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Figure.  Current E-Cigarette Use Percentages, by State Law Status, Sex, and Sexual Identity
Current E-Cigarette Use Percentages, by State Law Status, Sex, and Sexual Identity

This shows the relative elevations in e-cigarette use among sexual minority adolescents in states with no promotion of homosexuality laws (Arizona and Oklahoma) relative to those in states without such laws (Colorado and Arkansas).

Table.  Unadjusted Rates of E-Cigarette Use Among States With and Without No Promotion of Homosexuality Laws and Adjusted Odds Ratios Comparing E-Cigarette Use Between Statesa
Unadjusted Rates of E-Cigarette Use Among States With and Without No Promotion of Homosexuality Laws and Adjusted Odds Ratios Comparing E-Cigarette Use Between Statesa
1.
Gay, Lesbian & Straight Education Network. Laws that prohibit the “promotion of homosexuality”: impacts and implications. https://www.glsen.org/sites/default/files/GLSEN%20Research%20Brief%20-%20No%20Promo%20Homo%20Laws_1.pdf. Published 2018. Accessed February 26, 2019.
2.
Rosario  M, Schrimshaw  EW, Hunter  J.  Cigarette smoking as a coping strategy: negative implications for subsequent psychological distress among lesbian, gay, and bisexual youths.  J Pediatr Psychol. 2011;36(7):731-742. doi:10.1093/jpepsy/jsp141PubMedGoogle ScholarCrossref
3.
Hoffman  L, Delahanty  J, Johnson  SE, Zhao  X.  Sexual and gender minority cigarette smoking disparities: an analysis of 2016 Behavioral Risk Factor Surveillance System data.  Prev Med. 2018;113:109-115. doi:10.1016/j.ypmed.2018.05.014PubMedGoogle ScholarCrossref
4.
Margolis  KA, Donaldson  EA, Portnoy  DB, Robinson  J, Neff  LJ, Jamal  A.  E-cigarette openness, curiosity, harm perceptions and advertising exposure among U.S. middle and high school students.  Prev Med. 2018;112:119-125. doi:10.1016/j.ypmed.2018.04.017PubMedGoogle ScholarCrossref
5.
Behar  RZ, Wang  Y, Talbot  P.  Comparing the cytotoxicity of electronic cigarette fluids, aerosols and solvents.  Tob Control. 2018;27(3):325-333. doi:10.1136/tobaccocontrol-2016-053472PubMedGoogle ScholarCrossref
6.
McKelvey  K, Baiocchi  M, Ramamurthi  D, McLaughlin  S, Halpern-Felsher  B.  Youth say ads for flavored e-liquids are for them.  Addict Behav. 2019;91:164-170. doi:10.1016/j.addbeh.2018.08.029PubMedGoogle ScholarCrossref
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Research Letter
August 26, 2019

Association of No Promotion of Homosexuality Laws and Electronic Cigarette Use Disparities for Sexual Minority Youth

Author Affiliations
  • 1Department of Educational Psychology, University of Texas at Austin
JAMA Pediatr. 2019;173(10):991-993. doi:10.1001/jamapediatrics.2019.2729

Although US laws regarding sexual minorities have advanced in recent years, many state laws may still foster environments that can promote health disparities. As of March 2019, 7 US states (Texas, Arizona, South Carolina, Oklahoma, Louisiana, Alabama, and Mississippi) with nearly 9 million public school students1 have laws explicitly prohibiting positive portrayals of sexual minority individuals or nonheterosexual activities in public school education (no promotion of homosexuality [NPH] laws). Recent school climate studies have demonstrated that the presence of NPH laws in a state is associated with a greater likelihood that students with sexual minority status will experience harassment or assault at school.1 Thus, NPH laws may reflect and support school environments that exacerbate stress for these adolescents.2

Use of tobacco is a stress-driven health disparity for sexual minority individuals.3 Most research on tobacco use by members of sexual minority groups has focused on cigarette smoking, but use of e-cigarettes has increased rapidly in recent years, and in 2016, e-cigarettes became the most commonly used tobacco product among middle school and high school students.4 Adolescents believe that flavored e-liquids, which contain glycerin-based liquids not meant to be inhaled,5 are targeted toward them.6 We investigated the associations between current e-cigarette use and NPH laws by sexual orientation and sex.

Methods

The present study was waived for ethical review by the institutional review board at the University of Texas at Austin because it used publicly available data from the 2017 Youth Risk Behavior Survey (YRBS). Consent for state YRBS participation is obtained through active or passive parental permission. The State YRBS varies in assessment of sexual orientation and vaping product use. Thus, we selected 2 states that do not have NPH laws (Colorado and Arkansas) and collected all relevant data to compare with neighboring, demographically similar states that had NPH laws and collected all relevant data (Arizona and Oklahoma). Sexual orientation was assessed using self-identification (eg, gay/lesbian, bisexual). We controlled for age in analyses and assessed interactions between state laws, sex, and sexual orientation. Appropriate variables were designated as weights, strata, and clusters to account for the complex survey design of the YRBS. We used SPSS version 25 (IBM) for data analysis, with a 2-sided P value of .05 considered significant. Data analysis occurred from February 2019 to March 2019.

Results

The final analytic sample contained 5507 adolescents (of whom 3024 were in NPH states and 2483 in non-NPH states; 2752 were female and 2755 male; and 5011 [91.0%] were aged 13 to 17 years). Logistic regression results are presented in the Table. States with NPH laws had lower rates of e-cigarette use (odds ratio [OR], 0.65 [95% CI, 0.45-0.93]). However, examining across sexual orientation, e-cigarette use was lower only among heterosexual adolescents (OR, 0.59 [95% CI, 0.39-0.89]) and not sexual minority adolescents (1.11 [95% CI, 0.77-1.59]; P = .01). Decomposing the interactions by sex and sexual orientation, this trend appeared to be driven by heterosexual girls (OR, 0.48 [95% CI, 0.29-0.78]), with a marginal association among heterosexual boys (OR, 0.68 [95% CI, 0.45-1.01]); for sexual minority boys (OR, 1.53 [95% CI, 0.78-3.01]) and girls (OR, 0.97 [95% CI, 0.57-1.63]; all comparisons, P = .03), there was no reduction in e-cigarette use from living in an NPH state. The Figure displays the relative elevations in e-cigarette use in NPH states among sexual minority adolescents.

Discussion

These results demonstrated that, within the NPH law states assessed, sexual minority youth reported elevated risks of current e-cigarette use compared with their heterosexual peers. Students in the states without NPH laws had higher overall rates of e-cigarette use compared with those in the NPH states. In states without an NPH law, sexual minority students and heterosexual students had comparable rates of e-cigarette use. These findings suggest that there is a possible overall health benefit for adolescents who live in states with NPH laws with regard to e-cigarette use, but this health benefit is only present for heterosexual adolescents. The approach of pairing states driven by the data structure of the State YRBS and subsequent analyses may take into account state-level factors (eg, price of tobacco, smoke-free air laws). The NPH laws may be associated with increased stress for students who are sexual minority members, as reflected in higher rates of e-cigarette use.

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Article Information

Accepted for Publication: April 5, 2019.

Corresponding Author: Lexie Wille, BS, Department of Educational Psychology, University of Texas at Austin, 1912 Speedway Ave, Austin, TX 78725 (lexiewille@utexas.edu).

Published Online: August 26, 2019. doi:10.1001/jamapediatrics.2019.2729

Author Contributions: Ms Wille and Dr Parent had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: All authors.

Acquisition, analysis, or interpretation of data: Parent.

Drafting of the manuscript: All authors.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: All authors.

Administrative, technical, or material support: Wille.

Supervision: Parent.

Conflict of Interest Disclosures: None reported.

Disclaimer: The views expressed in this article are the authors’ and not an official position of the authors’ institution.

References
1.
Gay, Lesbian & Straight Education Network. Laws that prohibit the “promotion of homosexuality”: impacts and implications. https://www.glsen.org/sites/default/files/GLSEN%20Research%20Brief%20-%20No%20Promo%20Homo%20Laws_1.pdf. Published 2018. Accessed February 26, 2019.
2.
Rosario  M, Schrimshaw  EW, Hunter  J.  Cigarette smoking as a coping strategy: negative implications for subsequent psychological distress among lesbian, gay, and bisexual youths.  J Pediatr Psychol. 2011;36(7):731-742. doi:10.1093/jpepsy/jsp141PubMedGoogle ScholarCrossref
3.
Hoffman  L, Delahanty  J, Johnson  SE, Zhao  X.  Sexual and gender minority cigarette smoking disparities: an analysis of 2016 Behavioral Risk Factor Surveillance System data.  Prev Med. 2018;113:109-115. doi:10.1016/j.ypmed.2018.05.014PubMedGoogle ScholarCrossref
4.
Margolis  KA, Donaldson  EA, Portnoy  DB, Robinson  J, Neff  LJ, Jamal  A.  E-cigarette openness, curiosity, harm perceptions and advertising exposure among U.S. middle and high school students.  Prev Med. 2018;112:119-125. doi:10.1016/j.ypmed.2018.04.017PubMedGoogle ScholarCrossref
5.
Behar  RZ, Wang  Y, Talbot  P.  Comparing the cytotoxicity of electronic cigarette fluids, aerosols and solvents.  Tob Control. 2018;27(3):325-333. doi:10.1136/tobaccocontrol-2016-053472PubMedGoogle ScholarCrossref
6.
McKelvey  K, Baiocchi  M, Ramamurthi  D, McLaughlin  S, Halpern-Felsher  B.  Youth say ads for flavored e-liquids are for them.  Addict Behav. 2019;91:164-170. doi:10.1016/j.addbeh.2018.08.029PubMedGoogle ScholarCrossref
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