Abstract
Objectives:
This study aimed to analyze tobacco and marijuana use by middle and high school students identifying as bisexual, gay, lesbian, or heterosexual using data from the National Youth Tobacco Survey (NYTS) spanning from 2020 to 2022. By comparing substance use patterns among different sexual orientation groups, the study sought to identify disparities and potential socioeconomic factors influencing these behaviors.
Methods:
Data from the 2020 to 2022 NYTS were analyzed, focusing on responses regarding ever use of cigarettes, e-cigarettes, and marijuana by students of varying sexual orientations. Descriptive statistics and chi-square tests were employed to analyze differences in substance use and socioeconomic indicators between sexual orientation groups.
Results:
Of the 37 541 students included in the analysis, significant differences in substance use were observed among bisexual, gay, lesbian, and heterosexual students. Bisexual and gay/lesbian students exhibited higher rates of ever use of cigarettes, e-cigarettes, and marijuana compared to heterosexual students. In addition, socioeconomic differences, such as lower rates of family vehicle ownership and reduced access to vacations, were noted among bisexual and gay/lesbian students.
Conclusions:
The findings underscore significant differences in tobacco and marijuana use by adolescents based on sexual orientation, mirroring differences observed in LGBTQ adults. These results highlight the importance of targeted interventions, educational initiatives, and support systems tailored to the unique needs of LGBTQ youth. Addressing socioeconomic disparities and fostering inclusive environments are crucial steps in promoting the health and well-being of LGBTQ adolescents. Continued research and collaborative efforts are essential in mitigating health disparities and creating equitable environments for all adolescents.
Introduction
Cigarettes, e-cigarettes, and other tobacco products pose significant health risks in current and former users. 1 For this reason, research on the use of these products is extensive and provides information on individuals who are most likely to use them. One group that has a disproportionately increased rate of cigarette and tobacco product use and mortality is the lesbian, gay, bisexual, transgender, and gender queer (LGBTQ) community.2 -4 Research has consistently found that LGBTQ adults have higher use of tobacco products, e-cigarettes, and psychoactive substances. 5 While research on adult populations is extensive, research on LGBTQ child and adolescent populations is limited. This lack of comprehensive knowledge about this population at younger ages is especially concerning with some research showing younger ages of first using these products in the LGBTQ community. 6 With national surveys like the National Youth Tobacco Survey (NYTS), it has been possible to track the use of these products in adolescents since 1999, but this data set didn’t collect individual participant sexual orientation until 2020. 7 With the recent inclusion of sexual orientation questions, it is now possible to track the use of cigarettes, e-cigarettes, marijuana, and other products in LGBTQ youth and to compare their use with their heterosexual counterparts.7,8
This study uses the data collected by the NYTS from the years 2020 to 2022 and its’ new data inclusion of questions on sexual orientation to determine the use rates of cigarettes, e-cigarettes, and marijuana in students who report being bisexual, gay, or lesbian in comparison with their heterosexual counterparts to determine if differences seen in previous studies focusing on the adult population are also present in child and adolescent populations. The findings of this study and others like it provide the information for targeted health interventions focused on LGBTQ youth substance use, educational initiatives, and awareness campaigns focused on substance abuse prevention in this population, and spur parental and community support in creating more inclusive and supportive environments for LGBTQ youth.
Methods
The National Youth Tobacco Survey (NYTS) is a national school-based survey that collects data on tobacco product use from students in the United States from grades 6 to 12 (https://www.cdc.gov/tobacco/data_statistics/surveys/nyts/index.htm). 7 The NYTS began electronic data collection methods starting in 2019, and this practice of electronic data collection has continued through the 2022 cycle. Due to varying local and state contact precautions during the COVID-19 pandemic, the 2021 and 2022 methodology required 100% online survey administration. During this time, one-half of the surveys were completed in school and the other half were completed at home over the internet. Due to these differences in survey administration, comparisons cannot be made between 2021 or 2022 NYTS results and results from the 2019 and 2020 cycles which were conducted in-person on school campuses. Surveys were conducted through a secure website on which students watched a 2-min instructional video before completing the survey. Participation in the survey was voluntary, both for the schools and the students, with students also being given anonymity if they participated. Parents were also given the opportunity to opt their student out of participating in the survey per the CDC’s Institutional Review Board (IRB).
The 2021 and 2022 NYTS was a stratified, 3-stage cluster sample design meant to produce a sample of middle and high school students in the United States that was nationally representative. Sampling was done in stages with Primary Sampling Units (PSUs) being counties, groups of small counties, or parts of large counties within stratum, Secondary Sampling Units were schools within selected PSUs, and finally students within each selected school. Survey administration began in January of 2021 and 2022 and concluded in May of 2021 and 2022 for the 2021 and 2022 NYTS, respectively. The 2021 NYTS had a final sample consisting of 508 schools, with participation from 279 of those schools, yielding a participation rate of 54.9%. The 2022 NYTS had a final sample consisting of 574 schools, with participation from 341 of those schools, yielding a participation rate of 59.4%. The 2021 NYTS produced a total of 20 413 completed student questionnaires out of the 25 149 students sampled, yielding a student participation rate of 81.2%. The 2022 NYTS produced a total of 28 291 completed student questionnaires out of the 37 172 students sampled, yielding a student participation rate of 76.1%.
In this analysis, questions focusing on e-cigarette ever use, cigarette ever use, and marijuana ever use were compared between students who reported being bisexual and those reported being heterosexual and compared between students who reported being gay or lesbian and those reported being heterosexual. These variables were chosen as past research on adult LGBTQ populations has found differences in the use of these substances, and due to the NYTS asking about these specific substances with a limited focus on other psychoactive agents.
The NYTS data for 2021 and 2022 were obtained from the official website. Descriptive statistics were used to describe the study participants’ characteristics. Categorical variables were presented as frequencies; continuous variables were summarized using means and standard deviations or medians and ranges when appropriate. The characteristics of the gay/lesbian and bisexual groups were compared with the heterosexual group. Logistic regression was used to analyze the associations between cigarette, e-cigarette, and marijuana use and student sexual orientation, adjusting for covariates. The samples were weighted by the NYTS managers to account for unequal probabilities of selection response, and to match the sample demographic characteristics to the national population of middle and high school students The significance level was set at .05. Multiple testing adjustment was not performed. Analyses were performed using SAS (Windows version 9.3; SAS Institute, Cary, NC) and the statistical program R version 4.2.2 (https://cran.r-project.org/).
Results
A total of 20 413 and 28 291 students participated in the 2021 and 2022 NYTSs, respectively. After excluding students with missing values for ever cigarette use, ever e-cigarette use, ever marijuana use, or missing data on sexual description, the total number of students in the final data analysis was 37 541. When students were separated by sexuality, 4724 students reported being bisexual, 1614 students reported being gay or lesbian, and the remaining 31 203 students reported being heterosexual. A total of 7293 students reported ever using e-cigarettes, 3095 reported ever using cigarettes, and 5401 reported ever using marijuana (Table 1).
2021 to 2022 NYTS Students’ Characteristics.
Substance Use
When comparing the responses of ever use of these substances between students reporting different sexualities, statistically significant differences in responses were found among bisexual, gay or lesbian, and heterosexual students in the use of all three substances (Table 2). Higher percentages of students who reported being bisexual or being gay or lesbian reported that they had ever used e-cigarettes, ever used cigarettes, and ever used marijuana compared to students who reported being heterosexual (Table 2).
Differences Between Bisexual Gay/Lesbian and Heterosexual Students.
Home-Life and Socioeconomic Factors
Statistically significant differences in responses were found among students who reported being bisexual, gay or lesbian, or heterosexual in language spoken at home, family vehicle ownership, family computer ownership, and the number of vacations in the past 12 months (Table 2). Higher percentages of students who reported being bisexual or being gay or lesbian reported that their family didn’t own a vehicle or that their family had not traveled on vacation in the past 12 months.
Mental Health
When comparing the responses to survey questions related to mental health in students reporting different sexualities, statistically statistical difference in responses were found among bisexual, gay or lesbian, and heterosexual students in difficulty concentrating, remembering or making decisions, pleasure doing things, feeling down, depressed or hopeless, feeling nervous anxious or on edge, and not being able to stop or control worrying. Higher percentages of students who reported being bisexual or reported being gay or lesbian reported experiencing difficulty concentrating, remembering, or making decisions, reported having little interest or pleasure in doing things nearly every day, reported feeling down depressed or hopeless nearly every day, reported feeling nervous or anxious on edge nearly every day, or reported not being able to stop or control worrying nearly every day compared to heterosexual students (Table 2). All these variables appeared to have around a 3-fold higher prevalence in students reporting to be bisexual or reporting to be gay or lesbian compared to their heterosexual counterparts.
Logistic regression was used to analyze the association between the students’ sexual orientation and cigarette use, e-cigarette use, or marijuana use with adjustment for other covariables (Table 3). This analysis identified multiple factors associated with either an increased odds ratio for use of a particular product or a decreased odds ratio particular product. In general, the adjusted odds ratio for the use of cigarettes, e-cigarettes, and marijuana increased with age and some responses on mental health questions.
Cigarette, E-Cigarette, and Marijuana Use and Student Characteristics.
Note. Odds ratios were adjusted for all covariates. Numbers in bold are statistically significant and either above 1.0 or below 1.0. I
Supplemental Tables 4to 6 provide the adjusted odds ratios for factors associated with cigarette use (Supplemental Table 4), e-cigarette use (Supplemental Table 5), and marijuana use (Supplemental Table 6).
Discussion
This National Youth Tobacco Survey data demonstrate that there are significant differences in the use of substances by students reporting bisexual, gay, or lesbian sexualities. When compared to students reporting being heterosexual, students who reported being bisexual reported a 1.6-fold increased use of e-cigarettes, a 2.1-fold increased use of cigarettes, and a 1.9-fold increased use of marijuana. Students who reported being gay or lesbian reported a 1.5-fold increased use of e-cigarettes, a 1.9-fold increased use of cigarettes, and a 1.7-fold increased use of marijuana. These findings of increased use of tobacco and marijuana among adolescents of bisexual, gay or lesbian sexualities mirror those of previous studies done on adults that have found that substance use is higher in LGBTQ individuals than in heterosexual individuals.9 -11 While research on LGBTQ youth is limited, 5 Kerr et al found that LGBTQ college students had higher rates of alcohol, tobacco, and other drug use and misuse than heterosexual college students. While this study identifies significant associations between sexual orientation responses and substance use, socioeconomic factors, and mental health indicators, it is important to understand the observational design of this study limits any inference about causative relationships.
Explanations for why LGBTQ individuals have higher rates of use are not fully understood. It has been suggested by the Minority Stress Theory that members of the LGBTQ community have experienced chronic stressors related to their sexual orientation and that this has led to victimization, prejudice, and discrimination experiences that are unique to their community. 12 These experiences include structural and institutionalized discrimination, personal interactions of prejudice or victimization, the expectation of rejection or of victimization, and the internalization of others’ negative social attitudes toward LGBTQ individuals. This theory has been used to explain reason why LGBTQ individuals report higher rates of anxiety, depression, and other psychological disorders and why this population has higher rates of substance use and abuse.12,13 Psychological disorders and formal diagnosis of depression and anxiety are outside of the scope of the NYTS, but the results in this study do show that students who reported being bisexual, gay, or lesbian had higher rates of having little interest and pleasure in doing things, feeling down, depressed or hopeless, feeling nervous anxious, or on edge, and are unable to stop or control their worrying than their heterosexual counterparts. Although this study doesn’t directly measure all aspects of Minority Stress Theory, the findings align with the theory’s predictions. LGBTQ students reported higher rates of substance use and reported more indicators of mental health challenges than their heterosexual counterparts. These findings suggest that the minority stressors outlined by the theory may contribute to the observed differences. Future research should try to understand the specific stressors experienced by LGBTQ adolescents and their cumulative effects on health outcomes to better understand the interaction between minority stress and health-related behaviors.
Questions about homelife for students who took the NYTS also provide insight into potential socioeconomic differences between LGBTQ students and their heterosexual counterparts. This study found that bisexual students reported higher rates of living in families that did not own a vehicle and higher rates of not traveling on vacation in the past 12 months. Gay or lesbian students also reported higher rates of living in families that did not own a vehicle, didn’t own a computer, and having higher rates of not traveling on vacation in the past 12 months compared to heterosexual students. While this study cannot conclusively attribute characteristics of LGBTQ students to higher rates of poverty or limited access to resources, the results do offer insights into potential socioeconomic differences within these subpopulations. These potential socioeconomic challenges may be indicative of broader systemic issues that could impact family dynamics, access to education, and overall quality of life for LGBTQ youth. This context would be crucial in developing targeted interventions and support systems. Policymakers and healthcare professionals alike should consider the broader societal factors that contribute to the disparities observed in our study and should address any economic inequalities that could be affecting the over-all well-being within these communities. Future research could explore these connections in depth to provide a more complete understanding of economic differences observed among LGBTQ adolescents.
The use of surveys like the NYTS in adolescents with a wide range of ages has many limitations and requires several assumptions. Among them, it is assumed that the participants understood the questions and that they are aware of, can correctly identify, and can accurately recall the substances they have ever used in the past. For this study and the survey questions it relies on, it is important that adolescents understand and accurately report their sexuality at a mean age of 14.5 years. Adolescents undergo rapid developmental changes during this period of their lives, and their own self-awareness, cognitive abilities, and comprehension levels can all influence the accuracy of their responses. They may interpret questions differently by their developmental stage, cultural background, or personal experiences, or they may even provide responses that align with societal expectations. There are also a number of responses that were excluded from the final analysis because of missing data to the relevant survey questions. The effect of these missing responses should be minimal due to the very large number of responses analyzed, but it is impossible to conclude that they would have had no effect. Furthermore, the location where the student completed the survey could influence their survey responses, and the presence of other individuals, including parents or guardians, could have changed participant responses. Future studies may benefit from exploring age-specific nuances in survey administration and consider employing age-appropriate language or strategies to ensure participant comprehension and encourage accurate reporting.
Conclusion
This study indicates that there are differences in the use of cigarettes, e-cigarettes, and marijuana in adolescents of differing sexual orientations who took the NYTS from the years 2020 to 2022. There are significantly higher use rates of all 3 substances by individuals reporting bisexual, gay or lesbian sexual orientations compared to their heterosexual counterparts. These findings correspond with established findings that adult LGBTQ populations have higher use rates of tobacco, marijuana, and psychoactive substances compared to heterosexual populations, and this study also corroborates past studies that have found higher rates of depression and anxiety amongst LGBTQ populations. While the reasons for why these rates are higher in this population are not certain, this study shows that these trends are present in youth populations as well as adult populations. Examination of socioeconomic factors offer insights into potential economic disparities faced by the LGBTQ population. While caution is needed in definitive conclusions about the economic status of LGBTQ adolescents based on this study’s findings, they emphasize the importance of considering broader social and structural factors that contribute to health differences.
Healthcare professionals, policymakers, educators, and researchers should collaborate to develop targeted interventions, educational initiatives, and support systems that account for the unique needs of LGBTQ adolescents. Fostering inclusive environments, addressing potential socioeconomic inequalities, and considering age-specific nuances in research methodologies are essential steps toward promoting the health and well-being of LGBTQ youth. While this study contributes valuable insights, it is part of an ongoing dialog in understanding and addressing the health disparities faced by LGBTQ adolescents. Continued research, informed policy changes, and community-driven initiatives will have important roles in creating more equitable and supportive environments for all adolescents, irrespective of their sexual orientation.
Supplemental Material
sj-docx-1-jpc-10.1177_21501319241276790 – Supplemental material for An Analysis of Tobacco and Marijuana Use by Middle School and High School Bisexual and Homosexual Students Surveyed by the National Youth Tobacco Survey From 2020 to 2022
Supplemental material, sj-docx-1-jpc-10.1177_21501319241276790 for An Analysis of Tobacco and Marijuana Use by Middle School and High School Bisexual and Homosexual Students Surveyed by the National Youth Tobacco Survey From 2020 to 2022 by William Derrick, Shengping Yang and Kenneth Nugent in Journal of Primary Care & Community Health
Supplemental Material
sj-docx-2-jpc-10.1177_21501319241276790 – Supplemental material for An Analysis of Tobacco and Marijuana Use by Middle School and High School Bisexual and Homosexual Students Surveyed by the National Youth Tobacco Survey From 2020 to 2022
Supplemental material, sj-docx-2-jpc-10.1177_21501319241276790 for An Analysis of Tobacco and Marijuana Use by Middle School and High School Bisexual and Homosexual Students Surveyed by the National Youth Tobacco Survey From 2020 to 2022 by William Derrick, Shengping Yang and Kenneth Nugent in Journal of Primary Care & Community Health
Supplemental Material
sj-docx-3-jpc-10.1177_21501319241276790 – Supplemental material for An Analysis of Tobacco and Marijuana Use by Middle School and High School Bisexual and Homosexual Students Surveyed by the National Youth Tobacco Survey From 2020 to 2022
Supplemental material, sj-docx-3-jpc-10.1177_21501319241276790 for An Analysis of Tobacco and Marijuana Use by Middle School and High School Bisexual and Homosexual Students Surveyed by the National Youth Tobacco Survey From 2020 to 2022 by William Derrick, Shengping Yang and Kenneth Nugent in Journal of Primary Care & Community Health
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
Supplemental Material
Supplemental material for this article is available online.
References
Supplementary Material
Please find the following supplemental material available below.
For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.
For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.
