Smoking Among LGBT+ Youth: A School-Based Intervention to Facilitate Community Involvement
Smoking remains the leading cause of preventable deaths in the United States and is associated with increased risk for a variety of cancers, cardiovascular disease, and respiratory disease. Smoking prevention and education programs are particularly important for youth because earlier age of smoking onset is associated with lifetime nicotine dependence. (Newcomb, Heinz, Birkett, & Mustanski, 2014). LGBT+ individuals are at a heightened risk for smoking-related illness because rates of smoking in the LGBT+ community are up to 2.5 times higher than among heterosexual populations (Truth Initiative, 2018). This disparity reflects a complex history of marginalization, victimization, and targeting by tobacco companies. In order to address this inequity, LGBT-specific tobacco education/prevention interventions based on the principles of Community Based Participatory Research (CBPR) are urgently needed and could be created using the existing structure of high school Gay Straight Alliances (GSAs).
LGBT+ Smoking as a Public Health Issue
Violence and discrimination are determinants of health which dramatically impact the long-term health outcomes of marginalized and oppressed populations. According to the Minority Stress Model, experiences of discrimination and victimization can lead to negative health outcomes for such populations because these experiences foster a reliance on unhealthy coping mechanisms, such as substance use or risky sexual activity, in order to deal with chronic stressors. This is evident in the disproportionately high rates of cigarette smoking in the LGBT+ community compared to heterosexual populations. For example, using data from the Legacy Young Adult Cohort, a nationally representative longitudinal sample of young adults (18-34), Rath et al. found that 33% of LGB young adults, compared to 22% of heterosexual young adults reported any current tobacco use. The same study found that past 30-day cigarette use was higher in homosexual (35%) and bisexual (27%) persons compared to heterosexuals (18%) (Rath, Villanti, Rubenstein, & Vallone, 2013).
Such disproportionate levels of cigarette smoking are influenced both by targeted campaigns by tobacco companies and experiences of victimization/discrimination. These factors may be interpreted as violence or discrimination at an institutional or interpersonal level. In the 1990s, tobacco corporations began to advertise to members of the LGBT+ community through targeted marketing campaigns. For example, Philip Morris gained access to the LGBT+ market via corporate philanthropy when it settled a boycott by pledging large donations to AIDS research. Additionally, Project SCUM (Sub-Culture Urban Marketing), which targeted gay men and homeless populations, was launched in 1995 by R.J. Reynolds, a large tobacco company. Such targeted marketing campaigns successfully created a message that smoking is a normal part of LGBT+ life, and have impacted the long-term health of LGBT+ populations (Truth Initiative, 2018).
Besides targeting from tobacco corporations, smoking among LGBT+ youth and young adults has repeatedly been associated with psychological distress and LGBT+ victimization. In a study by Newcomb et al., LGBT+ victimization even predicted smoking rate for follow-up waves of questionnaires (Newcomb et al., 2014). This study concluded that “addressing experiences with victimization, the impact of psychological distress, and optimizing support from families and romantic partners” is crucial in optimizing the efficiency of prevention strategies (Newcomb et al., 2014, p. 2). Additionally, a study by Baskerville et al. concluded that there is a great need for LGBT-specific smoking prevention and cessation interventions after examining the outcomes of several relatively successful but small programs (Baskerville et al., 2017).
In order to address the disproportionately high rates of smoking in LGBT+ youth and young adults, tailored, culturally relevant smoking education guides and LGBT+ smoking cessation programs are needed. In order to achieve this goal, LGBT+ youth organizations such as Gay-Straight Alliances (GSAs) could be utilized to facilitate a culturally relevant educational framework based on the principles of CBPR (Israel, Schulz, Parker, & Becker, 2001).
In order for LGBT+ smoking prevention/cessation programs to be successful, it is crucial that they are tailored to the specific needs of the community. The participants in a successful Canadian intervention that targeted smoking in the LGBT+ community described the program as “excellent and very useful when tailored” and identified several community-specific themes as important for the program’s success, including “language and context of the LGBT community… Recognizing that social life is linked to bars and group outings…[and] recognizing the living situation of community members” (Baskerville et al., 2017, p. 59). The researchers concluded that “…an effective non-tailored program will not matter if the target community does not perceive the program to be LGBTQ+ focused as they likely will not use it” (Baskerville et al., 2017, p. 61). As such, it is crucial that any intervention aimed at reducing smoking rates in the LGBT+ community be based in the principles of CBPR.
As community-based programs largely led by LGBT+ youth and allies, high school GSAs could be utilized in order to apply the principles of CBPR to smoking prevention and cessation programs aimed at LGBT+ youth. GSAs originated from community-based youth programs and were adopted into a school context in the 1990s. There are now over 4,000 such clubs in educational institutions across the country. Although the structure and function of individual organizations varies widely, in general, GSAs are highly youth-driven and aim to create safe environments for LGBT+ youth to socialize, receive support, and engage in advocacy at the school or community level. They may also provide emotional support for youth experiencing victimization and encourage leadership opportunities (Poteat, Sinclair, DiGiovanni, Koenig, & Russell, 2013).
The presence of GSAs has been associated at the school level with positive mental health and school climate changes. Poteat et al. found that students at schools with GSAs had lower rates of suicidal ideation, suicide attempts, and smoking. Although these results could be skewed if GSAs are located at schools that are already more accepting for LGBT+ students, the researchers controlled for school size, socioeconomic status, and racial and sexual orientation diversity of the student body (Poteat et al., 2013). Regardless of whether the presence of GSAs themselves cause these positive changes, they are an important and underutilized resource in the fight against smoking among LGBT+ youth, especially considering that GSAs may provide a safe space for culturally-relevant smoking education to occur and represent an existing organizational structure for LGBT+ youth.
By utilizing both community leadership from high school GSA members and health expertise from local college professors specializing in Health Behavior/Health Education and public health students who are interested in smoking or LGBT+ health, such programs could utilize the diverse strengths of various stakeholder groups to effectively achieve their goals. Trained GSA student leaders and public health students could lead the discussions, allowing the program to be peer-led. Besides promoting the involvement of community members, the involvement of GSAs would also be helpful for the sustainability of such a program because GSAs are maintained by the voluntary efforts of their members, who pass control of the club down as older members graduate. Despite potential opposition from the tobacco industry, another key stakeholder in this situation, culturally-competent smoking education and cessation programs for LGBT+ youth represent a pressing public health need and must be addressed as such.
Violence and discrimination are key determinants of health which have impacted health outcomes of members of the LGBT+ community through their impact on cigarette smoking rates, which are disproportionately high for this population. As predicted by the Minority Stress Model, LGBT-related victimization and psychological distress have been associated with higher rates of smoking among LGBT+ youth. In order to solve this problem, culturally relevant, community based programs are needed. High school GSAs could be a valuable tool for the development and implementation of such programs given their community involvement and sustainability. Such a program could provide relevant and urgently needed information and services to members of the LGBT+ community who are experiencing extreme health inequities as a result of discrimination and victimization.
Baskerville, N. B., Dash, D., Shuh, A., Wong, K., Abramowicz, A., Yessis, J., & Kennedy, R. D. (2017, June 1). Tobacco use cessation interventions for lesbian, gay, bisexual, transgender and queer youth and young adults: A scoping review. Preventive Medicine Reports, Vol. 6, pp. 53–62. https://doi.org/10.1016/j.pmedr.2017.02.004
Israel, B., Schulz, A., Parker, E., & Becker, A. (2001). Community-based Participatory Research: Policy Recommendations for Promoting a Partnership A pproach in Health Research. 14(2), 182–197. https://doi.org/10.1080/13576280110051055
Newcomb, M. E., Heinz, A. J., Birkett, M., & Mustanski, B. (2014). A longitudinal examination of risk and protective factors for cigarette smoking among lesbian, gay, bisexual, and transgender youth. Journal of Adolescent Health, 54(5), 558–564. https://doi.org/10.1016/j.jadohealth.2013.10.208
Poteat, V. P., Sinclair, K. O., DiGiovanni, C. D., Koenig, B. W., & Russell, S. T. (2013). Gay-Straight Alliances Are Associated With Student Health: A Multischool Comparison of LGBTQ and Heterosexual Youth. Journal of Research on Adolescence, 23(2), 319–330. https://doi.org/10.1111/j.1532-7795.2012.00832.x
Rath, J. M., Villanti, A. C., Rubenstein, R. A., & Vallone, D. M. (2013). Tobacco Use by Sexual Identity Among Young Adults in the United States. Nicotine & Tobacco Research, 15(11), 1822–1831. https://doi.org/10.1093/NTR/NTT062
Truth Initiative. (2018). Tobacco Use in LGBT Communities. Retrieved April 18, 2020, from https://truthinitiative.org/research-resources/targeted-communities/tobacco-use-lgbt-communities