Discrimination, Internalized Homophobia, and Smoking in Young Men Who Have Sex with Men

Background and Purpose: Studies show that experiences of discrimination are associated with negative health behaviors, including smoking in young men who have sex with men (YMSM). YMSM have higher smoking prevalence compared to their heterosexual counterparts. Guided by the Minority Stress Model and risk and resilience framework, experiences of stressors may be further exacerbated by minority status that can lead to internalized homophobia (IH) and poor health behaviors such as smoking. Furthermore, resilience may exacerbate or minimize the responses to such stressors. Thus, processing IH may vary across individuals, which can influence smoking behavior. The purpose of this paper is to 1) examine the association of experiences of discrimination and smoking and 2) evaluate if levels of IH will moderate this relationship in young men who have sex with men (YMSM).

Methods: YMSM who were 18-34 years old and resided in the United States completed an online survey from June 2021 through May 2022. The explanatory variable is discrimination using the 14-item Heterosexist Harassment, Rejection, and Discrimination Scale (HHRDS). The primary outcome variables are past 30-day cigarette and e-cigarette use, and secondary outcomes are ever-cigarette and e-cigarette use, and lifetime cigarette use. The moderating variable is internalized homophobia using the 9-item Internalized Homophobia Scale (IHP). Covariates included age, race/ethnicity, education, and household income. We implemented logistic regression analysis, two-way interactions, and post-hoc analysis using Stata 17 SE.

Results: Of the N=325 participants, mean discrimination was M=37.90 (range = 14-73; SD=12.05) and internalized homophobia was M=19.17 (range = 9-33; SD=6.00). About 35% had low internalized homophobia, 43% had middle or average, and 22% had high internalization. Fifty-seven percent reported ever using cigarettes, 52% used over 100 cigarettes in their lifetime, 51% used cigarettes in the past 30-days, 38% ever using e-cigarettes, and 36% used e-cigarettes in the past 30-days. Experiences of heterosexist discrimination were associated with increased odds of ever using cigarettes (Adjusted Odds Ratio [AOR] = 1.07; 95% CI: 1.04, 1.10), using over 100 cigarettes in their lifetime (AOR = 1.07; 95% CI: 1.04, 1.10), using cigarettes in the past-30 days (AOR = 1.07; 95% CI: 1.04, 1.10), ever using e-cigarettes (AOR = 1.07; 95% CI: 1.04, 1.10), and using e-cigarettes in the past-30 days (AOR = 1.08; 95% CI: 1.04, 1.11). Two-way interactions showed IHP moderated the relationship between discrimination and smoking across all smoking outcomes except for past 30-day e-cigarette use among those with middle or average IHP.. Notably, the positive association between IHP and smoking was stronger among YMSM with high scores of discrimination and low IHP.

Conclusion and Implications: The results from this study emphasize the tangled relationship between experiences of discrimination because of one’s sexual orientation and how levels of IH may influence the risk of smoking as a form of coping in YMSM. Social workers need to continue to address and work towards supporting policies that challenge homophobia in society.