Unfair and Unjust Practices Harm LGBTQ+ People and Drive Health Disparities
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.12 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.11 Some examples of historical policies and practices in the United States (US) that have led to mental and physical health risks and challenges, and related long-term outcomes, for LGBTQ+ people include:
- 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 fourteen US 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.13
- 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.14 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.11
- Some LGBTQ+ people have experienced harm and distress caused by people expressing anti-LGBTQ+ views using hate crimes: threats, verbal abuse, vandalism, and violence.15,16 As of 2017, fewer than half of US states offered legal protection from discrimination based on sexual orientation.5
LGBTQ+ people have also experienced discrimination and harm from health care systems and medical science. For example:
- Organized medicine in the U.S. 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 1973.17
- 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.18
There are also current reasons—like the ones explored below—that help explain why commercial tobacco affects the health of LGBTQ+ people.
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.7,19,20,21
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.22
- 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.19 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).”22 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.23
- 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.24 Tobacco companies work to promote their brands in these spaces and sponsor nightclub after-parties in bars and clubs.22
- 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.7,25,26 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.27 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.23
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 reducing the number of stores in a neighborhood to sell commercial tobacco products or prohibiting sales altogether.29
Other steps 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.30
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.31,32,33 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.34,35
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.36
- 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.37
- LGBTQ+ youth who attend schools with LGBT-friendly policies and student groups are less likely to begin smoking.38
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.39,40 Smoking cigarettes also leads to disease and disability and harms nearly every organ in the body.7
† 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.
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- Buchting FO, Emory KT, Scout, Kim Y, Fagan P, Vera LE, & Emery S. Transgender Use of Cigarettes, Cigars, and E-Cigarettes in a National Study. Am J Preventive Med, 2017;53(1): e1–e7 [accessed 2022 Mar 1].
- Gentzke AS, Wang TW, Cornelius M, et al. Tobacco Product Use and Associated Factors Among Middle and High School Students — National Youth Tobacco Survey, United States, 2021. MMWR Surveill Summ. 2022; 71(No. SS-5):1–29 [accessed 2022 Apr 28].
- Gentzke AS, Wang TW, Jamal A, Park-Lee E, Ren C et al. Tobacco Product Use Among Middle and High School Students — United States, 2020. Morb Mortal Wkly Rep, 2020;69(50): 1881-88 [accessed 2022 Mar 1].
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- Helleberg M, Afzal S, Kronborg G, Larsen CS, Pedersen G, et al. Mortality attributable to smoking among HIV-1-infected individuals: a nationwide, population-based cohort study. Clin Infect Dis, 2013;56(5): 727-34 [accessed 2022 Mar 1].
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- 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 [accessed 2022 Mar 1].
- Drescher J. Out of DSM: Depathologizing Homosexuality.Behavioral Sciences, 2015;5(4): 565-575 [accessed 2022 Mar 1].
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