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

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.

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.

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.

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.

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.