part attributed to targeted marketing and increased burden of stress. Support is needed for this population.

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