In contrast to recent reports that lesbians are more likely than heterosexual women to smoke (e.g., Austin et al., 2004
; Burgard, Cochran, and Mays, 2005
; Case et al., 2004
; Cochran et al., 2001
; Mays, Yancey, Cochran, Weber, and Fielding, 2002
; Tang et al., 2004
), we found no difference in overall rates of current smoking when comparing lesbians with demographically similar heterosexual women. Current smoking rates for both lesbians and heterosexual women in this study were slightly lower than recent estimates of 22% for women in the U.S. general population (USDHHS, 2001
), and may be explained in part by the fact that study participants—both lesbian and heterosexual women—had higher levels of education than is typical of women in U.S. national probability samples. In addition, although bivariate relationships indicated that prevalence of lifetime smoking was higher among lesbians than among heterosexual women, in our multivariate analyses controlling for age, education, and race we found no differences in smoking prevalence by sexual orientation. Results of multivariate analyses that examined the interaction effects of sexual orientation on the relationships between other demographic characteristics (age and education) and lifetime smoking were also not significant, suggesting that the relationships between most of the demographic characteristics and smoking were similar for lesbian and heterosexual women overall. However, when we examined smoking rates separately by race/ethnicity, we found that African-American lesbians were more likely than African-American heterosexual women and White lesbians to be current smokers.
Studies have consistently found a positive relationship between stress or negative affect and the initiation or continuation of smoking (Carmody, 1989
; Cohen, Kamarck, and Mermelstein, 1983
; Jarvik, Caskey, Rose, Herskovic, and Sadeghpour, 1989
; Mitchell and Perkins, 1998
; Perkins and Grobe, 1992
; Posner, Leitner, and Lester, 1994
; Steward et al., 1996). A small but growing literature suggests that lesbians are at heightened risk for psychological distress and depression (Cochran and Mays, 1994, 2000
; DiPlacido, 1998
; Fergusson, Horwood, and Beautrais, 1999
; Gilman et al., 2001
; Hughes, Haas, Razzano, Cassidy, and Matthews, 2000
; Kerr and Emerson, 2003
; Matthews, Hughes, Razzano, Johnson, and Cassidy, 2002
; Meyer, 2003
) and that this risk may be compounded in lesbians who are members of racial/ethnic minority groups. For example, Greene (1994)
asserts that African-American lesbians live in a sociocultural context of discrimination that creates a unique set of psychological demands and stressors. These multiple minority statuses—being female, African American, and lesbian—constitute a form of triple jeopardy (Greene, 1994
), which may compound the risk for smoking.
Although psychological distress is important, it is clear from the literature that women’s smoking is influenced by a variety of interrelated factors. Less educated women are known to be particularly vulnerable to smoking initiation and resistant to smoking cessation interventions (Warnecke et al., 2001
; Watson et al., 2003
). Consistent with studies of smoking in the general population (Fiore et al., 1989
), we found that education was the most robust predictor of smoking for both lesbians and heterosexual women. Level of education was inversely related to both current and lifetime smoking. Low educational level may be a proxy for lifestyle factors and stressful life conditions that are the more direct predictors of smoking. High stress, lack of social and material resources, and poor health habits—including smoking—are interrelated and associated with low socioeconomic status (Manfredi, Lacey, Warnecke, and Buis, 1992
; Tang et al., 2004
In addition to stress, race, age, education, and socioeconomic status, other important influences on smoking include cultural gender-role norms; tobacco advertising; perceptions of risks and benefits of smoking; peer-group norms and behaviors; and other health behaviors, such as alcohol and other substance use (Hughes and Jacobson, 2003
; USDHHS, 2001
; Watson et al., 2003
). Sexual orientation may interact with some or all of these factors in ways that influence risk for smoking. For example, lesbians are less likely than heterosexual women to adhere to traditional female gender-role norms and more likely to drink alcohol (Hughes, 2005
; Hughes and Wilsnack, 1997
)—factors that may increase risk for smoking. Conversely, lesbians tend to be more highly educated, in part because of fewer family roles and responsibilities (Rothblum and Factor, 2001
), and they appear to be less influenced by societal pressures to be thin (Herzog, Newman, Yeh, and Warshaw, 1992; Owen, Hughes, and Owens-Nicholson, 2003
; Siever, 1994
)—factors associated with lower risk of smoking among women. Although interesting and potentially important, until population-based studies that include large samples of lesbians are more feasible, the above hypotheses will remain untested and the question of whether lesbians are more likely than heterosexual women to smoke will remain unanswered. Clearly, more research is needed to determine whether the relationships among sexual orientation and other potential and/or posited risk factors for smoking, such as race and education, are additive, interactive, both, or neither. Determining the critical necessary conditions (individual and environmental) for smoking behaviors (e.g., initiation, continuation, frequency, attributed meanings, changes in patterns of use) “demands” asking the types of legitimate
questions posited by von Foerster.3
Although data are limited it appears that lesbians are at least as likely as heterosexual women to smoke. Age, education and racial/ethnic group differences in smoking rates in our study and in others’ research (see e.g., Camp, Klesges, and Reylea, 1993
) suggest the importance of tailored smoking prevention and cessation strategies. For example, interventions targeting low-income African-American lesbians should not only address potential knowledge deficits and attitudinal beliefs regarding the association between smoking and health risks (Manfredi, Lacey,Warnecke, and Buis, 1992
; Sanchez, Meacher, and Beil, 2005
), but also the perceived benefits of smoking to reduce stress and manage daily pressures (Lacy et al., 1993).
Because most smokers begin smoking in adolescence (USDHHS, 2001
), prevention efforts must also target young lesbians. Programs for lesbian and gay youth must, at minimum, address societal stigma and negative stereotypes associated with homosexuality and with race/ethic minority status, as well as tobacco marketing images that target the lesbian and gay population (Austin et al., 2004
; Goebel, 1994
; Mathews, 1999
; Stevens, Carlson, and Hinman, 2004
Given the well-established association between smoking and drinking alcohol (Little, 2000
), and findings that lesbians are more likely than heterosexual women to drink alcohol (Hughes and Wilsnack, 1997
), interventions should address these co-occurring health-risk behaviors. Further, because lesbians appear more likely to have higher body mass than heterosexual women (Markovic, Aaron, Danielson, Schmidt, and Janosky, 2000; Owens, Hughes, and Owens-Nicholson, 2003
), lesbians of all ages should be made aware of the compounded health risks associated with smoking and excessive alcohol use and smoking and obesity. These combinations of health risks, added to lesbians’ lower rates of preventive health care (Hutchinson, Thompson, and Cederbaum, 2006
; Rankow, 1998
; White and Dull, 1997
), may place lesbians at disproportionately high risk for cardiovascular disease and certain cancers.
These findings must be interpreted in light of the limitations of the data. First, the study was limited by the available data related to smoking and its correlates. Because the MWHS was intended to assess a large and broad range of health behaviors and health indicators, few questions about smoking were included. No information about age of initiation of smoking, or about social networks or social settings (such as bars), that may have influenced smoking, was collected. In addition, questions about religiosity and acculturation, factors known to influence smoking, were limited or absent. Although questions from previous studies were used whenever possible, the survey questionnaire included relatively few standardized scales or batteries of questions. The use of standardized measures of smoking is necessary to permit comparisons of findings across studies. Such comparisons are especially important in research with stigmatized populations because so few studies use probability samples, making it difficult to reliably estimate prevalence.
Our lesbian sample was large and came from several urban geographic regions in the United States—factors that strengthen generalizability. However, study participants classified as lesbian (or heterosexual) cannot be assumed to represent the larger populations of women who self-identify as such. We defined sexual orientation on the basis of participants’ responses to questions about same-gender attraction and behavior. Although sexual identity is generally highly correlated with behavior and attraction (Hughes, Haas, and Avery, 1997
; Laumann, Gagnon, Michael, and Michaels, 1994
), a substantial proportion of women who have sex with other women do not self-identify as lesbian. Further, some evidence suggests that women who engage in same-gender sexual behavior but do not self-identify as lesbian may be more likely to engage in health-risk behaviors, such as substance use and misuse (Cochran and Mays, 2000
; Hughes and Boyd, 2004; Markovic, Aaron, Danielson, Schmidt, and Janosky, 1999
; McCabe, McCabe, Hughes, Bostwick, and Boyd, 2005
), than do women who do identify as such. Thus, using different definitions of sexual orientation may result in different findings regarding smoking and other health-risk behaviors.
As with other volunteer-based studies, and particularly given that we were unable to calculate a reliable response rate, it is possible that our sample may have included healthier and more educated participants. Indeed, the educational level of both the lesbian and the heterosexual groups was substantially higher than that of women in the general population (U.S. Census Bureau, 2003
), which suggests that we likely underestimated the risk of smoking in both groups. Almost without exception, studies of lesbians have included highly educated samples. Lower education and income—the most common markers of lower socioeconomic status—are linked to a number of health-risk behaviors in women (Agency for Healthcare Research and Quality [AHRQ], 2005
). The fact that educational level did not differ between lesbians and heterosexual women in this study may help explain the absence of differences in overall rates of smoking based on sexual orientation. Researchers should be aware of demographic differences and their potential impact and build in statistical controls for educational level.
Although our inclusion of a comparison group of demographically similar heterosexual women permitted us to control for many demographic and lifestyle factors—other than sexual orientation—that might have influenced smoking rates differently for lesbians and heterosexual women, our method of recruiting the comparison group may have masked actual sexual-orientation differences in rates of smoking. Studies suggest that one of the strongest risk factors for smoking among women (particularly adolescent and young women) is exposure to peers who smoke (USDHHS, 2001
). Thus, having lesbians pass along a duplicate questionnaire to a heterosexual friend or acquaintance may have resulted in a comparison group with smoking and other behavioral risk factors similar to those of the lesbians in the study.
Finally, because of the small number of lesbians in the Hispanic, Asian American, Native American, and other racial/ethnic minority groups included in our sample, we did not have adequate statistical power to test for racial/ethnic differences in these groups. We combined participants who were not African American or White into one “other racial/ethnic group” category. Given that smoking rates are known to vary substantially by race/ethnicity (USDHHS, 2001
), interpretations about this group must be made with particular care. Studies such as that of Mays, Yancey, Cochran, Weber, and Fielding (2002)
are needed to better understand smoking rates and risk for smoking among racial/ethnic minority lesbians.
Despite these limitations, our study is one of very few to examine smoking among lesbians and of even fewer to include a comparison group of heterosexual women. We suggest that studies with larger groups of racial/ethnic-minority and less-educated lesbians be conducted to more systematically examine the influence of sexual orientation on smoking in these high-risk groups. In addition, studies are needed that examine lesbians’ smoking patterns and predictors of smoking in greater depth.