0
We're unable to sign you in at this time. Please try again in a few minutes.
Retry
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
Retry
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
Access to paid content on this site is currently suspended due to excessive activity being detected from your IP address 54.82.122.194. Please contact the publisher to request reinstatement.
Article |

Community-Level Determinants of Tobacco Use Disparities in Lesbian, Gay, and Bisexual Youth:  Results From a Population-Based Study FREE

Mark L. Hatzenbuehler, PhD; Nicolien F. Wieringa, PhD; Katherine M. Keyes, PhD
[+] Author Affiliations

Author Affiliations: Center for the Study of Social Inequalities and Health (Dr Hatzenbuehler) and Department of Epidemiology (Dr Keyes), Columbia University, New York, New York; and Center for Population Research in LGBT Health, The Fenway Institute, Boston, Massachusetts (Drs Hatzenbuehler and Wieringa).


Arch Pediatr Adolesc Med. 2011;165(6):527-532. doi:10.1001/archpediatrics.2011.64.
Text Size: A A A
Published online

Objective  To determine whether characteristics of the social environment surrounding lesbian, gay, and bisexual (LGB) youth contribute to their rates of tobacco use after controlling for established community-level risk factors.

Design  Cross-sectional.

Setting  Population-based study of youth.

Participants  A total of 31 852 eleventh-grade students (1413 LGB individuals [4.44%]) in Oregon completed the Oregon Healthy Teens survey in 2006-2008.

Main Exposures  We created a composite index of the social environment in 34 Oregon counties. This measure included the proportion of same-sex couples, the presence of gay-straight alliances in schools, and school policies (nondiscrimination and antibullying) that specifically protected LGB students.

Main Outcome Measures  Any tobacco use in the past 30 days.

Results  A more supportive social environment for LGB youth was significantly associated with reduced tobacco use (odds ratio, 0.92; 95% confidence interval, 0.90-0.94). This effect remained robust after controlling for sociodemographic variables and multiple community-level risk factors for tobacco use, including median county-level income, exposure to cigarette advertisements, exposure to teacher and peer smoking in schools, and school smoking rules.

Conclusion  This study documents an association between an objective measure of the social environment and sexual orientation–related disparities in tobacco use. These results highlight the need for structural-level interventions that reduce smoking behaviors in LGB youth.

Lesbian, gay, and bisexual (LGB) populations have significantly higher levels of tobacco use compared with heterosexuals.1 These tobacco-related disparities emerge early in adolescence25 and persist across the life course.68 Data from the Growing Up Today Study,2 a large community-based cohort of more than 16 000 adolescents in the United States, indicated that sexual orientation–related disparities in tobacco use persisted after adjusting for established adolescent smoking risk factors, such as depressive symptoms, self-esteem, and familial smoking habits. Continued disparities after accounting for salient risk factors at the individual level suggest the need to consider whether factors at the structural level, namely, social environments with greater antigay stigma and discrimination, may account for the higher prevalence of tobacco use in LGB youth.

There is accumulating evidence that the social contexts in which youth reside shape adolescent smoking patterns because individual-level characteristics (eg, expectancies, genetic risk, and personality characteristics) do not fully explain findings that rates of youth smoking vary across different communities.9 Schools represent one salient social context for youth, and several studies have shown that school smoking policies1012 and school structure (eg, exposure to teacher and peer smoking at school)13,14 affect students' smoking rates. Another social context in which youth are embedded is their residential neighborhood. Although the effect of neighborhood characteristics (eg, concentration of poverty) on smoking prevalence has received more research attention in adults,15,16 recent studies have indicated that neighborhoods also influence adolescent smoking rates.17 A particularly important aspect of neighborhoods with respect to the prevalence of youth tobacco use is exposure to smoking advertisements. Numerous studies1821 have revealed higher rates of tobacco use in youth who are exposed to more tobacco marketing and advertisements.

Together these studies demonstrate the predictive utility of incorporating measures of community context into studies of youth tobacco use and raise the possibility that characteristics of the social environment surrounding LGB youth may also contribute to their use of tobacco. Of course, many of the community-level factors reviewed previously herein are likely to predict smoking in LGB youth because schools and neighborhoods are contexts that are common to both LGB adolescents and their heterosexual peers. However, other attributes of the social environment unique to LGB youth may also confer risk for tobacco use.22 For example, LGB individuals experience stigma due to their sexual minority status23 and have significantly higher rates of discrimination24 and victimization25 than do heterosexuals. Researchers26,27 have postulated the importance of these contextual influences in creating risk for adverse health outcomes in LGB populations. Existing research, however, has largely relied on self-report measures of the social environment,28 which are confounded with health status and can, therefore, lead to biased estimates.29 Few studies have attempted to link an objectively defined (ie, non–self-report) index of the social environment to rates of tobacco use in LGB adolescents.

The present study sought to address this gap in the literature by examining whether the social context in which LGB adolescents are embedded may predict tobacco use in a large population-based sample of youth (N = 31 852). The 2 study aims were (1) to test whether characteristics of the social environment surrounding LGB youth (hereafter referred to as “the social environment”) contribute to their rates of tobacco use and (2) to explore the role of exposure to cigarette advertisements, teacher and peer smoking in schools, and school smoking rules in confounding any observed association between the social environment and smoking.

SAMPLE AND SETTING

Data were obtained from the Oregon Healthy Teens (OHT) study, which is based on the Youth Risk Behavior Survey. The Youth Risk Behavior Survey was designed by the Centers for Disease Control and Prevention to measure the prevalence of behaviors and risk factors associated with the leading causes of youth morbidity and mortality. Annual OHT surveys are administered to more than one-third of Oregon's 8th- and 11th-grade public school students. Sexual orientation is assessed in the survey to 11th graders. We pooled data from 2006 (when sexual orientation was first assessed) to 2008 (the most recent data) to increase the sample size of LGB participants. Almost three-quarters of the school districts (74.10%) that were initially selected chose to participate in the OHT study. Participating students came from 297 schools in 34 counties. The questionnaire was available in English and Spanish. All the participants were assured that the survey is anonymous and voluntary, and parents provided passive consent for their children to participate. The study met all the ethical obligations for research involving secondary analysis of de-identified data.

MEASURES

Demographic variables, including sex and race/ethnicity, were obtained via self-report. Sexual orientation was assessed via a single item asking respondents to indicate “which of the following best describes you.” Four response options were given: heterosexual (straight), gay or lesbian, bisexual, and not sure. Of the 33 714 respondents, 30 439 (90.3%) self-identified as heterosexual, 301 (0.9%) as gay or lesbian, and 1112 (3.3%) as bisexual. We excluded 653 participants (1.9%) who indicated that they were “not sure” about their sexual orientation. An additional 1209 respondents did not complete the sexual orientation item. The final sample size was 31 852. See Table 1 for a description of the sample.

Table Graphic Jump LocationTable 1. Demographic Characteristics of the Oregon Healthy Teens Study by Self-reported Sexual Orientation: 2006-2008
Independent Variable

Drawing on recent research on LGB community climate,26 we created an index of the social environment that was composed of the following 4 items: (1) the proportion of same-sex couples living in the counties, (2) the proportion of schools with gay-straight alliances, (3) the proportion of schools with antibullying policies that specifically protected gay students, and (4) the proportion of schools with antidiscrimination policies that included sexual orientation. Each of the 34 Oregon counties included in the 2006-2008 OHT surveys received a value for these 4 items. Data on same-sex couples were obtained from the 2000 US Census, which includes a count of same-sex partner households by county. We divided this number by the total number of households in the county to create the proportion of same-sex couples living in each county.30 The number of gay-straight alliances in each school district was obtained from the Gay and Lesbian Education Network; we created a variable of the proportion of schools in each district that had a gay-straight alliance. The OHT study does not release data on the individual schools that participated in the survey. Consequently, we created a variable of the proportion of schools in each of the 197 Oregon school districts that had antibullying and nondiscrimination policies related to sexual orientation using data from the Oregon Department of Education. We then aggregated these school measures to the county level so that all social environment variables were consistent geographically.

A factor analysis of these data indicated that these 4 items loaded onto a single factor (range of factor loadings, 0.65-0.83) that explained 55.84% of the variance in social climate; the items demonstrated good internal consistency (α = .73). Consequently, these values were summed to create an index of the extent to which the social environment was supportive of gay and lesbian youth in that county. Based on the mean of this sum, we created a z score that reflected the deviation of the value from the mean; the z scores ranged from −9.03 to 4.26. A value of 2.0 for the social environment variable means that the value for that county is 2 SD above the overall mean (ie, is more supportive of gay and lesbian individuals).

Outcome Variable

Participants were asked the number of days they smoked cigarettes during the past 30 days. We created a dichotomous variable indicating any tobacco use in the past 30 days. The Youth Risk Behavior Survey, on which the OHT survey was based, showed excellent test-retest reliability, with the tobacco frequency variable having a κ of 80.1.31

Covariates

The OHT survey includes several measures of community-level predictors of tobacco use. Participants were asked 2 questions about exposure to cigarette advertisements, including whether they had seen an advertisement promoting cigarettes on a storefront or in the store or in a magazine. These 2 items were summed to create a total score (range, 0-2). Participants were also asked 5 questions about the smoking environment in their school, including whether they had been taught about tobacco in school during the last 12 months; there was a rule against tobacco use in their school; they had seen teachers, staff, or other adults smoke on school property during the past 12 months; they had seen students smoke on school property; and they had seen teachers, staff, or other adults use chewing tobacco on school property. Finally, we included the median income in each county, obtained from the US Census, as an additional community-level covariate in all the analyses.

STATISTICAL ANALYSIS

The analysis consisted of 2 steps. First, we tested for differences in tobacco use between LGB and heterosexual youth using basic descriptive cross-tabulations. Second, we examined whether the social environment was significantly associated with tobacco use after adjusting for multiple community-level risk factors for tobacco use by using generalized estimating equations (GEEs). A GEE is a method developed for handling clustered data in which the observations in each cluster are correlated with each other.32 Given that OHT study respondents were nested in their county of residence, we used GEE to account for the correlations among observations from each individual in the same county. Owing to power considerations, we combined lesbian and gay youth with bisexual youth, as well as boys and girls, similar to other population-based studies.24,33

Compared with their heterosexual peers, LGB respondents were significantly more likely to have smoked in the past 30 days. Sixty-one of 183 gay youth (33.3%), 103 of 278 bisexual male youth (37.1%), and 3351 of 15 076 heterosexual male youth (22.2%) had used tobacco in the past 30 days (F = 46.98, P < .001). Thirty-three of 118 lesbian youth (28.0%), 364 of 834 bisexual female youth (43.6%), and 2565 of 15 363 heterosexual female youth (16.7%) had used tobacco in the past 30 days (F = 398.92, P < .001).

In multivariate GEE models controlling for sociodemographic characteristics, each of the community-level risk factors for smoking except school teaching about tobacco remained significant predictors of tobacco use (Table 2, model 1).

Table Graphic Jump LocationTable 2. Associations Between Individual- and Community-Level Characteristics and Tobacco Use in the Past 30 Days in the OHT Study Sample, 2006-2008

Next, we ran GEE models to examine associations between the social environment and tobacco use in the past 30 days. In the unadjusted model, a 5-point increase in the supportiveness of the social environment was associated with a 10% decrease in the odds of tobacco use in the past 30 days (odds ratio [OR], 0.88; 95% confidence interval [CI], 0.87-0.89). In the model adjusted for demographics (sex, race/ethnicity, and sexual orientation), supportive social environments remained significantly associated with less tobacco use (OR, 0.88; 95% CI, 0.87-0.89). In the final model adjusted for demographics and community-level predictors of tobacco use, supportive social environments continued to be associated with lower levels of tobacco use (Table 2, model 2). A 5-point increase in the supportiveness of the social environment was associated with an 8% decrease in the odds of tobacco use in the past 30 days (OR, 0.92; 95% CI, 0.90-0.94).

In samples of heterosexual adolescents, there is accumulating evidence that smoking rates are driven, in part, by characteristics of the community context.9 The central aim of the present study was to identify social/contextual factors that may explain the higher rates of tobacco use by LGB youth. Previous research34 showed that an objective measure of the social context (ie, the presence of LGB campus resources) was associated with tobacco use in sexual minority female college students. We extend these findings by demonstrating that the social environment was associated with rates of smoking in LGB youth. Indeed, the interaction between the social environment and tobacco use approached statistical significance (P = .07), suggesting some specificity to the effect of the social environment on smoking rates in LGB youth. We showed that these effects are independent of established community-level risk factors for tobacco use, including exposure to tobacco advertising,1821 exposure to peer and adult smoking at school,13,14 and an absence of policies against smoking.1012

Although LGB youth were less likely to smoke in environments that are more supportive of homosexuality, the effect of LGB status on smoking rates changed little after adjusting for the measure of the social environment. These results indicate that there are additional mechanisms driving the disparity between LGB and heterosexual individuals that were not accounted for in the present study. For example, there are other contextual effects (eg, antigay attitudes of community residents) that were not included in this measure of the social climate that may be associated with tobacco use. Moreover, because the OHT survey examines risk factors for morbidity and mortality in all youth, measures of determinants that are unique to LGB individuals are excluded, such as experiences of minority stress, a well-documented risk factor for poor health in LGB individuals.35 Research3640 has documented associations between general life stressors and smoking and has revealed physiologic mechanisms through which smoking may reduce the negative sequelae of stress. Thus, studies with more comprehensive measures of contextual factors and minority stressors are needed to identify mechanisms that link aspects of harmful social environments to smoking behaviors in LGB youth.

This study has several limitations. First, the data are cross-sectional, which precludes our ability to infer causal relationships between the social environment and tobacco use. Prospective studies that examine how the social environment affects trajectories of tobacco use are needed to establish causal inferences. Second, this study was conducted in Oregon, which could restrict the generalizability of the results. Replication of these findings in other social contexts is, therefore, warranted. Third, the OHT survey is a school-based sample of youth; consequently, runaway and homeless youth were not sampled. Lesbian, gay, and bisexual individuals are overrepresented among homeless youth41; consequently, this study likely missed a vulnerable subpopulation of LGB youth. On the other hand, a negative social environment is likely to be an even stronger predictor of health-risk behaviors, including tobacco use, in LGB homeless youth. As such, noninclusion of homeless youth likely biased these results toward the null. Future studies are, therefore, needed to replicate these findings using samples of youth from diverse social contexts. Fourth, research from the National Longitudinal Study of Adolescent Health has indicated that the prevalence of tobacco use in sexual minority youth differs as a function of the operationalization of sexual orientation (ie, attraction, relationships, and self-identification).42,43 Because the OHT study assessed self-identification only, these results require replication with other measures of sexual orientation. Fifth, the OHT study does not release data on the specific schools that participated in the survey. The variables on school policies were, therefore, aggregated across the district level, which meant that they were less sensitive indicators than were measures of individual school policies. This likely reduced the power to detect a significant reduction in sexual orientation–related disparities in tobacco after adjusting for the measure of the social environment. Consequently, an important direction for future research is the development of ecologic measures that are more proximal to LGB youth (eg, neighborhoods), which will provide an opportunity to test the sensitivity of this study's results across different spatial scales.44 Nevertheless, the fact that we could document an association between social climate at the county level and tobacco use suggests that these results are likely conservative estimates of the effect of the social environment on the prevalence of smoking in LGB youth. Conversely, previous studies45,46 of “place effects” and the health of LGB populations have been conducted at the state level, and, thus, areas as small as counties may not reflect all aspects of the community climate.47 Future studies incorporating measures at multiple levels of place (state, county, neighborhood, and school) are important to comprehensively characterize the social environment in which youth are embedded.

Despite these limitations, the present study had several noteworthy advantages for studying relationships between community-level risk factors and tobacco use. The large population-based sample of Oregon youth offers a methodological strength over most studies of LGB adolescents, which rely on self-selected convenience samples,48,49 which can lead to biased estimates of the association between sexual orientation and health.50 In addition, many previous studies examining the mental health of LGB youth51 have recruited LGB and heterosexual respondents from different venues, which introduces sampling biases.52 In contrast, in the OHT study, LGB and heterosexual participants were recruited using identical sampling methods. A final methodological strength is the objective measure of the social environment. Previous studies have used self-report measures of stress appraisals, such as perceived discrimination.24 These subjective measures may capture how LGB individuals construe their experience of living in harmful social environments, but such measures are confounded with mental health status.29 In contrast, our objective index of the social environment occurred outside the control of the individual and could not be caused by individual-level factors that might also affect the dependent variable, which helps rule out endogeneity.

Tobacco use is the leading preventable cause of death in the United States.53 Lesbian, gay, and bisexual adolescents smoke at significantly higher rates than do their heterosexual peers, which can place them on poor health trajectories throughout the life course. Despite myriad studies documenting this increased risk, there is a scarcity of research on determinants of tobacco-related disparities in LGB youth, particularly those at the social and structural levels, which has hindered the development of effective preventive interventions. The present study is among the first to document that aspects of the social environment that are particularly relevant to LGB youth may contribute to disparities in tobacco use in LGB adolescents beyond other community-level risk factors for smoking. Only a handful of states participating in the Youth Risk Behavior Survey assess sexual orientation, and few release data at the county level, precluding examination of contextual effects on health. The present results point to the need for better data collection efforts modeled on the OHT study.

In addition, these results have potentially important implications for understanding the etiology of sexual orientation–related disparities in tobacco use. Moreover, these findings contribute to and extend an emerging body of literature23,27,35 highlighting the need for community- and structural-level interventions that address health disparities in LGB populations. In particular, the present data suggest that school policies that encourage supportive structures (eg, gay-straight alliances) and prohibit violent behaviors (eg, antibullying policies) can reduce the disproportionate burden of adverse health outcomes in LGB youth. Careful attention to common and unique concerns of LGB adolescents are needed to ensure that such population-based interventions attenuate, rather than exacerbate, existing sexual orientation–related disparities in tobacco use.54

Correspondence: Mark L. Hatzenbuehler, PhD, Center for the Study of Social Inequalities and Health, Columbia University, 722 W 168th St, Room 1612, New York, NY 10032 (mlh2101@columbia.edu).

Accepted for Publication: December 13, 2010.

Author Contributions: Dr Hatzenbuehler had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Hatzenbuehler. Acquisition of data: Hatzenbuehler and Wieringa. Analysis and interpretation of data: Hatzenbuehler and Keyes. Drafting of the manuscript: Hatzenbuehler. Critical revision of the manuscript for important intellectual content: Hatzenbuehler, Wieringa, and Keyes. Statistical analysis: Hatzenbuehler and Keyes. Administrative, technical, and material support: Wieringa.

Financial Disclosure: None reported.

Funding/Support: This work was supported by the Center for Population Research in LGBT Health at The Fenway Institute and the Eunice Kennedy Shriver National Institute of Child Health and Human Development under award R21HD051178.

Role of the Sponsor: The funders had no role in the design and conduct of the study; in the collection, analysis, and interpretation of the data; or in the preparation, review, or approval of the manuscript.

Disclaimer: The content is the sole responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Additional Information: Dr Hatzenbuehler is a Robert Wood Johnson Foundation Health and Society Scholar at Columbia University, New York, New York.

Additional Contributions: We thank the Robert Wood Johnson Foundation Health and Society Scholars program for its financial support.

Lee  JGGriffin  GKMelvin  CL Tobacco use among sexual minorities in the USA, 1987 to May 2007: a systematic review. Tob Control 2009;18 (4) 275- 282
PubMed
Austin  SBZiyadeh  NFisher  LBKahn  JAColditz  GAFrazier  AL Sexual orientation and tobacco use in a cohort study of US adolescent girls and boys. Arch Pediatr Adolesc Med 2004;158 (4) 317- 322
PubMed
Easton  AJackson  KMowery  PComeau  DSell  R Adolescent same-sex and both-sex romantic attractions and relationships: implications for smoking. Am J Public Health 2008;98 (3) 462- 467
PubMed
Garofalo  RWolf  RCKessel  SPalfrey  SJDuRant  RH The association between health risk behaviors and sexual orientation among a school-based sample of adolescents. Pediatrics 1998;101 (5) 895- 902
PubMed
Russell  STDriscoll  AKTruong  N Adolescent same-sex romantic attractions and relationships: implications for substance use and abuse. Am J Public Health 2002;92 (2) 198- 202
PubMed
Cochran  SDMays  VMBowen  D  et al.  Cancer-related risk indicators and preventive screening behaviors among lesbians and bisexual women. Am J Public Health 2001;91 (4) 591- 597
PubMed
Gruskin  EPGreenwood  GLMatevia  MPollack  LMBye  LL Disparities in smoking between the lesbian, gay, and bisexual population and the general population in California. Am J Public Health 2007;97 (8) 1496- 1502
PubMed
Stall  RDGreenwood  GLAcree  MPaul  JCoates  TJ Cigarette smoking among gay and bisexual men. Am J Public Health 1999;89 (12) 1875- 1878
PubMed
Wilcox  P An ecological approach to understanding youth smoking trajectories: problems and prospects. Addiction 2003;98 ((suppl 1)) 57- 77
PubMed
Aveyard  PMarkham  WALancashire  E  et al.  The influence of school culture on smoking among pupils. Soc Sci Med 2004;58 (9) 1767- 1780
PubMed
Moore  LRoberts  CTudor-Smith  C School smoking policies and smoking prevalence among adolescents: multilevel analysis of cross-sectional data from Wales. Tob Control 2001;10 (2) 117- 123
PubMed
Pentz  MABrannon  BRCharlin  VLBarrett  EJMacKinnon  DPFlay  BR The power of policy: the relationship of smoking policy to adolescent smoking. Am J Public Health 1989;79 (7) 857- 862
PubMed
Barnett  TAGauvin  LLambert  MO’Loughlin  JParadis  GMcGrath  JJ The influence of school smoking policies on student tobacco use. Arch Pediatr Adolesc Med 2007;161 (9) 842- 848
PubMed
Poulsen  LHOsler  MRoberts  CDue  PDamsgaard  MTHolstein  BE Exposure to teachers smoking and adolescent smoking behaviour: analysis of cross sectional data from Denmark. Tob Control 2002;11 (3) 246- 251
PubMed
Ahern  JGalea  SHubbard  ASyme  SL Neighborhood smoking norms modify the relation between collective efficacy and smoking behavior. Drug Alcohol Depend 2009;100 (1-2) 138- 145
PubMed
Datta  GDSubramanian  SVColditz  GAKawachi  IPalmer  JRRosenberg  L Individual, neighborhood, and state-level predictors of smoking among US Black women: a multilevel analysis. Soc Sci Med 2006;63 (4) 1034- 1044
PubMed
Chuang  YCEnnett  STBauman  KEFoshee  VA Neighborhood influences on adolescent cigarette and alcohol use: mediating effects through parent and peer behaviors. J Health Soc Behav 2005;46 (2) 187- 204
PubMed
Gilpin  EAPierce  JPRosbrook  B Are adolescents receptive to current sales promotion practices of the tobacco industry? Prev Med 1997;26 (1) 14- 21
PubMed
Biener  LSiegel  M Tobacco marketing and adolescent smoking: more support for a causal inference. Am J Public Health 2000;90 (3) 407- 411
PubMed
Feighery  EBorzekowski  DLSchooler  CFlora  J Seeing, wanting, owning: the relationship between receptivity to tobacco marketing and smoking susceptibility in young people. Tob Control 1998;7 (2) 123- 128
PubMed
Sargent  JDDalton  MBeach  MBernhardt  AHeatherton  TStevens  M Effect of cigarette promotions on smoking uptake among adolescents. Prev Med 2000;30 (4) 320- 327
PubMed
Remafedi  G Lesbian, gay, bisexual, and transgender youths: who smokes, and why? Nicotine Tob Res 2007;9 ((suppl 1)) S65- S71
PubMed
Herek  G Confronting sexual stigma and prejudice: theory and practice. J Soc Issues 2007;63905- 925
Mays  VMCochran  SD Mental health correlates of perceived discrimination among lesbian, gay, and bisexual adults in the United States. Am J Public Health 2001;91 (11) 1869- 1876
PubMed
Balsam  KFRothblum  EDBeauchaine  TP Victimization over the life span: a comparison of lesbian, gay, bisexual, and heterosexual siblings. J Consult Clin Psychol 2005;73 (3) 477- 487
PubMed
Oswald  RFCutherbertson  CLazarevic  VGoldberg  AE New developments in the field: measuring community climate. J GLBT Fam Stud 2010;6214- 228
Hatzenbuehler  ML Social factors as determinants of mental health disparities in LGBT populations: implications for public policy. Soc Issues Policy Rev 2010;431- 62
Bontempo  DED’Augelli  AR Effects of at-school victimization and sexual orientation on lesbian, gay, or bisexual youths' health risk behavior. J Adolesc Health 2002;30 (5) 364- 374
PubMed
Meyer  IH Prejudice as stress: conceptual and measurement problems. Am J Public Health 2003;93 (2) 262- 265
PubMed
Romero  APRosky  CJBadgett  MVLGates  GJ Census Snapshot: Oregon.  Los Angeles, CA Williams Institute, UCLA School of Law February2008;
Brener  NDCollins  JLKann  LWarren  CWWilliams  BI Reliability of the Youth Risk Behavior Survey Questionnaire. Am J Epidemiol 1995;141 (6) 575- 580
PubMed
Diggle  PJLiang  KYZeger  SL Analysis of Longitudinal Data.  New York, NY Oxford University Press Inc1994;
Fergusson  DMHorwood  LJBeautrais  AL Is sexual orientation related to mental health problems and suicidality in young people? Arch Gen Psychiatry 1999;56 (10) 876- 880
PubMed
Eisenberg  MEWechsler  H Social influences on substance-use behaviors of gay, lesbian, and bisexual college students: findings from a national study. Soc Sci Med 2003;57 (10) 1913- 1923
PubMed
Meyer  IH Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: conceptual issues and research evidence. Psychol Bull 2003;129 (5) 674- 697
PubMed
Benowitz  NL Pharmacology of nicotine: addiction and therapeutics. Annu Rev Pharmacol Toxicol 1996;36597- 613
PubMed
Benowitz  NL Pharmacologic aspects of cigarette smoking and nicotine addiction. N Engl J Med 1998;3191318- 1330
Kirschbaum  CWüst  SStrasburger  CJ “Normal” cigarette smoking increases free cortisol in habitual smokers. Life Sci 1992;50 (6) 435- 442
PubMed
Porcu  PSogliano  CCinus  MPurdy  RHBiggio  GConcas  A Nicotine-induced changes in cerebrocortical neuroactive steroids and plasma corticosterone concentrations in the rat. Pharmacol Biochem Behav 2003;74 (3) 683- 690
PubMed
Piazza  PVLe Moal  ML The role of stress in drug self-administration. Trends Pharmacol Sci 1998;19 (2) 67- 74
PubMed
Cochran  BNStewart  AJGinzler  JACauce  AM Challenges faced by homeless sexual minorities: comparison of gay, lesbian, bisexual, and transgender homeless adolescents with their heterosexual counterparts. Am J Public Health 2002;92 (5) 773- 777
PubMed
Marshal  MPFriedman  MSStall  R  et al.  Sexual orientation and adolescent substance use: a meta-analysis and methodological review. Addiction 2008;103 (4) 546- 556
PubMed
Udry  JRChantala  K Risk assessment of adolescents with same-sex relationships. J Adolesc Health 2002;31 (1) 84- 92
PubMed
Diez Roux  AV Neighborhoods and health: where are we and were do we go from here? Rev Epidemiol Sante Publique 2007;55 (1) 13- 21
PubMed
Hatzenbuehler  MLMcLaughlin  KAKeyes  KMHasin  DS The impact of institutional discrimination on psychiatric disorders in lesbian, gay, and bisexual populations: a prospective study. Am J Public Health 2010;100 (3) 452- 459
PubMed
Rostosky  SSRiggle  EDBHorne  SGMiller  AD Marriage amendments and psychological distress in lesbian, gay and bisexual (LGB) adults. J Couns Psychol 2009;5656- 66
Messer  LC Invited commentary: beyond the metrics for measuring neighborhood effects. Am J Epidemiol 2007;165 (8) 868- 873
PubMed
Rosario  MRotheram-Borus  MJReid  H Gay-related stress and its correlates among gay and bisexual male adolescents of predominantly Black and Hispanic background. J Community Psychol 1996;24136- 159
Savin-Williams  RCReam  GL Suicide attempts among sexual-minority male youth. J Clin Child Adolesc Psychol 2003;32 (4) 509- 522
PubMed
Meyer  IHWilson  PA Sampling lesbian, gay, and bisexual populations. J Couns Psychol 2009;5623- 31
Safren  SAHeimberg  RG Depression, hopelessness, suicidality, and related factors in sexual minority and heterosexual adolescents. J Consult Clin Psychol 1999;67 (6) 859- 866
PubMed
Diamond  LM New paradigms for research on heterosexual and sexual-minority development. J Clin Child Adolesc Psychol 2003;32 (4) 490- 498
PubMed
Centers for Disease Control and Prevention, Cigarette smoking-attributable morbidity—United States, 2000. MMWR Morb Mortal Wkly Rep 2003;52 (35) 842- 844
PubMed
Frohlich  KLPotvin  L Transcending the known in public health practice: the inequality paradox: the population approach and vulnerable populations. Am J Public Health 2008;98 (2) 216- 221
PubMed

Figures

Tables

Table Graphic Jump LocationTable 1. Demographic Characteristics of the Oregon Healthy Teens Study by Self-reported Sexual Orientation: 2006-2008
Table Graphic Jump LocationTable 2. Associations Between Individual- and Community-Level Characteristics and Tobacco Use in the Past 30 Days in the OHT Study Sample, 2006-2008

References

Lee  JGGriffin  GKMelvin  CL Tobacco use among sexual minorities in the USA, 1987 to May 2007: a systematic review. Tob Control 2009;18 (4) 275- 282
PubMed
Austin  SBZiyadeh  NFisher  LBKahn  JAColditz  GAFrazier  AL Sexual orientation and tobacco use in a cohort study of US adolescent girls and boys. Arch Pediatr Adolesc Med 2004;158 (4) 317- 322
PubMed
Easton  AJackson  KMowery  PComeau  DSell  R Adolescent same-sex and both-sex romantic attractions and relationships: implications for smoking. Am J Public Health 2008;98 (3) 462- 467
PubMed
Garofalo  RWolf  RCKessel  SPalfrey  SJDuRant  RH The association between health risk behaviors and sexual orientation among a school-based sample of adolescents. Pediatrics 1998;101 (5) 895- 902
PubMed
Russell  STDriscoll  AKTruong  N Adolescent same-sex romantic attractions and relationships: implications for substance use and abuse. Am J Public Health 2002;92 (2) 198- 202
PubMed
Cochran  SDMays  VMBowen  D  et al.  Cancer-related risk indicators and preventive screening behaviors among lesbians and bisexual women. Am J Public Health 2001;91 (4) 591- 597
PubMed
Gruskin  EPGreenwood  GLMatevia  MPollack  LMBye  LL Disparities in smoking between the lesbian, gay, and bisexual population and the general population in California. Am J Public Health 2007;97 (8) 1496- 1502
PubMed
Stall  RDGreenwood  GLAcree  MPaul  JCoates  TJ Cigarette smoking among gay and bisexual men. Am J Public Health 1999;89 (12) 1875- 1878
PubMed
Wilcox  P An ecological approach to understanding youth smoking trajectories: problems and prospects. Addiction 2003;98 ((suppl 1)) 57- 77
PubMed
Aveyard  PMarkham  WALancashire  E  et al.  The influence of school culture on smoking among pupils. Soc Sci Med 2004;58 (9) 1767- 1780
PubMed
Moore  LRoberts  CTudor-Smith  C School smoking policies and smoking prevalence among adolescents: multilevel analysis of cross-sectional data from Wales. Tob Control 2001;10 (2) 117- 123
PubMed
Pentz  MABrannon  BRCharlin  VLBarrett  EJMacKinnon  DPFlay  BR The power of policy: the relationship of smoking policy to adolescent smoking. Am J Public Health 1989;79 (7) 857- 862
PubMed
Barnett  TAGauvin  LLambert  MO’Loughlin  JParadis  GMcGrath  JJ The influence of school smoking policies on student tobacco use. Arch Pediatr Adolesc Med 2007;161 (9) 842- 848
PubMed
Poulsen  LHOsler  MRoberts  CDue  PDamsgaard  MTHolstein  BE Exposure to teachers smoking and adolescent smoking behaviour: analysis of cross sectional data from Denmark. Tob Control 2002;11 (3) 246- 251
PubMed
Ahern  JGalea  SHubbard  ASyme  SL Neighborhood smoking norms modify the relation between collective efficacy and smoking behavior. Drug Alcohol Depend 2009;100 (1-2) 138- 145
PubMed
Datta  GDSubramanian  SVColditz  GAKawachi  IPalmer  JRRosenberg  L Individual, neighborhood, and state-level predictors of smoking among US Black women: a multilevel analysis. Soc Sci Med 2006;63 (4) 1034- 1044
PubMed
Chuang  YCEnnett  STBauman  KEFoshee  VA Neighborhood influences on adolescent cigarette and alcohol use: mediating effects through parent and peer behaviors. J Health Soc Behav 2005;46 (2) 187- 204
PubMed
Gilpin  EAPierce  JPRosbrook  B Are adolescents receptive to current sales promotion practices of the tobacco industry? Prev Med 1997;26 (1) 14- 21
PubMed
Biener  LSiegel  M Tobacco marketing and adolescent smoking: more support for a causal inference. Am J Public Health 2000;90 (3) 407- 411
PubMed
Feighery  EBorzekowski  DLSchooler  CFlora  J Seeing, wanting, owning: the relationship between receptivity to tobacco marketing and smoking susceptibility in young people. Tob Control 1998;7 (2) 123- 128
PubMed
Sargent  JDDalton  MBeach  MBernhardt  AHeatherton  TStevens  M Effect of cigarette promotions on smoking uptake among adolescents. Prev Med 2000;30 (4) 320- 327
PubMed
Remafedi  G Lesbian, gay, bisexual, and transgender youths: who smokes, and why? Nicotine Tob Res 2007;9 ((suppl 1)) S65- S71
PubMed
Herek  G Confronting sexual stigma and prejudice: theory and practice. J Soc Issues 2007;63905- 925
Mays  VMCochran  SD Mental health correlates of perceived discrimination among lesbian, gay, and bisexual adults in the United States. Am J Public Health 2001;91 (11) 1869- 1876
PubMed
Balsam  KFRothblum  EDBeauchaine  TP Victimization over the life span: a comparison of lesbian, gay, bisexual, and heterosexual siblings. J Consult Clin Psychol 2005;73 (3) 477- 487
PubMed
Oswald  RFCutherbertson  CLazarevic  VGoldberg  AE New developments in the field: measuring community climate. J GLBT Fam Stud 2010;6214- 228
Hatzenbuehler  ML Social factors as determinants of mental health disparities in LGBT populations: implications for public policy. Soc Issues Policy Rev 2010;431- 62
Bontempo  DED’Augelli  AR Effects of at-school victimization and sexual orientation on lesbian, gay, or bisexual youths' health risk behavior. J Adolesc Health 2002;30 (5) 364- 374
PubMed
Meyer  IH Prejudice as stress: conceptual and measurement problems. Am J Public Health 2003;93 (2) 262- 265
PubMed
Romero  APRosky  CJBadgett  MVLGates  GJ Census Snapshot: Oregon.  Los Angeles, CA Williams Institute, UCLA School of Law February2008;
Brener  NDCollins  JLKann  LWarren  CWWilliams  BI Reliability of the Youth Risk Behavior Survey Questionnaire. Am J Epidemiol 1995;141 (6) 575- 580
PubMed
Diggle  PJLiang  KYZeger  SL Analysis of Longitudinal Data.  New York, NY Oxford University Press Inc1994;
Fergusson  DMHorwood  LJBeautrais  AL Is sexual orientation related to mental health problems and suicidality in young people? Arch Gen Psychiatry 1999;56 (10) 876- 880
PubMed
Eisenberg  MEWechsler  H Social influences on substance-use behaviors of gay, lesbian, and bisexual college students: findings from a national study. Soc Sci Med 2003;57 (10) 1913- 1923
PubMed
Meyer  IH Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: conceptual issues and research evidence. Psychol Bull 2003;129 (5) 674- 697
PubMed
Benowitz  NL Pharmacology of nicotine: addiction and therapeutics. Annu Rev Pharmacol Toxicol 1996;36597- 613
PubMed
Benowitz  NL Pharmacologic aspects of cigarette smoking and nicotine addiction. N Engl J Med 1998;3191318- 1330
Kirschbaum  CWüst  SStrasburger  CJ “Normal” cigarette smoking increases free cortisol in habitual smokers. Life Sci 1992;50 (6) 435- 442
PubMed
Porcu  PSogliano  CCinus  MPurdy  RHBiggio  GConcas  A Nicotine-induced changes in cerebrocortical neuroactive steroids and plasma corticosterone concentrations in the rat. Pharmacol Biochem Behav 2003;74 (3) 683- 690
PubMed
Piazza  PVLe Moal  ML The role of stress in drug self-administration. Trends Pharmacol Sci 1998;19 (2) 67- 74
PubMed
Cochran  BNStewart  AJGinzler  JACauce  AM Challenges faced by homeless sexual minorities: comparison of gay, lesbian, bisexual, and transgender homeless adolescents with their heterosexual counterparts. Am J Public Health 2002;92 (5) 773- 777
PubMed
Marshal  MPFriedman  MSStall  R  et al.  Sexual orientation and adolescent substance use: a meta-analysis and methodological review. Addiction 2008;103 (4) 546- 556
PubMed
Udry  JRChantala  K Risk assessment of adolescents with same-sex relationships. J Adolesc Health 2002;31 (1) 84- 92
PubMed
Diez Roux  AV Neighborhoods and health: where are we and were do we go from here? Rev Epidemiol Sante Publique 2007;55 (1) 13- 21
PubMed
Hatzenbuehler  MLMcLaughlin  KAKeyes  KMHasin  DS The impact of institutional discrimination on psychiatric disorders in lesbian, gay, and bisexual populations: a prospective study. Am J Public Health 2010;100 (3) 452- 459
PubMed
Rostosky  SSRiggle  EDBHorne  SGMiller  AD Marriage amendments and psychological distress in lesbian, gay and bisexual (LGB) adults. J Couns Psychol 2009;5656- 66
Messer  LC Invited commentary: beyond the metrics for measuring neighborhood effects. Am J Epidemiol 2007;165 (8) 868- 873
PubMed
Rosario  MRotheram-Borus  MJReid  H Gay-related stress and its correlates among gay and bisexual male adolescents of predominantly Black and Hispanic background. J Community Psychol 1996;24136- 159
Savin-Williams  RCReam  GL Suicide attempts among sexual-minority male youth. J Clin Child Adolesc Psychol 2003;32 (4) 509- 522
PubMed
Meyer  IHWilson  PA Sampling lesbian, gay, and bisexual populations. J Couns Psychol 2009;5623- 31
Safren  SAHeimberg  RG Depression, hopelessness, suicidality, and related factors in sexual minority and heterosexual adolescents. J Consult Clin Psychol 1999;67 (6) 859- 866
PubMed
Diamond  LM New paradigms for research on heterosexual and sexual-minority development. J Clin Child Adolesc Psychol 2003;32 (4) 490- 498
PubMed
Centers for Disease Control and Prevention, Cigarette smoking-attributable morbidity—United States, 2000. MMWR Morb Mortal Wkly Rep 2003;52 (35) 842- 844
PubMed
Frohlich  KLPotvin  L Transcending the known in public health practice: the inequality paradox: the population approach and vulnerable populations. Am J Public Health 2008;98 (2) 216- 221
PubMed

Correspondence

CME
Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.
NOTE:
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).
Submit a Comment

Multimedia

Some tools below are only available to our subscribers or users with an online account.

Related Content

Customize your page view by dragging & repositioning the boxes below.

Articles Related By Topic
Related Topics
PubMed Articles