Sex and Sexual Identity Differences in Poly-tobacco Use and Psychological Distress in U.S. Adults: Results From the National Health Interview Survey

Abstract

Introduction

Poly-tobacco use (PTU), or the concomitant use of two or more nicotine and tobacco products, are a growing public health concern. Adults reporting increased psychological distress (PD) experience profound nicotine and tobacco health-related disparities. Sexual minority (SM) adults report more PTU and higher levels of PD than heterosexuals, yet little is known about patterns of nicotine and tobacco use and its relationship to PD in SM populations.

Aims and Methods

The purpose of this study was to investigate sexual identity differences in PD and PTU. Data were drawn from the 2016–2018 National Health Interview Survey (N = 83 017), an annual cross-sectional survey of a nationally representative sample of U.S. adults. PD was assessed using the Kessler Psychological Distress Scale (K6). We fit sex-stratified, weighted, adjusted logistic models to compare PTU and PD by sexual identity.

Results

PTU was more prevalent in adults with higher K6 scores. Female adults and SM adults had significantly higher K6 scores and were significantly more likely to experience serious PD when compared to their male and heterosexual counterparts.

Conclusions

The current study provides a snapshot of trends in PTU in relation to PD, gender, and sexual identity. Findings suggest higher rates of both PD and PTU in SM adults. Further research examining the mechanisms underlying this disparity is critical to the development of effective intervention and prevention strategies.

Implications

Little is known about sex and sexual identity differences in the relations between patterns of tobacco product use and PD. This study is the first to examine the effect of gender and sexual identity on both PD and PTU. SMs reported higher rates of PD and were more likely to be poly-tobacco users. As new ways of engaging nicotine/tobacco continue to proliferate, health risks will endure especially for marginalized populations. An increased understanding of the psychological and social correlates of PTU in SMs is warranted.

Although the last few decades have seen significant declines in the rate of cigarette smoking among adults in the United States,¹ alternative forms of consumption like smokeless tobacco (SLT) and emerging tobacco products such as electronic nicotine delivery systems (ENDS) have not seen the same decline.² In fact, according to data from the Federal Trade Commission, tobacco product sales increased for the first time in two decades during the current Coronavirus disease 2019 pandemic. SLT sales increased by nearly 1 million pounds between 2019 and 2020.³ An increasingly diverse market of alternative tobacco products may contribute to the growing prevalence of poly-tobacco use (PTU), or the concomitant use of two or more nicotine/tobacco products.² The proliferation of alternative tobacco products and the rise in use are a significant public health concerns. Though noncombustible nicotine/tobacco products are widely considered significantly less harmful when compared to combustible products, noncombustibles are not without health risks,^2,4–6 as risk may vary depending on consumption type.⁶

A robust body of research shows that sexual minority (SM) individuals (or individuals that do not identify as heterosexual) account for a disproportionate amount of nicotine/tobacco use and are at exceptionally high risk for adverse nicotine/tobacco health-related outcomes.^7–9 Among SM adults both ENDS and cigarette smoking prevalences are between 1.5 and 2.5 times higher than that of heterosexuals.^5,10 SM adults are also more likely to smoke cigars, cigarillos, and hookah when compared to their heterosexual peers.^1,11 Among females in particular, SMs report an earlier age of smoking initiation, tend to smoke more cigarettes per day and are more likely to be nicotine dependent when compared to heterosexual females.

Although these differences have been documented in population-based samples, relatively little empirical attention has been given to the possible mechanisms underlying nicotine and tobacco-related disparities among SMs. The prevailing minority stress model asserts that the experience of discrimination, internalized homophobia, and societal and familial rejection can create a hostile and stressful environment for SM individuals.¹² The subsequent social environment contributes to stress-related substance use behaviors, leading to disparities in adverse health outcomes.¹² The model assumes that minority stress is unique in that it can further complicate the daily stress and hassles associated with routine everyday life. A robust body of literature supports this assertion.^12–15 SMs continue to face heterosexist discrimination across various domains of their lives. One in three SM adults in the United States reported experiencing discrimination related to their sexual identity within the past year.¹⁵ Research has shown that the frequency of experiences of discrimination mitigates the association of sexual identity with psychiatric morbidity.¹³ SMs might engage in health-risk behaviors, such as nicotine and tobacco product use, to manage the negative effects of minority stress.

Despite an overall decline in cigarette smoking in the general population, SM disparities remain. The tobacco industry promotes a narrative that smoking reduces stress and that nicotine/tobacco products can be used to shift one’s consciousness away from the hassles of life.^16,17 Expectedly, a significant portion of the tobacco industry’s marketing strategy targets marginalized groups, including SMs, the psychologically vulnerable, and other minoritized populations.^18,19 Psychological distress (PD), or the nonspecific symptoms of stress, depression, and anxiety, has been found to influence nicotine/tobacco initiation, use and dependence.^20,21 Adults with PD report higher rates of cigarette smoking, ENDS use, and PTU when compared to adults without PD.^21,22

While the relations between sex, sexual identity, and nicotine/tobacco use have increasingly been examined in population-based studies few studies have examined PTU in SM populations.^23,24 To the best of the author’s knowledge there is no published research examining whether SMs are more likely to report PTU when compared to heterosexuals.²⁵ Even more specifically, there have been no national probability-based samples assessing the impact of PD on patterns of tobacco/nicotine product use in SM populations.²⁶ As such, the main objectives of the current study were to examine sex and sexual identity differences between PD and PTU among adults in the United States using pooled data from a nationally representative survey.

Methods

We used data collected from the National Health Interview Survey (NHIS) between 2016 and 2018.²⁷ The NHIS is the principal source of information on the health of civilian, noninstitutionalized adults ≥18 years in the United States. It is one of the health data collection programs of the National Center for Health Statistics (NCHS), which is a division of the Centers for Disease Control and Prevention (CDC). Data are collected through a personal household interview conducted by interviewers employed and trained by the US Census Bureau according to procedures specified by the NCHS. The NHIS is approved by the research ethics review board of the NHCH. Respondents provided oral consent before study participation. A detailed description of the study protocol has been previously reported and is available for review.²⁷ For more information about NSDUH methods, see: https://www.datafiles.samhsa.gov/study-series/national-survey-drug-use-and-health-nsduh-nid13517.

The analytic variables for this study were drawn from the NHIS Family Core and Sample Adult Core modules. The Family Core module collects data on each member of the family, including health insurance status and total combined family income. The Sample Adult Core module contains data from one adult over the age of 18 years randomly selected from each family and includes information on age, sex, sexual identity, and substance use.

Measures

Sociodemographic Variables

Demographic variables include age (continuous and categorical: 18–24; 25–44; 45–64; 65 years and over), sex (male; female), race (white; black/African American; American Indian; Alaska Native; Asian; Multiple or race not releasable), ethnicity (Hispanic; non-Hispanic), marital status (married or living with partner; widowed/divorced/separated; never married), income ($0–$34 999; $35 000–$74 999; $75 000–$99 999; $100 000 and over), working status (currently working; not currently working), and census region (Northeast; Midwest; South; West).

Sexual Identity

Adult participants were asked: “Which of the following best represents how you think of yourself?” (1) Gay or lesbian, (2) straight, that is, not gay or lesbian, (3) bisexual, (4) something else, or (5) I don’t know the answer. Responses were then categorized as “heterosexual” (HS) or “sexual minority” (SM); with the latter category including individuals who answered “gay or lesbian,” “bisexual,” “something else,” or “I don’t know.”

Psychological Distress

The Kessler PD Scale-6 (K6) is a six-item questionnaire designed to identify persons with a high likelihood of having a diagnosable mental health condition using as few questions as possible.²⁸ It was developed for use in general-purpose health surveys because it is short, has strong psychometric properties and can detect more than 90% of DSM-IV diagnoses across sociodemographic subpopulations, as determined by the Structured Clinical Interview for DSM-IV criteria.^28–30 The K6 asks how often during the past 30 days the respondent felt nervous, hopeless, restless, or fidgety; so depressed that nothing could cheer them up; or that everything was an effort; or worthless. Responses are on a four-point scale (0 = none of the time, 1 = a little of the time, 2 = most of the time, or 3 = all of the time). Statistical analysis includes K6 as both a continuous and categorical variable. The sum of the response codes for the six items was used for the continuous item, with higher scores indicating more significant PD. For the categorial item, we used cutoff points previously reported in the literature to dichotomize K6 scores with a score of 13 or above, indicating serious PD.²⁰

Tobacco Use

We examined the use of five tobacco products: cigarettes, electronic cigarettes (e-cigs, ENDS), cigars and cigarillos, pipe tobacco, and SLT.

Cigarette Smoking Status

Cigarette smoking status was defined as current, former, or never smoker. Respondents were considered current smokers if they reported having smoked ≥100 cigarettes in their lifetime and endorsed currently smoking cigarettes some days or every day. Respondents were considered former smokers if they reported having smoked ≥100 cigarettes in their lifetime but were not current smokers at the time of the survey. Never smokers were those who reported that they had not smoked ≥100 cigarettes in their lifetime.

ENDS Use

Respondents were asked: “Have you used electronic cigarettes, even once?” and “Do you now use electronic cigarettes every day, some days, or not at all?” Respondents who answered “yes” to the first question and “every day” or “some days” to the second question were classified as current ENDS users.

Cigar Use

Respondents were asked: “Have you ever smoked a regular cigar, cigarillo, or little filtered cigar, even once?” and “Do you now smoke a regular cigar, cigarillo, or little filtered cigar every day, some days, or not at all?” Respondents who answered “yes” to the first question and “every day” or “some days” to the second question were classified as current cigar users.

Pipe Tobacco Use

Respondents were asked: “Have you ever smoked with a pipe filled with tobacco―either pipe, water pipe, or hookah, even once?” and “Do you now smoke with a pipe filled with tobacco―either pipe, water pipe, or hookah every day, some days, or not at all?” Respondents who answered “yes” to the first question and “every day” or “some days” to the second question were classified as current pipe tobacco users.

Smokeless Tobacco Use (SLT)

Respondents were asked: “Have you ever used smokeless tobacco products, even once?” and “Do you now use smokeless tobacco every day, some days, or not at all?” Respondents who answered “yes” to the first question and “every day” or “some days” to the second question were classified as current SMT users.

Poly-tobacco Use

We defined PTU as currently using two or more tobacco products. In contrast, exclusive tobacco use refers to the use of only one tobacco product.

Statistical Analysis

The analytic sample was restricted to participants with available sexual identity data. Sample weights, provided by the NCHS, were used to adjust for nonresponse and the varying probabilities of selection, including those resulting from oversampling. Of the 104 341 participants in the sample, 66 658 were excluded due to incomplete sexual identity data, yielding a total of 83 017 participants. There were 37 683 males, which included 36 134 (95.9%) HS males and 1549 (4.1%) SM males, and 45 334 females, including 43 384 (95.7%) HS females and 1950 (4.3%) SM females. Data were analyzed using JASP³¹ and SPSS version 27.³² A Little’s test was used to assess patterns in the missing observations. This analysis indicated that the data were missing completely at random (MCAR).³²

Univariate analyses were conducted to examine the distribution of each variable. Tobacco product use outcomes were then modeled, stratified by sex, to generate sex-specific crude and adjusted odds ratios (AOR). Covariates were selected based on sociodemographic variables that varied significantly by sexual identity; age (continuous and categorical), income (categorical), race and ethnicity (categorical), and region (categorical).

Results

Participant Characteristics

Table 1 (female) and Table 2 (male) provide descriptive statistics of demographic variables by sexual identity. The mean age of the sample was M = 51.1, SD = 18.5, with the majority identifying as White (81%) or female (55%). SM participants were significantly younger than their HS counterparts, more likely to have an income of less than $34 000, and more likely to live in either the Northeast or West when compared to HS, who were more likely to live in the South or Midwest. SM females were significantly more likely to be currently employed when compared to HS females. While SM males were significantly less likely to be currently employed when compared to HS males.

Psychological Distress

Overall, 3.5% of the sample met the criteria for serious PD (M = 2.80, SD = 4.03), as indicated by a score of 13 or above on the K6. Respondents with and without serious PD differed significantly on a number of sociodemographic variables including sex (p < .001), sexual identity (p < .001), age (p < .001), income (p < .001), race (p < .001), ethnicity (p < .001), employment status (p < .001), and region (p < .001). Compared to respondents without serious PD, those with serious PD were more likely to be female, a SM, aged 45–64 years old, and to report an annual income of $0–$34 999. Those with serious PD were less likely to be Asian American and less likely to be employed.

Prevalence and adjusted odds for serious PD for SM respondents as compared to HS respondents are displayed in Table 3. SM respondents had significantly higher K6 scores and were nearly three times as likely to meet the criteria for serious PD Among female respondents, PD scores among SM females (M = 5.1, SD = 5.3) were significantly higher than those of HS females (M = 3.0, SD = 4.1). SM females were also more likely to meet the criteria for serious PD when compared to HS females (10.5% vs. 4.1%). Similarly, PD scores among SM males (M = 4.2, SD = 4.9) were significantly higher than those of HS males (M = 2.4, SD = 3.7). SM males were also more likely to meet the criteria for serious PD when compared to HS males (7.2% vs. 2.6%).

Tobacco Use

Twenty percent of respondents reported current use of any tobacco product; 14.4% were current cigarette smokers; 3.1% were current ENDS users, 3.8% were current cigar users, 1.1% were current pipe tobacco users, and 2.3% were SLT users. The prevalence of PTU in the current sample was 3.9%. Respondents that were PTU users differed significantly on a number of sociodemographic variables including sex (p < .001), sexual identity (p < .001), age (p < .001), income (p < .001), race (p < .001), ethnicity (p < .001), employment status (p < .001), and region (p < .001). The prevalence and adjusted odds of each tobacco use outcome for SM as compared to HS are provided in Table 4 (female) and Table 5 (male). SM females were significantly more likely to report current cigarette, ENDS, cigar, pipe, and SLT when compared to Heterosexual Female (Table 4), AOR of PTU for SM females were 2.86 (95% CI, 2.25–3.65). SM males were more likely to be current cigarette and pipe tobacco users, but were less likely to report ENDS, cigar, and SLT use (Table 5). Sexual identity was not a significant predictor of PTU in male respondents.

Discussion

The present study adds to the existing research on PD and patterns of tobacco use by examining the role of sexual identity in the relationship between PD and PTU in a nationally representative sample of adults. We found that SM individuals reported higher levels of PD and were more likely to meet the criteria for serious PD. Although SMs tended to use more tobacco products, there was heterogeneity in usage by both sex and sexual identity. SM females were significantly more likely to be a current cigarette, ENDS, cigar, pipe, and SLT users, while SM males were more likely to be current cigarette and pipe tobacco users when compared to their heterosexual peers.

Though SM males had significantly higher PD scores and were significantly more likely to be nicotine and tobacco users when compared to Heterosexual Male, sexual identity was not a predictor of PTU in male respondents. This was a surprising finding given that according to the Minority Stress Theory stressful environmental factors and the ensuing PD might explain the substance used-related health disparities that SM experience, but may suggest the gender differences in the relationship between minority stress and patterns of nicotine and tobacco product use in SM populations.¹²

Sexual identity was a significant effect modifier in female respondents. SM females were significantly more likely to be a current cigarette smoker, use ENDS, cigar, pipe, and SLT when compared to Heterosexual Female SM females also had significantly higher PD scores, were more likely to meet criteria for serious PD, and were more likely to be PTU. Yet, contrary to what was expected, the relationship between PD and PTU was more robust in Heterosexual Female than in SM females. These findings are consistent with previous research demonstrating higher levels of PD and higher tobacco use among SM females when compared to Heterosexual Female. However, the current study measures and models for understanding PD and its relation to PTU, do not adequately capturing why SM females experience such increased rates of PD and PTU. Future studies, including measurement development, may be needed, as well as qualitative and mixed methods research which can capture some of the nuances in furthering our understanding of the relationship between PD and PTU in SM populations.

Future research should also consider other contextual factors implicated in PTU in SM populations such as social environments where substance use is normalized and prevalent.³³ PTU is particularly concerning in emerging adulthood, the developmental period characterized by experimentation with identity and health behaviors.^34,35 This may be particularly true for SM young adults, whose disproportionate nicotine and tobacco burden is often explained using the minority stress framework. In the current study, we found that the likelihood of PTU decreased with age, consistent with research indicating that emerging adults report more PTU than older age groups.^36–38 Given that emerging adulthood is characterized by an increase in risk-taking behaviors,^33,39 future studies should investigate the possible associations between PD and other risks—such as hazardous drinking, illicit drug use, driving while intoxicated, and casual unprotected sexual behavior,^40,41 which are already heightened in emerging adult samples.^33,42,43

Furthermore, inclusive social environments for SM individuals, such as gay and lesbian bars and/or PRIDE parades and festivals, have been noted for being particularly permissive of nicotine and tobacco, alcohol, “club-drugs,” and other substances.^44–46 This may be because of the disproportionate amount of targeted advertising and industry marketing as documented earlier.^16,17 The tendency for those social environments to take a more accepting approach to substances in reaction to a larger society that further marginalizes an already stigmatized community^14,46–48 may be a contributing factor in their permissive attitude toward substances. Understanding the motivations behind the disproportionate levels of nicotine and tobacco use in SM populations can aid researchers and policy-makers in the development of more effective, targeted, risk-specific interventions and prevention strategies.

The current study is not without limitations. For example, the study was not an experimental design and thus fully observed. All of the analyses conducted were cross-sectional meaning that causality cannot be inferred. Another limitation of the present study is that the sexual identity data collected by NHIS were very limited in the scope of human sexuality. NHIS data includes sex, which is a measure of biological physiology, but is a limited measure as it is collected within the binary of male and female, and does not account for the lived experiences of nonbinary individuals.^49,50 Gender is not experienced solely within a binary and should thus include gender nonconforming individuals’ experience (including but not limited to transgender people as well as nonbinary individuals).⁵¹

Although there is no safe nicotine and tobacco product, noncombustible products may help reduce the risk of tobacco-related harms for adult smokers who switch completely from combusted cigarettes, but all tobacco products can lead to nicotine addiction and contain toxic, cancer-causing chemicals that can cause serious health problems. Future research should examine differences in risk as it relates to PTU combination type.

Another limitation in the current study is the use of the self-report K6 form as opposed to a clinical interview. While self-report measures are an inexpensive way to collect information, these measures may lack reliability because of bias in response or insight and can lack the diagnostic accuracy of a clinical interview.⁵² Study strengths include the use of a weight-adjusted population-based sample, and more than adequate sample size allowing for a representative interpretation of prevalence and generalizability.

Sex and sexual identity differences in nicotine and tobacco use are well documented, as are the differences in the experience of PD. As new tobacco products proliferate and health risks from PTU grow, an increased understanding in the correlates and patterns of tobacco use in SM populations is needed. While there is an established need for culturally tailored tobacco prevention and cessation interventions for the SM population, investigating PTU and the associated risk behaviors will offer nuanced insights into how to tailor programs across the diversity of risks. There continues to be a significant gap in the area of substance use prevention and cessation interventions for SM populations. Future investigations should be attentive to cultural differences in substance use attitudes, norms, and messaging. Research is needed to develop effective, tailored interventions for cessation and prevention within the SM community.

Supplementary Material

A Contributorship Form detailing each author’s specific involvement with this content, as well as any supplementary data, are available online at https://dbpia.nl.go.kr/ntr

Funding

This work was supported by research grants K23DA048161 and R01MH108793 from the National Institute on Drug Abuse and the National Institutes of Mental Health. The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institute on Drug Abuse, the National Institutes of Mental Health, or the US Government.

Acknowledgments

This manuscript was prepared using public access datasets obtained from the National Center for Health Statistics (NCHS) and does not reflect the opinions or views of the NCHS or the US Government.

Declaration of Interests

None declared.

Data Availability

Data publicly available for download: Centers for Disease Control and Prevention. National Health Interview Survey: 2016 Data Release. https://www.cdc.gov/nchs/nhis/nhis_2016_data_release.htm. DOI: 10.18128/D070.V6.12 (2016). Centers for Disease Control and Prevention. National Health Interview Survey: 2017 Data Release. https://www.cdc.gov/nchs/nhis/nhis_2017_data_release.htm. DOI: 10.18128/D070.V6.2 (2017). Centers for Disease Control and Prevention. National Health Interview Survey: 2018 Data Release. https://www.cdc.gov/nchs/nhis/nhis_2018_data_release.htm. DOI: 10.18128/D070.V6.3 (2018).

References