INTRODUCTION

The use of tobacco has changed dramatically over the past several years. While cigarette smoking has fallen to historic lows among US adults¹, there has been a marked increase in the use of electronic nicotine delivery systems (ENDS), and approximately 4.6% of adults are current users². In cases of dual use (both cigarettes and ENDS), recent research indicates that many dual users progress to exclusively using cigarettes³. Historically, lesbian, gay and bisexual (LGB) individuals have higher rates of smoking⁴, often attributed to targeted tobacco advertising^5,6, exposure to stressors (i.e. minority status, stigma, homophobia, and gay bashing)^7,8 and psychological distress⁹. The same tendency of elevated ENDS use among LGB individuals has recently been documented¹⁰. However, LGB groups are not homogeneous and differences may exist between tobacco use by men and women within the groups.

Compared to heterosexual women, current cigarette use (past 30 days) has been found to be consistently higher among lesbian and bisexual women^11–16. A similar finding for current cigarette use was noted when comparing gay and heterosexual men^11–16, but elevated use among bisexual men has not been a consistent finding^12–15.

Despite rapid proliferation of ENDS use, few studies have examined use of such devices by LGB individuals and, when investigations have occurred, the findings are less consistent than findings for cigarette smoking^10,11,15,16. Current ENDS use has been found to be higher in bisexual women^11,15 compared to heterosexual women, and in bisexual men¹⁶ compared to heterosexual men. No differences have been observed when comparing lesbian women and gay men to their heterosexual counterparts. One national survey found higher rates of dual cigarette and ENDS use among LGB adults, but that difference was not significant¹⁷. The purpose of this research was to examine differences in cigarette smoking, ENDS use and dual use among LGB subgroups.

METHODS

RESULTS

Of the 2087 participants, gay/lesbian and bisexual participants accounted for approximately 9% of male and 19% of female participants (Table 1). Male participants were similar in age, race, education, income, and employment status across gays, bisexuals and heterosexuals. However, ethnic representation and marital status varied significantly by sexual orientation (Table 1, Males). Specifically, 74.2% of bisexual men were Hispanic compared to 50.8% of heterosexuals and 54.9% of gay men, and 76.5% of gay men and 74.2% of bisexual men were not married compared to 53.8% of heterosexuals. In contrast, female participants significantly differed between lesbians, bisexuals and heterosexuals for almost all the characteristics except employment status (Table 1, Females). For example, lesbian and bisexual women were younger and more likely to be Hispanic, unmarried, and earn less income.

For multiple tobacco use status, after adjusting for demographics, socioeconomic status, and marital status, there were no significant differences in the likelihood of current ENDS use only or dual use as opposed to cigarette smoking only between gay men and their heterosexual counterparts, or between bisexual men and their heterosexual counterparts (Table 2, Males). However, bisexual women were 1.85 times (AOR=1.85; 95% CI: 1.19–2.87; p=0.0062) more likely to report dual use in contrast to cigarette only use compared to heterosexual women, but there was no difference in the likelihood of current ENDS only use as opposed to cigarette smoking only between bisexual and heterosexual women (Table 2, Females). Also, no significant differences were found in the likelihood of tobacco use between lesbian and heterosexual women.

DISCUSSION

Similar to the findings of Li et al.¹⁵ and Emory et al.¹¹, our findings support that there is increased current use of ENDS among bisexual women compared to heterosexual or lesbian women when controlling for demographic variables. While Li et al.¹⁵ focused on participants aged 18–25 years, the age of our participants was similar to those of Emory et al.¹¹ in that we recruited participants up to 64 years old. In contrast, Hoffman et al.¹⁶ found no difference in ‘current’ ENDS use and an increase in ‘ever’ ENDS use among bisexual women. When examining ENDS use in terms of ‘lifetime’ use, Wheldon et al.²² found lesbian and bisexual women were at greater risk compared to heterosexual women. One important finding from our study is the increased risk of dual use (ENDS and cigarettes) among bisexual women. When examining poly-tobacco use, Delahanty et al.²³ found bisexual women were more likely to use two or more tobacco products compared to gay men. However, within the LGB groups, differences in the use of combustible plus non-combustible products were not found. As additional investigations take place, it is important to clarify product-use behaviors (e.g. various combinations for dual use or poly-use, frequency and intensity of use, type and contents) to more fully understand harm potential.

The findings in this study regarding men were similar to those of both Li et al.¹⁵ and Emory et al.¹¹ in that there was no difference in current ENDS use when comparing gay or bisexual men to their heterosexual counterparts. In contrast, Hoffman et al.¹⁶ found a difference when comparing male bisexual ever ENDS use and current ENDS use to their heterosexual counterparts¹⁶. It is important to note that their sample contained greater than 3000 gay/bisexual men, which may have allowed for greater sensitivity to detect ENDS use differences.

CONCLUSIONS

When controlling for demographic factors, there is increased likelihood of dual use, among bisexual women compared to lesbian or heterosexual women. This report is one of the first to reveal significantly elevated patterns of dual use in this group, a finding that should be further addressed in future research. These findings, especially the greater use patterns by bisexual women, suggest that targeted health messages may be needed to raise awareness of risk in specific LGB groups and that future research with these populations is necessary to better understand differences in tobacco perceptions and use.