Young People Coming Out as Bisexual Twice as Likely to Start Smoking

Changing sexual identities was associated with an increased risk of smoking initiation among young people, according to federal survey data.

Odds that adolescents and young adults would take up smoking were 72% higher, after adjustment, in those who reported changing sexual identities (95% CI 34%-120%) relative to those consistently reporting heterosexual identity, according to Alyssa F. Harlow, MPH, of Boston University School of Public Health, and colleagues writing in JAMA Pediatrics.

The risk was concentrated among youth identifying as bisexual — such that, compared to consistently heterosexual participants, the risk of starting to smoke (after adjustment for covariates) was higher for those:

• Coming out as bisexual after identifying as heterosexual (aOR 2.24, 95% CI 1.72-2.29)
• Coming out as bisexual after identifying as lesbian or gay (aOR 1.99, 95% CI 1.20-3.29)
• Coming out as bisexual after identifying with other sexual identities such as queer or asexual (aOR 2.20, 95% CI 1.40-3.46)
• Consistently bisexual throughout the study (aOR 1.60, 95% CI 0.89-2.88)

“People who have recently come out may be experiencing new forms of discrimination and stress, leading to smoking as a coping mechanism,” Harlow told MedPage Today. “They may also be meeting new people or engaging in new social groups within the LGB+ community, where there are higher rates of smoking.”

Harlow said the strong associations seen among bisexual youth may be a result of the bisexual community experiencing greater psychological distress than gay, lesbian, or heterosexual communities, although this was not something directly examined in the study.

“Bisexual young people might experience stigma from both the heterosexual population as well as from within the LGB+ community,” Harlow said.

Smoking is more prevalent among LGB adults than among heterosexual adults (20.5% vs 15.3%), according to CDC data. High rates of smoking have also been tied to longstanding aggressive marketing from tobacco companies that sponsor events or festivals within the LGBT community, according to the agency. In the mid-1990s, for example, internal R.J. Reynolds documents showed that the company specifically targeted LGBT and homeless populations with cigarette promotions.

The current study involved data from four waves of the longitudinal Population Assessment of Tobacco and Health survey, starting in years 2013-2014 and ending in 2016-2018. Harlow and colleagues compared smoking rates among LGB+ and heterosexual respondents 14-29 years old who were nonsmokers at the first wave of the survey.

In total, 7,843 smoking-naive individuals with a mean age of 20.1 years participated. Some 87% of participants reported being consistently heterosexual throughout the study period, while 5% came out as LGB+ across various waves of the study. The remainder were consistently LGB+ (3.6%) or had some other LGB+ pattern (4.4%).

At wave 4, 6% of the cohort was currently smoking, defined as smoking “even one or two puffs” within the past 30 days. Compared to consistently heterosexual respondents, a higher risk of current smoking was shown in people who consistently reported being LGB+ (aOR 1.63, 95% CI 1.00-2.66), and who had other LGB+ patterns such as changing from heterosexual to asexual (aOR 1.63, 95% CI 1.03-2.56).

There was no increased risk of smoking among respondents who came out as lesbian, gay, or another sexual identity (aOR 0.91, 95% CI 0.52-1.60); respondents who consistently reported being lesbian, gay, or another unlisted sexual identity (aOR 0.90, 95% CI 0.43-1.87); or those with other LG+ patterns (aOR 0.91, 95% CI 0.55-1.49).

It’s possible some respondents identified as LGB+ in the survey but not publicly, which is a limitation, the authors noted. This community is also very diverse and there may be factors that were unaccounted for that are influencing the association such as family supports or social environments.