The Forgotten Drug: How Nicotine Impacts the Mental Health of the LGBT Community

Background and Purpose: Tobacco use remains a leading cause of death and disease in the U.S., particularly among populations such as the LGBT community who hold historically marginalized identities. LGB adults smoke and vape more than heterosexual adults (16.1% vs. 12.3%; 13% vs. 3.7%). Tobacco use prevalence among transgender adults is four times higher than cisgender adults. Research attributes these disparities to a combination of stigma, isolation, socialization, trauma-history, and industry marketing. Tobacco product use has also been found to contribute to poorer mental health. Members of the LGBT population are two-four times more likely to experience mental health problems than the general population and mental illness has been found to double the risk of smoking. Despite this, little research has examined how mental health influences tobacco use among this population.

Methods: The current study pooled four years (2018-2021) of the CDC’s Behavioral Risk Factor Surveillance Survey (BRFSS) from North Carolina (N=15,605), the nation’s top tobacco producing state. Individuals were considered as LGBT (n=574) if they identified as “lesbian, gay, or bisexual” or responded “Yes” to identifying as transgender. Poor mental health was indicated by having 14 or more poor mental health days in the past month. Chi-squared tests examined differences between LGBT individuals and the general population on dichotomous tobacco use outcomes. Logistic regression and moderation analyses were used to examine the effects of identifying as LGBT and mental health status on tobacco use.

Results: Compared to the general population, LGBT individuals were equally likely to have smoked 100 cigarettes in their lifetime (42.5% vs. 42.7%, p=.91), but were significantly more likely to be current smokers (23.0% vs. 15.4%, p<.001) and to have ever used e-cigarettes (40.2% vs. 18.6%, p<.001). Among current tobacco users, LGBT individuals were more likely to use tobacco products everyday (40.9% vs. 25.9%). LGBT individuals were also more likely to have poor mental health compared to the general population (28.9% vs. 11.7%, p<.001). Logistic regression models revealed that identifying as LGBT and having poor mental health both predicted being a current smoker (ORs = 1.39, p<.05 and OR = 2.63, p<.001) and smoking everyday among current smokers (ORs = 1.80 and 2.16, p<.01). The effect of poor mental health on these outcomes were not found to differ between LGBT individuals and the general population.

Conclusions: Individuals identifying as LGBT are at increased risk for tobacco product use and use with greater intensity than the general population. The drivers of poor mental health among LGBT individuals may also contribute to disparities in tobacco use. Policy and programs aimed at reducing tobacco product use among this population needs to concurrently address mental health and trauma while developing positive social identity and integration. Future research, supported by data with sufficient sample sizes of LGBT individuals, is needed to examine tobacco use prevalence, precipitates, and impacts, particularly among LGBT individuals holding intersectional identities.