Association of Coming Out as Lesbian, Gay, and Bisexual+ and Risk of Cigarette Smoking in a Nationally Representative Sample of Youth and Young Adults

Abstract

This cohort study assesses whether young people who change their sexual identity are associated with having higher risk of cigarette smoking initiation and current smoking compared with those with consistent sexual identities.

Key Points

Question

Is changing sexual identity associated with increased risk of cigarette smoking initiation and current smoking?

Findings

In this nationally representative cohort study of 7843 youth and young adults, those who changed their sexual identity from heterosexual to bisexual were more likely than those with consistent heterosexual identities to initiate smoking and be current smokers during 3 years of follow-up. There was no increased risk for youth and young adults changing from heterosexual to lesbian, gay, or other nonheterosexual identities.

Meaning

In this study, coming out as bisexual was associated with increased risk of initiating cigarette smoking and current smoking in youth and young adults.

Abstract

Importance

Coming out as lesbian, gay, bisexual, or other identities besides heterosexual (LGB+) may represent a susceptible period for cigarette smoking initiation in youth and young adults.

Objective

To assess whether young people who change their sexual identity have higher risk of cigarette smoking initiation and current smoking compared with those with consistent sexual identities.

Design, Setting, and Participants

This cohort study used data from the nationally representative Population Assessment of Tobacco and Health study (wave 1, 2013-2014; wave 2, 2014-2015; wave 3, 2015-2016; wave 4, 2016-2018). Youth and young adults aged 14 to 29 years who were never smokers at wave 1 were included in this study. Analysis began October 2018 and ended June 2020.

Exposures

Consistent sexual identity (consistently heterosexual, consistently LGB+) vs changing sexual identity (coming out as LGB+, other LGB+ patterns) based on 4 waves of sexual identity data. Identities were further classified by distinguishing between bisexual and lesbian, gay, and other nonheterosexual identities.

Main Outcomes and Measures

Smoking initiation and current cigarette smoking at wave 4.

Results

Among 7843 individuals who never smoked at wave 1, 6991 (90.7%) reported a consistent sexual identity, and 852 (9.3%) changed sexual identity across waves. The mean (SE) baseline age of participants who reported consistent heterosexuality was 20.1 (0.8) years; consistently LGB+, 20.0 (3.7) years; coming out as LGB+, 18.0 (2.9) years, and other LGB+ pattern, 20.3 (3.8) years. A total of 14.1% (weighted) initiated smoking, and 6.3% were current smokers at wave 4. Compared with consistently heterosexual identities, coming out as LGB+ (23% vs 13%; odds ratio [OR], 1.72; 95% CI, 1.34-2.20), consistently LGB+ identities (17% vs 13%; OR, 1.45; 95% CI, 1.03-2.04), and other LGB+ patterns (17% vs 13%; OR, 1.47; 95% CI, 1.04-2.08) were positively associated with smoking initiation by wave 4. Compared with consistently heterosexual identities, ORs for smoking initiation were 2.24 (28% vs 13%; 95% CI, 1.72-2.92) for coming out as bisexual, 1.99 (23% vs 13%; 95% CI, 1.20-3.29) for consistently LGB+ with change to/from bisexual, and 2.20 (23% vs 13%; 95% CI, 1.40-3.46) for other LGB+ patterns with change to/from bisexual identity. Current smoking estimates were similar to those for smoking initiation.

Conclusions and Relevance

Compared with consistently heterosexual identities, changing sexual identity over follow-up was associated with smoking initiation and current smoking. The risk associated with changing sexual identities was concentrated among participants coming out as bisexual or reporting other changes in their identity to/from being bisexual. More research is needed on mechanisms underlying the association between changing sexual identity and smoking initiation to inform tailored prevention programs and tobacco regulations.