Unfair and Unjust Practices Harm LGBTQ+ People and Drive Health Disparities

At a glance

  • The tobacco industry targets the LGBTQ+ community with marketing and advertising.
  • Stress can increase commercial tobacco use and can make health problems worse.
A gay couple smiling at the camera


Sexual and gender minority groups have experienced harassment, discrimination, and been exposed to forms of violence related to unfair and unjust practices, policies, and conditions.1 Experiences of discrimination and stressful socioenvironmental conditions are associated with commercial tobacco product and other substance use and, in turn, can contribute to poor health outcomes.A2 Some examples of historical policies and practices in the United States (U.S.) that have led to mental and physical health risks and challenges, and related long-term outcomes, for LGBTQ+ people include:B

  • Laws targeting LGBTQ+ people by making same-sex relationships illegal. These laws were in place from the time the nation was founded until 2003. In 1960, all fifty states had laws against same-sex sexual activity. Before the 2003 Supreme Court ruling in Lawrence v. Texas, sexual activity between people of the same sex was illegal in 14 U.S. states, Puerto Rico, and the U.S. military. Making same-sex relationships a crime led to unjust practices that harmed LGBTQ+ people, including discrimination in finding housing and jobs and children being removed from their parents' care.3
  • Marriage bans prevented many LGBTQ+ people from having the same rights as straight married couples, such as job protection while caring for a sick spouse and the ability to add spouses to employer-sponsored health insurance plans.4 Until the 2015 U.S. Supreme Court ruling (Obergefell vs. Hodges), states were not required to recognize marriages between same-sex couples and many states denied same-sex couples the right to marry. Marriage bans caused stigma and made same-sex couples less equal in the eyes of the law, adding to chronic stress.2
  • Some LGBTQ+ people have experienced harm and distress caused by people expressing anti-LGBTQ+ views using hate crimes: threats, verbal abuse, vandalism, and violence. 56As of 2017, fewer than half of U.S. states offered legal protection from discrimination based on sexual orientation.7
Lesbian couple sitting on couch with infant
LGBTQ+ people face challenges that may make them more likely to use commercial tobacco.

LGBTQ+ people have also experienced discrimination and harm from health care systems and medical science. For example:

  • Organized medicine in the United States has often made stigma around same-sex attraction worse by using supposedly scientific reasons for this discrimination. For instance, the American Psychiatric Association’s official diagnostic book (the Diagnostic & Statistical Manual) stated that homosexuality was a mental disorder until 1973.8
  • Between 1923 and 1981, the state of Oregon had people who committed “crimes against nature” (a way it described same-sex sexual activity) sterilized without their consent.9

There are also current reasons—like the ones explored below—that help explain why commercial tobacco affects the health of LGBTQ+ people.

Justice Building
Until 2015, states were not required to recognize marriages between same-sex couples.

The tobacco industry targets the LGBTQ+ community with marketing and advertising.

Marketing plays a big role in whether people try or use commercial tobacco products. Being around commercial tobacco ads makes smoking appear more appealing and increases the chance that someone will try smoking for the first time or start using commercial tobacco products regularly.10111213

Tobacco companies spend billions of dollars each year to aggressively market their products. They also target specific populations, including the LGBTQ+ population, and flood them with commercial tobacco advertising.14

  • Donations and Sponsorships. In the early 1990s, tobacco companies were among the first large corporations to advertise in magazines and newspapers targeted at LGBTQ+ readers, sponsor Pride parades, and give donations to organizations serving LGBTQ+ people.11 Tobacco companies said in documents not shown to the public that these sponsorships and ads were marketing tactics designed to attract LGBTQ+ people to their products. In the 1990s, they gave one LGBT+ marketing strategy the code name “Project SCUM (Sub-Culture Urban Marketing).”14 Tobacco companies still advertise at festivals and other community events held by and for LGBTQ+ people and give to local and national groups serving LGBTQ+ people and people living with HIV.
  • Targeted advertising. Tobacco companies advertise heavily in publications with gay and lesbian readership, often using images that show LGBTQ+ people using tobacco as a “normal” part of life.15
  • Nightlife Marketing: Bars and clubs have traditionally been one of the few spaces in which LGBTQ+ people have felt safe to meet and socialize openly.16 Tobacco companies work to promote their brands in these spaces and sponsor nightclub after-parties in bars and clubs.14
  • Marketing flavored tobacco products to LGBTQ+ people using symbolism. Adding flavors (like menthol) to commercial tobacco products can mask the harshness of tobacco, promote youth initiation, lead to establishment of product use, and can contribute to lifelong tobacco use.71718 Ads for flavored tobacco products have used LGBTQ+ symbolism, including phrases like “Take pride in your flavor” or images of colored packages arranged like a rainbow.19 Tobacco companies have also heavily marketed menthol cigarettes to LGBTQ+ people. This can help to explain why about 36% of LGBTQ+ people who smoke use menthol cigarettes compared to 29% of straight people who smoke.15
e-cigarettes' in rainbow LGBT colors
Tobacco companies market their products using LGBTQ+ symbolism.

Public health strategies can help reduce the pressure to buy that comes with heavy advertising and discounts. To help protect LGBTQ+ people from tobacco price promotions and discourage tobacco product use, states and communities could consider increasing prices and prohibiting price discounts, prohibiting the sale of flavored tobacco products, and either allowing fewer stores in a neighborhood to sell commercial tobacco products or prohibiting tobacco product sales altogether.20

Another step that states and communities can take include making all workplaces smokefree—with no exceptions. Many workplaces are now covered by a smokefree law—but gaps in smokefree protections often leave out bars and nightclubs. In places that do not have comprehensive smokefree laws bartenders and servers in LGBT nightclubs can be harmed by exposure to secondhand smoke.21

Stress can increase commercial tobacco use, and can make health problems worse.

When people face many forms of stress—like financial problems, discrimination, or unsafe neighborhoods—they can be more likely to smoke.222324 Most LGBTQ+ people say they have experienced some form of harassment or discrimination because of their sexual orientation or gender identity. More than half have had slurs used against them, and 57% report that they or a close friend have been threatened with violence.2526

The link between discrimination, stress, and commercial tobacco helps to explain why:

  • Gay college students are more likely to smoke when they have to hide their orientation.27
  • Transgender people who have faced discrimination in ways that do not respect their gender identity—such as having to use IDs with the wrong gender—are more likely to smoke than transgender people who are supported in their gender identity.28
  • LGBTQ+ youth who attend schools with LGBT-friendly policies and student groups are less likely to begin smoking.29

When people have severe or long-lasting stress, their bodies respond by raising stress hormones and keeping them raised. When this goes on for a long time, they may develop health problems like high blood pressure or a faster heart rate.3031 Smoking cigarettes also leads to disease and disability and harms nearly every organ in the body.10

Couple sitting at the bottom of stairs with LGBT colors.
Stress can make people more likely to smoke.
  1. "Commercial tobacco" means harmful products that are made and sold by tobacco companies. It does not include "traditional tobacco" used by Indigenous groups for religious or ceremonial purposes.
  2. The term "LGBTQ+" is used on this page to refer to people who are lesbian, gay, bisexual, or transgender, with the plus sign indicating inclusion of people who are queer, questioning, intersex, asexual, or who hold other gender/sex/romantic identities not specifically identified. Many studies cited on this page only looked at certain groups within the greater LGBTQ+ community. When single terms like "gay" or "lesbian," or acronyms like "LGB" are used on this page, this corresponds with how terms are used in the cited studies. More studies are needed to understand the ways that commercial tobacco and exposure affects other groups in the LGBTQ+ community.
  1. McCabe SE, Hughes TL, Matthews AK, et al. Sexual orientation discrimination and tobacco use disparities in the United States. Nicotine Tob Res. 2019;21(4):523–531.
  2. Helleberg M, Afzal S, Kronborg G, et al. Mortality attributable to smoking among HIV-1-infected individuals: a nationwide, population-based cohort study. Clin Infect Dis. 2013;56(5): 727–734.
  3. Weinmeyer, R. The decriminalization of sodomy in the United States. AMA J Ethics. 2014;16(11):916–922.
  4. Perone AK. Health Implications of the Supreme Court's Obergefell vs. Hodges Marriage Equality Decision. LGBT Health. 2015;2(3):196–199.
  5. Herek GM. Hate crimes and stigma-related experiences among sexual minority adults in the United States: prevalence estimates from a national probability sample. J Interpers Violence. 2009;24(1): 54–74.
  6. Bostwick WB, Boyd CJ, Hughes TL, West BT, McCabe SE. Discrimination and mental health among lesbian, gay, and bisexual adults in the United States. Am J Orthopsychiatry. 2014;84(1):35–45.
  7. Caceres BA, Brody A, Luscombe RE, et al. A systematic review of cardiovascular disease in sexual minorities. Am J Public Health. 2017;107(4):e13–e21.
  8. Drescher J. Out of DSM: depathologizing homosexuality. Behav Sci. 2015;5(4): 565–575.
  9. Josefson D. Oregon's governor apologises for forced sterilisations. BMJ. 2002;325(7377):1380.
  10. U.S. Dept of Health and Human Services. The Health Consequences of Smoking: 50 Years of Progress. A Report of the Surgeon General. U.S. Dept of Health and Human Services, 2014. Accessed March 1, 2022. https://www.ncbi.nlm.nih.gov/books/NBK179276/
  11. Carson NJ, Rodriguez D, Audrain-McGovern J. Investigation of mechanisms linking media exposure to smoking in high school students. Prev Med. 2005;41(2):511–520.
  12. Charlesworth A, Glantz SA. Smoking in the movies increases adolescent smoking: a review. Pediatrics. 2005;116(6):1516–1528.
  13. National Cancer Institute. The role of the media in promoting and reducing tobacco use. U.S. Dept of Health and Human Services, 2008.
  14. Stevens P, Carlson LM, Hinman JM. An analysis of tobacco industry marketing to lesbian, gay, bisexual and transgender (LGBT) populations: strategies for mainstream tobacco control and prevention. Health Promot Pract. 2004;5(3 Suppl):129S–134S.
  15. Smith EA, Malone RE. The outing of Philip Morris: advertising tobacco to gay men. Am J Public Health. 2003;93(6):988–993.
  16. Ryan H, Wortley PM, Easton A, Pederson L, Greenwood G. Smoking among lesbians, gays, and bisexuals: a review of the literature. Am J Prev Med. 2001;21(2):142–149.
  17. U.S. Dept of Health and Human Services. Preventing Tobacco Use Among Youth and Young Adults: A Report of the Surgeon General. U.S. Dept of Health and Human Services, 2012. Accessed March 1, 2022. https://www.ncbi.nlm.nih.gov/books/NBK99237/
  18. U.S. Dept of Health and Human Services. E-Cigarette Use Among Youth and Young Adults. A Report of the Surgeon General. U.S. Dept of Health and Human Services, 2016. Accessed March 1, 2022. https://www.ncbi.nlm.nih.gov/books/NBK538680/
  19. Trinkets & Trash: Artifacts of the Tobacco Epidemic. Marketing smokeless tobacco moist snuff, snus, and dissolvables. University of Medicine & Dentistry of New Jersey.
  20. Robertson L, McGee R, Marsh L, Hoek J. A systematic review on the impact of point-of-sale tobacco promotion on smoking. Nicotine Tob Res. 2015;17(1):2–17.
  21. Fallin A, Neilands TB, Jordan JW, Ling PM. Secondhand smoke exposure among young adult sexual minority bar and nightclub patrons. Am J Public Health. 2014;104(2):e148–e153.
  22. Slopen N, Kontos EZ, Ryff CD, Ayanian JZ, Albert MA, Williams DR. Psychosocial stress and cigarette smoking persistence, cessation, and relapse over 9-10 years: a prospective study of middle-aged adults in the United States. Cancer Causes Control. 2013;24(10):1849–1863.
  23. Slopen N, Dutra LM, Williams DR, et al. Psychosocial stressors and cigarette smoking among African American adults in midlife. Nicotine Tob Res. 2012;14(10):1161–1169.
  24. Purnell JQ, Peppone LJ, Alcaraz K, et al. Perceived discrimination, psychological distress, and current smoking status: results from the Behavioral Risk Factor Surveillance System Reactions to Race module, 2004-2008. Am J Public Health. 2012;102(5):844–851.
  25. Robert Wood Johnson Foundation. Discrimination in America: Experiences and Views of LGBTQ Americans. Robert Wood Johnson Foundation, National Public Radio, Harvard T.H. Chan School of Public Health; 2017. Accessed March 1, 2022. https://www.rwjf.org/en/insights/our-research/2017/10/discrimination-in-america--experiences-and-views.html
  26. Parent MC, Arriaga AS, Gobble T, Wille L. Stress and substance use among sexual and gender minority individuals across the lifespan. Neurobiol Stress. 2018;10:100146.
  27. Cochran SD, Bandiera FC, Mays VM. Sexual orientation-related differences in tobacco use and secondhand smoke exposure among U.S. adults aged 20–59 years: 2003–2010 National Health and Nutrition Examination Surveys. Am J Public Health. 2013;103(10):1837–1844.
  28. Shires DA, Jaffee KD. Structural discrimination is associated with smoking status among a national sample of transgender individuals. Nicotine Tob Res. 2016;18(6):1502–1508.
  29. Eisenberg ME, Erickson DJ, Gower AL, et al. Supportive community resources are associated with lower risk of substance use among lesbian, gay, bisexual, and questioning adolescents in Minnesota. J Youth Adolesc. 2020;49(4):836–848.
  30. Juster RP, McEwen BS, Lupien SJ. Allostatic load biomarkers of chronic stress and impact on health and cognition. Neurosci Biobehav Rev. 2010;35(1):2–16.
  31. Guyll M, Matthews KA, Bromberger JT. Discrimination and unfair treatment: relationship to cardiovascular reactivity among African American and European American women. Health Psychol. 2001;20(5):315–325.