LGBTQ HealthLink

By Amanda Fallin, PhD, RN, Assistant Research Professor, University of Kentucky College of Nursing. For Amanda’s complete bio click here.

The tobacco control movement in the United States has been a public health success story. It’s been 50 years since the Surgeon General’s landmark report on the dangers of smoking, and the landscape has completely changed—smoking is no longer a sign of affluence or an ever-present behavior. Although there has been a dramatic decline in smoking rates across the nation, tobacco use is now concentrated among high risk groups- people living in the U.S. South and tobacco-growing states, people in poverty, and sexual minorities.

Even in a major tobacco-growing state with high smoking rates, lesbian, gay, and bisexual (LGB) youth smoke at twice the rate of their heterosexual counterparts in Kentucky. One in three of Kentucky’s LGB youth report current smoking compared to 15 percent of their straight counterparts according to the 2015 Youth Risk Behavior Survey (YRBS). Notably, 28 percent of LGB youth (compared to 10 percent among heterosexual youth) in Kentucky reported smoking their first cigarette before age 13. LGB young Kentuckians are particularly burdened by tobacco use, as a result of compound risks of living in a state with pro-tobacco social norms, persistently high smoking rates, and limited tobacco-control policies.

Tobacco addiction is widely viewed as a pediatric disease: the vast majority of all adult daily smokers began smoking before the age of 18. Kentucky has consistently led the nation in youth smoking. Smoking rates are particularly high in Kentucky’s Appalachian region, an area plagued by decades of persistent poverty. Despite being disproportionately burdened by tobacco-related death, disease and associated medical costs, Kentucky has weak policies that hinder smoking. The tobacco tax is low ($.60 compared to $4.35 in New York), and the state spends one tenth of the recommended funds on tobacco control programs. While tobacco advocates in many other states are passing smoke-free policies in beaches and parks, two third of Kentuckians live in communities where smoking is not legally prohibited in restaurants or bars. Kentucky’s tobacco heritage and pro-tobacco social norms hinder tobacco control policy. For example, a mural of the tobacco harvest has adorned the Bourbon County Courthouse rotunda for more than a century. A Bourbon County elected official explained why he would not vote for a smoke-free policy, “Burley [kind of tobacco used to make cigarettes] put me through school. Burley built this courthouse, burley built the schools, burley put food on the table…just about every county farm raised some amount of tobacco.”

In the nearly 50 years since the Stonewall Riots in New York City launched the modern LGBT rights movement, activists have made tremendous gains in civil rights; however, this progress has not been uniform around the country. LGB people living in rural areas continue to experience stigma, discrimination and obstruction of their rights. A culture of “don’t ask, don’t tell” persists in many rural regions where religious beliefs and culture preclude openly acknowledging minority sexual orientation, even among friends and family. The additional stress involved with being “closeted, added to instances of outright victimization, form a minority stress phenomenon that adds to health risks and risk behaviors in this population.  In 2015, 60 percent of Kentucky’s LGB youth reported feeling sad or hopeless, and 40 percent had seriously contemplated suicide in the past year. In addition, LGB youth were significantly more likely to report using alcohol or other substances. Compared to their straight peers, LGB youth reported using heroin or any form of cocaine at a six-fold rate. There is a well-documented link between adverse mental health, substance abuse, and smoking.

Despite the excessive smoking rates and other high-risk behaviors in LGB Kentucky youth, there has been clear progress in Kentucky. For example, a smoke-free law was recently passed Clay County, Kentucky, an Appalachian community. Gay marriage is the law of the land in all 50 states, and eight Kentucky communities have fairness ordinances prohibiting discrimination based on sexual orientation and gender identity.

However, dramatic action is needed to reduce the smoking disparity facing LGB youth in Kentucky. Kentucky needs to catch up with the rest of the nation by integrating the recommended CDC’s Best Practices for Comprehensive Tobacco Control Programs, which embraces smoke-free workplaces. Support structures for LGB youth and their families are needed in their schools and communities, including in Kentucky’s rural and remote regions. Finally, healthcare providers need to create welcoming and inclusive practices to foster trusting relationships with their LGB clientele. Healthcare providers can serve as a safe space for LGB and questioning youth, as well as provide integrated care to youth facing a range of issues, including family rejection, mental health or substance abuse issues, and homelessness. Interested healthcare providers can take action today to reduce tobacco related disparities among LGB youth by joining the GLMA Health Professionals Advancing LGBT Equality list of LGBT friendly providers. Strong intervention is needed to prevent LGB youth from beginning a tobacco addiction that can lead to premature death and disease.

The opinions expressed in this column belong to the author and do not necessarily represent the views of the University of Kentucky.

Kentucky transgender data was not available for this blog.