Examining sexual identity stability and change over time and associations with tobacco use in a nationally representative US sample

Individuals who identify as lesbian, gay, or bisexual (i.e., sexual minorities) are more likely to use tobacco, meet criteria for a tobacco use disorder (TUD), and have tobacco-related health consequences compared to heterosexual individuals. (Johnson et al., 2019, Kasza et al., 2020, Kerridge et al., 2017, McCabe et al., 2018, Schuler et al., 2018, Vogel et al., 2019) Extant research identifies heterogeneity of tobacco product use and TUD prevalence among individuals who identify as sexual minorities, including particularly high prevalence among sexual minority women and bisexual individuals. (Johnson et al., 2019, Kerridge et al., 2017, Schuler et al., 2018).

Most research examining sexual identity differences in tobacco use has been cross-sectional and almost all has focused on sexual identity as a static construct. There is considerable evidence that many individuals experience changes in their sexual identity over time (Savin-Williams et al., 2012, Rivas, 2015, Mock and Eibach, 2012, Katz-Wise, 2015, Diamond, 2016, Diamond, 2000, Diamond et al., 2020) and these changes occur more often among women than men. (Katz-Wise, 2015, Diamond and Butterworth, 2008) One study using the National Longitudinal Survey of Adolescent Health found that 6.2 % of young adult men and 11.9 % of young adult women had a change in sexual identity using two assessments six years apart. (Savin-Williams et al., 2012) Another study of adolescents and young adults, found that 9.4 % of adolescents had a change in identity over a three year period. (Harlow et al., 2021) These changes can encompass multiple types of changes: from heterosexual to gay, lesbian, or bisexual identity, changes within sexual minority identities (e.g., from gay to bisexual), and changes from a sexual minority identity to heterosexual identity. Individuals may change identities more than once.

The stress of any identity change may be accompanied by psychological stress from changes to one’s self-concept and the social stress from changes in how one is perceived by others. (Thoits, 2013) However, a transition to a sexual minority identity may be accompanied by additional minority stress including increased social stigma and discrimination from heterosexual and non-heterosexual peers. (Oswalt et al., 2016) Recent literature has linked higher levels of psychological and social stressors to tobacco and other substance use and increased minority stress has been implicated in sexual orientation disparities in tobacco and other substance use. The potential for increased stress during a transition to a sexual minority identity may lead to particularly increased likelihood of stress-related tobacco use. A study of adolescents found a positive association between identity change and cigarette use intitiation. (Harlow et al., 2021) Another study of young adults found those who newly adopted a sexual minority identity over the one year follow-up used tobacco more frequently than those who reported a consistent heterosexual identity. (Krueger et al., 2022) However, it is important to understand if this association extends to other tobacco outcomes, if the association is found among males and females, and to examine this at older ages beyond young adulthood.

Understanding changes in sexual identity and whether a change to a sexual minority identity is a particularly vulnerable period for tobacco use has significant public health implications for both developing interventions to reach groups most at risk for tobacco-related consequences and for understanding the mechanisms behind the heightened risk of tobacco use among sexual minority individuals. In this study, we examined sexual identity stability and change over time, an innovation over the typical static conceptualization of sexual identity, and its association with increases in tobacco product use and TUD symptoms.

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