Secondhand Smoke and E-Cigarette Aerosol Exposure by Sexual Identity

Secondhand cigarette smoke (SHS) and secondhand e-cigarette aerosol (SHA) exposure among youth might increase susceptibility to tobacco product initiation, use, and associated morbidity.1,2 More than one-third (33%) of US middle- and high-school students report SHS and SHA exposure.2,3 Although disparities in SHS and SHA exposure have been documented by sex, race, and ethnicity,2 understanding prevalence of SHS and SHA by sexual identity among youth is crucial to inform tailored prevention strategies that focus on sexual minority (SM) youth, a population with heightened risk for tobacco initiation. To address this knowledge gap, we examined US national data to examine the prevalence of SHS and SHA exposure by sexual identity. We hypothesized that SM youth would have a higher prevalence of SHS and SHA exposure in the past month than heterosexual youth.We conducted a cross-sectional analysis of the 2022 National Youth Tobacco Survey (N = 28 291); a survey on tobacco use behaviors among US middle- and high-school students using a stratified, multistage sampling (weighted response rate = 45.2%). We examined 4 exposure outcomes: past 30-day exposure to (1) indoor SHS, (2) outdoor SHS, (3) indoor SHA, and (4) outdoor SHA. The independent variable was self-reported sexual identity (ie, heterosexual [straight], gay or lesbian, bisexual, and unsure). The covariates were gender (boys, girls), age (middle, high school), race and ethnicity (non-Hispanic [NH] White, NH Black, Hispanic, NH other races), current use of any tobacco products (none, any), and familial and peer use of any tobacco products (none, any).Descriptive analyses examined differences in exposures by sexual identity. Four multivariable binomial logistic regressions (for each outcome) examined associations between outcomes and sexual identity, controlling for covariates. To understand the interaction effects between sexual identity and age and gender, we also stratified the models by age (middle and high school students) and sex (boys and girls). A Bonferroni adjustment was applied for multiple comparisons and statistical significance was defined as 0.0125 (= 0.05/4). We followed the Strengthening the Reporting of Observational Studies in Epidemiology guidelines. All analyses incorporated complex survey weights. The Yale institutional review board deemed this study exempt because we analyzed publicly available deidentified data.Overall, 73.8% of the sample identified as heterosexual (straight), 4.5% as gay/lesbian, 11.8% as bisexual, and 9.9% were unsure about their sexual identity. Prevalence of exposure to indoor SHS and SHA (40.3% and 36.9%, respectively) were lower than outdoor exposure (55.0% and 40.9% respectively; Table 1). After controlling for covariates, gay/lesbian youth were more likely than heterosexual youth to be exposed to indoor SHS (adjusted odds ratio [aOR] = 1.35; 95% confidence interval [CI], 1.10–1.65), indoor SHA (aOR = 1.43; 95% CI, 1.16–1.75), and outdoor SHA (aOR = 1.43; 95% CI, 1.12–1.81) (Table 2). Stratified analyses of middle-school students and boys showed that gay/lesbian youth (versus heterosexual youth) were more likely to be exposed to SHS and SHA (Table 2).Altogether, >16 million youth reported SHS and SHA exposure indoors and/or outdoors, of which 2.9 million (∼18%) were SM youth. More than half of gay/lesbian youth report SHS or SHA exposure, and SM youth were 1.3 times more likely to report any exposure than heterosexual youth.The disparity in SHS and SHA exposure may be driven by multiple factors, such as high tobacco use by SM youth, related to minority stress and lesbian, gay, exual, transgender and queer– targeted tobacco marketing.4,5 Nonetheless, the reasons for high prevalence of past-month SHS and SHA in SM youth warrant further exploration. Because chronic SHS exposure has been shown to be linked to tobacco initiation and lower likelihood of quitting tobacco, research is also needed to better characterize the intensity, and acute and chronic effects of SHS and SHA exposures among SM youth.6Study limitations include those related to the cross-sectional school-based study design (eg, self-report bias), unmeasured confounders (eg, other substance use), and lack of assessment of the full range of sexual and gender identities (eg, asexual, pansexual) or chronic exposure to smoke and aerosol. Nonetheless, this study highlights the need to reduce health disparities in SHS and SHA exposure for SM youth. It also suggests that SM youth might benefit from targeted countermarketing messaging, counseling strategies, universally enforced smokefree laws, education about why and how they should be avoiding SHA and SHS exposure, and anticipatory guidance around the risks of secondhand exposure to smoke and aerosols.