Psychological, Normative, and Environmental Barriers to Tobacco Cessation that Disproportionally Affect Sexual Minority Tobacco Users

Sex differences in tobacco use, attempts to quit smoking, and cessation among dual users of cigarettes and e-cigarettes: Longitudinal findings from the US Population Assessment of Tobacco and Health Study

SIGNIFICANCE

A growing number of adults use more than one tobacco product, with dual use of cigarettes and e-cigarettes being the most common combination. Monitoring sex disparities in tobacco use is a public health priority. However, little is known regarding whether dual users differ by sex.

METHODS

Data came from Waves 4-6 (12/2016-11/2021) of the Population Assessment of Tobacco and Health Study, a US nationally-representative longitudinal survey. This analysis included current adult dual users of cigarettes and e-cigarettes. We used weighted generalized estimating equations to assess the association between sex and (1) making a cigarette quit attempt (n = 1882 observations from n = 1526 individuals) and (2) smoking cessation (n = 2081 observations from n = 1688 individuals) across two wave pairs, adjusting for age, education, ethnicity, time-to-first cigarette after waking, and e-cigarette use frequency.

RESULTS

Among US dual users, 14.1% (95% Confidence Intervals [Cl] = 11.9-16.4) of females and 23.4% (20.0-26.9) of males were young adults (aged 18-24), 11.7% (9.2-14.2) of females and 14.4% (11.6-17.2) of males had

CONCLUSION

US females who dual use e-cigarettes and cigarettes were more likely to attempt to quit smoking, but not more likely to succeed at quitting, than males.

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Key Words

• Cigarette smoking
• Cohort studies
• Dual use
• E-cigarette
• Electronic nicotine delivery systems
• Nicotine dependence
• Quit attempt
• Sex differences
• Smoking cessation

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Affiliation(s)

Elias M Klemperer Vermont Center on Behavior & Health, Department of Psychiatry, University of Vermont, United States of America.
Loren Kock Vermont Center on Behavior & Health, Department of Psychiatry, University of Vermont, United States of America
Marc Jerome P Feinstein Vermont Center on Behavior & Health, Department of Psychiatry, University of Vermont, United States of America
Sulamunn R M Coleman Vermont Center on Behavior & Health, Department of Psychiatry, University of Vermont, United States of America
Diann E Gaalema Division of Cardiovascular Medicine, University of Texas Medical Branch, United States of America
Stephen T Higgins Vermont Center on Behavior & Health, Department of Psychiatry, University of Vermont, United States of America

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Cigarette smoking behaviors and nicotine dependence at the intersection of sexual identity and sex in the United States: Findings from the National Survey on Drug Use and Health

INTRODUCTION

Cigarette smoking is disproportionately high among lesbian, gay, and bisexual (LGB) adults. Yet, collapsing these identities into a monolith can disguise important within group disparities (e.g., lesbian/gay versus bisexual female). The purpose of this study is to report recent national prevalence estimates and trends of cigarette smoking behaviors and nicotine dependence by sexual identity and sex.

METHODS

Data were from the 2015-2019 National Survey on Drug Use and Health (n = 210,392; adults 18+), a nationally representative, repeated cross-sectional study of substance use and mental health in the U.S. We examined bivariate and multivariable associations between sexual identity and cigarette smoking measures (i.e., former smoking, lifetime smoking, current smoking, current daily smoking, nicotine dependence) by sex. We also examined linear time trends in current and former smoking. Covariates included age, race/ethnicity, education, annual household income, and survey year.

RESULTS

Bisexual women had the highest unadjusted prevalence of current smoking (31 %) and lowest of former smoking (25 %). LGB females and males had higher adjusted prevalence of current smoking, daily smoking, and nicotine dependence than heterosexual adults. Bisexual females and gay and bisexual males had lower adjusted prevalence of former smoking (adjusted prevalence ratio range: 0.78-0.85) than heterosexual counterparts.

DISCUSSION

This is the first study to identify disproportionately low prevalence of former smoking among bisexual females. Paired with findings of high prevalence of current cigarette smoking and nicotine dependence, these data suggest that tobacco control interventions targeted toward bisexual females are urgently needed to reduce the burden of cigarette smoking among these individuals.

Tobacco Use and Tobacco Dependence Management

Tobacco use is a major public health problem and the leading cause of preventable deaths in the United States and worldwide. Tobacco dependence determines tobacco use and is largely due to nicotine addiction. Such dependence is a disease resulting in a strong desire or compulsion to take tobacco, with difficulty in cessation of tobacco, along with persistent use despite overtly harmful consequences.

Intentions and Attempts to Quit Smoking Among Sexual Minoritized Adult Smokers After Exposure to the Tips From Former Smokers Campaign

IMPORTANCE

Significant disparities exist in smoking behaviors by sexual minority status in the US.

OBJECTIVE

To examine potential differences in the associations between exposure to the Tips From Former Smokers (Tips) campaign and intentions and attempts to quit smoking by sexual minority status.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study used data from the wave 5 survey of the Population Assessment of Tobacco and Health study. Data from 8072 adults who were currently established cigarette smokers were collected from December 2018 to November 2019 and analyzed in August 2021. The Population Assessment of Tobacco and Health study is an ongoing cohort study representative of the noninstitutionalized US population. Sample weights were applied to account for the complex sampling strategies.

EXPOSURES

Dichotomized self-reported frequent Tips exposure (often and very often) and infrequent exposure (never, rarely, and sometimes).

MAIN OUTCOMES AND MEASURES

Outcomes were intention to quit within 12 months, any serious quit attempts in the past 12 months, and number of serious quit attempts in the past 12 months. Multivariate logistic and ordinal logistic regressions were used to estimate the weighted associations between exposure and each outcome. Interactions between Tips exposure and sexual minority status were examined to explore potential differences.

RESULTS

A total of 8072 participants (mean [SD] age, 44.7 [14.8] years; 3888 [53.2%] male; 4962 [67.4%] non-Hispanic White; and 915 [9.5%] sexual minoritized individuals [ie, those who identified as lesbian, gay, bisexual, or another minoritized sexual identity]) were included. Frequent Tips exposure was associated with higher odds of quit intentions and attempts overall (adjusted odds ratio [aOR], 1.25; 95% CI, 1.07-1.46 for intention to quit within 12 months; aOR, 1.26; 95% CI, 1.08-1.47 for serious quit attempts in the past 12 months; and aOR, 1.24; 95% CI, 1.06-1.44 for number of serious quit attempts in the past 12 months). These associations were significantly stronger for heterosexual smokers than sexual minoritized smokers, as indicated by the significant interaction terms (aOR, 0.58; 95% CI, 0.36-0.96 for intention to quit within 12 months; aOR, 0.41; 95% CI, 0.24-0.70 for serious quit attempts in the past 12 months; and aOR, 0.40; 95% CI, 0.24-0.67 for number of serious quit attempts in the past 12 months). Subgroup analysis showed that heterosexual smokers who reported frequent Tips exposure were more likely to intend to quit within 12 months (aOR, 1.29; 95% CI, 1.10-1.53), have had any serious quit attempts in the past 12 months (aOR, 1.34; 95% CI, 1.13-1.58), and have had more serious quit attempts (aOR, 1.32; 95% CI, 1.12-1.54) than heterosexual smokers who reported infrequent exposure. In contrast, there was no association for sexual minoritized smokers (aOR, 0.82; 95% CI, 0.52-1.30 for intention to quit within 12 months; aOR, 0.65; 95% CI, 0.39-1.07 for serious quit attempts in the past 12 months; and aOR, 0.62; 95% CI, 0.38-1.00 for number of serious quit attempts in the past 12 months).

CONCLUSIONS AND RELEVANCE

These findings suggest that significant differences exist in the associations between Tips exposure and quit intentions or attempts by sexual minority status. More targeted campaign content for sexual minoritized smokers may be needed to increase quit intentions and attempts among this group.

Differences in Quit Attempts, Successful Quits, Methods, and Motivations in a Longitudinal Cohort of Adult Tobacco Users by Sexual Orientation

INTRODUCTION

Sexual minority (SM) tobacco users are less likely to successfully quit than heterosexuals, yet little evidence describes cessation behaviors in this population over time.

AIMS AND METHODS

Our study investigated quit motivations, attempts, and methods in a longitudinal cohort of adult tobacco users by sexual orientation. Participants (N = 1177) completed interviews every 6 months through 48 months and reported quit attempts (24-hour tobacco free), successful quits (7-day point prevalence abstinence), motivations, and methods. Chi-squared and Fisher's exact tests assessed differences by heterosexual and SM orientation, gender, and quit outcome (attempt-only vs. successful quit).

RESULTS

Quit rates were similar for heterosexual and SM adults. Over half attempted to quit at least once over 48 months, but few remained abstinent (SM: 16.9%; heterosexual: 12.1%). Most used nicotine replacement therapy (SM: 31.9%; heterosexual: 26.1%) or tobacco product substitution (SM: 27.7%; heterosexual: 21.2%). Few used quitlines (SM: 4.3%; heterosexual: 1.3%) or Internet-based programs (SM: 6.4%; heterosexual: 1.3%). Quit motivations included health concerns, family, and physical fitness. Participants reporting a successful quit were more likely to report a household member quit smoking than 24-hour quit attempters. Among participants reporting a successful quit, more SM than heterosexual participants reported that a coworker quit smoking (55.6% vs. 33.1%, p = .009).

CONCLUSIONS

We found few differences between heterosexual and SM tobacco users in our sample. Many repeatedly attempt to quit, yet few used evidence-based methods. Leveraging online quit programs, health messages, and family members in tailored cessation interventions may help SM and heterosexual tobacco users successfully quit.

IMPLICATIONS

SM and heterosexual tobacco users evidenced few differences in quit behaviors. Over 4 years, a majority attempted to quit, with over a third making repeated quit attempts. Nicotine replacement therapy and tobacco product substitution were mostly used during quit attempts; however, more SM than heterosexual men reported using web-based quit programs. Personal health and family concerns were universal motivations to quit, yet SM women also cited physical fitness as a primary motivation. Tobacco users reporting that a household member stopped smoking were more likely to successfully quit. More SM than heterosexual men reported that a coworker quit smoking.