LGBTQIA+ Populations

Sexual and Gender Minority Individuals

As it stands, the term “sexual minority” refers to individuals such as lesbian, gay, bisexual, asexual, or pansexual persons whose sexual orientation differs from the heterosexual norm. The term “gender minority” refers to individuals such as transgender and non-binary individuals whose gender identity differs from the sex they were assigned at birth, while cisgender refers to individuals whose gender identity aligns with their sex assigned at birth. The research presented here on gender minorities is limited and tends to focus on transgender individuals.  

Here, we will use the following acronyms: sexual minority (SM), sexual and gender minority (SGM), lesbian, gay and bisexual (LGB), lesbian, gay, bisexual, and transgender (LGBT), and lesbian, gay, bisexual, transgender, queer, and more identities (LGBTQ+). The terms sexual minorities and LGB, and sexual and gender minorities and LGBT/LGBTQ+, are often used interchangeably in this research.  

Tobacco use associated morbidity and mortality 

  • The percentage of adults identifying as LGBTQ+ has more than doubled over the past decade from 3.5% in 2012 to 7.2% in 2022, or approximately 24 million individuals.1 

  • The current prevalence of any tobacco use among SM adults based on data from the National Health Interview Survey is 27.4% compared to 18.4% among those who identify as heterosexual/straight.2 A recent systematic review of 30 existing studies on tobacco use among SM subgroups showed that the prevalence of current cigarette use is higher among bisexual women (37.7%), lesbian women (31.7%), gay men (30.5%), and bisexual men (30.1%), compared to heterosexual women (16.6%) and heterosexual men (21.0%).3  

  • The prevalence of tobacco use is linked with intersectionality and varies across SM subgroups.The risk of tobacco use is heightened at the intersection of race, gender identity, and sexual minority status. Smoking risk is 21% higher among White, 55% higher among Black, 119% higher among Hispanic/Latinx, and 145% higher among multiracial/other race SM women compared to White heterosexual women.5 

  • Few studies have examined rates of tobacco use among transgender individuals.6 The most recent study using data from a nationally representative sample of adults collected between 2016 and 2018 shows that transgender individuals are significantly more likely to report current use of any tobacco product (50.33% vs 23.35%), cigarettes (42.98% vs 19.15%), e-cigarettes (15.18% vs 4.61%), and cigars (18.55% vs 5.61%) compared to cisgender counterparts.7  

  • In an impact analysis, gay and bisexual men died from HIV/AIDS-related causes at a higher rate than smoking-related causes between 2005-2014.8 However, it is estimated that smoking-related deaths will surpass HIV-related deaths in the upcoming decades among gay and bisexual men.8 Similar studies on the health toll of smoking among other SGM populations are lacking.  

  • Due to concurrent tobacco use, drug use, and mental health-related factors, SGM individuals are at an increased risk for all-cause mortality, cardiovascular disease, coronary heart disease, stroke, and many cancer types (such as lung, oral, and digestive).9,10,11,12 

  • Despite higher smoking rates among the LGBT community, their intentions to quit smoking are comparable to those of the general population.13,14 


Patterns of tobacco use 

  • Bisexual men and women exhibit a higher risk for tobacco use, as well as earlier onset of smoking compared to lesbian and gay counterparts.3,4,13 These disparities are heightened among women: bisexual women are on average over a year younger at the time of their first cigarette, smoke 7 cigarettes more per day, and have double the odds of nicotine dependence compared to heterosexual women.13 

  • A disproportionate amount of SM females prefer menthol cigarettes over regular cigarettes.15,16 SM females are two times more likely to report past 30-day menthol cigarette use compared to heterosexual women (lesbian/gay 14.83%, bisexual 18.27%, and heterosexual 6.98%).15 Over 50% of SM women who smoke prefer to smoke menthol over regular cigarettes, compared to 43% of heterosexual women and 39% of the general population.15 Menthol cigarette use is associated with increased cigarette dependence and worse cessation outcomes.16 


Reasons for high rates of tobacco use  

  • LGBT individuals have a higher prevalence of mental health and substance use disorders compared to their heterosexual counterparts.17-19 The minority stress model attributes these disparities to the excess stress stemming from experiences of discrimination,20,21 victimization (particularly during childhood),22 internalized homophobia,23 and psychological distress,2 which may be associated with increased use of substances among marginalized populations.18   

  • SM individuals have high rates of other substance use, which may be linked with tobacco use.17,24 In a nationally representative sample of SM subgroups, there was a high prevalence of opioid use (prescription opioids and heroin), binge drinking, and stimulant use (cocaine and methamphetamines) compared to their heterosexual counterparts.24 

  • Past year cannabis use is significantly higher among gay men (40.8%) and bisexual men (42.9%) compared to straight men (23.9%), as well as among lesbian women (39.0%) and bisexual women (45.9%) compared to straight women (17.5%).25 

  • In a nationally representative sample of adults, LGB individuals had a higher prevalence of past-year anxiety disorders, mood disorders.19  

  • An analysis of national data revealed that over two-thirds of LGBT adults experience discrimination in their lifetime.20,22,26 

  • LGB adults who reported experiences of discrimination based on sexual orientation, gender, and race were four times more likely to have a substance use disorder in the past year than adults who did not report experiences of discrimination.20 Conversely, LGB adults who reported no lifetime discrimination showed similar rates to that of heterosexual adults.20 

  • When it comes to tobacco use, the relationship is similar. Experiences of structural discrimination (related to housing, education, and work) are associated with increased smoking among a nationally representative sample of transgender individuals.26 

  • Among SM individuals, experiences of past-year sexual orientation discrimination were associated with a greater probability of cigarette smoking and any tobacco use disorder compared to those with lower levels or no experiences with discrimination.21 

  • There is a longstanding history of the Tobacco Industry targeting LGBT populations through aggressive marketing campaigns, community outreach, promotions, and funding.10,23,27,28 

  • In 1995, R.J. Reynolds Tobacco Company initiated Project SCUM, a deliberate plan to increase cigarette sales among gay men in the San Francisco Castro District and unhoused individuals in the Tenderloin.28 

  • In recent years, national data has shown that LGBT individuals are disproportionately exposed to pro-tobacco media and tobacco product advertising compared to non-LGBT counterparts. LGBT individuals are also less likely to be exposed to anti-tobacco content and resources.28,29 


Barriers to quitting 

  • System and structural barriers 

  • LGBT individuals face healthcare barriers such as higher rates of provider discrimination,30,31 reduced access to treatment, and barriers to access health insurance, 32,33 which may negatively impact access to cessation services and tobacco treatment.  

  • Few smoking cessation interventions reflect the lived experiences of LGBT individuals and are implemented by LGBT providers.14,30 There is also limited healthcare provider training to increase competency and comfort in addressing LGBT-specific health issues.31 

  • Individual level-barriers 

  • Compared to heterosexual counterparts, SM adults who have never used substances perceive lower risks associated with multiple substance use behaviors, including smoking more than one pack of cigarettes a day.34   

  • Community-level barriers 

  • SGM individuals are at higher risk for health issues including HIV/AIDS, sexually transmitted infections, mental health challenges, and non-tobacco-related substance use (alcohol, drugs, opioids) which might take precedence over concerns related to tobacco use.35 

  • Environmental barriers 

  • Overall, LGBT individuals are more frequently exposed to second-hand smoke compared to non-LGBT counterparts,36,37 which reduces the likelihood of smoking cessation.38 

LGBTQI + Youth and tobacco use 

  • In 2022, 11.3% of middle and high school students (3.08 million) reported current tobacco use, including 16.0% who identified as lesbian, gay, or bisexual, and 16.6% who identified as transgender).39 

  • Discrimination based on sexual orientation peaks during adolescence at age 18 (26.9%) and decreases with age.40 

  • According to nationally representative data, LGBT, Black, and Hispanic adolescents are more likely to engage with at least one form of online tobacco marketing compared to heterosexual and White counterparts, increasing their risk of initiating smoking.41,42  

  • Negative environmental factors such as LGBT victimization,43 school-based violence,44 and the number of perceived rejecting reactions,45 are associated with increased tobacco use among LGBT youth. Characteristics of a more supportive social environment such as greater frequency of LGBT community events, higher quality youth organizations, and anti-discrimination policies are associated with reduced tobacco use among LGBT youth.46,47 


Promising approach to quitting 

  • Concordant care, with LGBTQ+ providers caring for LGBTQ+ individuals, can increase feelings of comfort and trust in healthcare settings for SGM populations.48,49 However, due to a lack of available LGBTQ+ providers, concordant care is not always an option.49 Diversifying the healthcare workforce30 and implementing LGBTQ+ health education programs for students and providers can improve access to culturally competent care for LGBTQ+ patients.30,50    

  • LGBTQ+ individuals have emphasized the importance of tailoring smoking cessation interventions to meet their needs.51,52 LGBTQ+-tailored interventions should include participants and counselors who identify with LGBTQ+ identities, focus on centering lived experiences, take place in LGBTQ+-safe spaces, and encourage connections among LGBTQ+ individuals.52  

  • A recent randomized controlled trial of a 90-day smoking cessation Facebook intervention, the Put it Out Project, highlights the potential for culturally tailored interventions to improve smoking cessation rates among SGM individuals. The intervention included surface-level tailoring that included pictures and symbols representative of SGM populations, and deep-level tailoring that included cultural context and experiences (e.g., tobacco industry targeted marketing). SGM participants in the LGBTQ+-tailored Facebook intervention were three times as likely as those in the non-tailored group to self-report abstinence at 6 months post-intervention (34.5% vs 12.3%).53  

  • However, results from other recent randomized control trials suggest that SGM-tailored interventions yield comparable smoking cessation outcomes to non-tailored interventions but are more accessible and preferable to SGM individuals.54-58 This underscores the need for further research into how tailored approaches can improve cessation rates.  

  • Findings from eight studies on anti-tobacco media campaigns for LGBT individuals indicate that topics such as personal health, cost, the health of loved ones, and addiction prevalence are most resonant to LGBT smoking individuals.14  

  • Partnerships with SGM communities to tackle the primary drivers of tobacco disparities, such as lower perceived smoking risk, might include collaborations with community organizations at LGBTQ+ events, educational campaigns and media initiatives that highlight lived experiences, and joint advocacy efforts with community leaders for policy changes.10,28,31 

  • The implementation of a comprehensive smoke-free air policy in communities could help reduce smoking rates and exposure among the SGM community.14,31,59 For example, smoke-free community policies in Missouri were linked to lower smoking prevalence (19% vs 25%) and greater intention to quit smoking (94% vs 76%) among SGM populations.60  



1 Jones, J. M. U.S. LGBT Identification Steady at 7.2%. Gallup (2023). 

2 Cornelius, M. E. et al. State-Specific Prevalence of Adult Tobacco Product Use and Cigarette Smoking Cessation Behaviors, United States, 2018-2019. Prev Chronic Dis 20, E107 (2023). 

3 Li, J. et al. Tobacco Use at the Intersection of Sex and Sexual Identity in the U.S., 2007-2020: A Meta-Analysis. Am J Prev Med 60, 415-424 (2021). 

4 Emory, K. et al. Intragroup Variance in Lesbian, Gay, and Bisexual Tobacco Use Behaviors: Evidence That Subgroups Matter, Notably Bisexual Women. Nicotine Tob Res 18, 1494-1501 (2016). 

5 Schuler, M. S., Prince, D. M., Breslau, J. & Collins, R. L. Substance Use Disparities at the Intersection of Sexual Identity and Race/Ethnicity: Results from the 2015-2018 National Survey on Drug Use and Health. LGBT Health 7, 283-291 (2020). 

6 Kidd, J. D. et al. A scoping review of alcohol, tobacco, and other drug use treatment interventions for sexual and gender minority populations. J Subst Abuse Treat 133, 108539 (2022). 

7 Sawyer, A. N., Bono, R. S., Kaplan, B. & Breland, A. B. Nicotine/tobacco use disparities among transgender and gender diverse adults: Findings from wave 4 PATH data. Drug Alcohol Depend 232, 109268 (2022). 

8 Max, W. B., Stark, B. B., Sung, H. Y. & Offen, N. B. Deaths from smoking and from HIV/AIDS among gay and bisexual men in California, 2005-2050. Tob Control 29, 305-311 (2020). 

9 Passaro, R. C. et al. Speed kills: Associations between methamphetamine use, HIV infection, tobacco use, and accelerated mortality among gay and bisexual men in Los Angeles, CA 20years after methamphetamine dependence treatment. Drug Alcohol Depend 195, 164-169 (2019). 

10 Acosta-Deprez, V. et al. Tobacco Control as an LGBTQ+ Issue: Knowledge, Attitudes, and Recommendations from LGBTQ+ Community Leaders. Int J Environ Res Public Health 18 (2021). 

11 Caceres, B. A. et al. A Systematic Review of Cardiovascular Disease in Sexual Minorities. Am J Public Health 107, e13-e21 (2017). 

12 Helleberg, M. et al. Mortality attributable to smoking among HIV-1-infected individuals: a nationwide, population-based cohort study. Clin Infect Dis 56, 727-734 (2013). 

13 Fallin, A., Goodin, A., Lee, Y. O. & Bennett, K. Smoking characteristics among lesbian, gay, and bisexual adults. Prev Med 74, 123-130 (2015). 

14 Lee, J. G., Matthews, A. K., McCullen, C. A. & Melvin, C. L. Promotion of tobacco use cessation for lesbian, gay, bisexual, and transgender people: a systematic review. Am J Prev Med 47, 823-831 (2014). 

15 Ganz, O. & Delnevo, C. D. Cigarette Smoking and the Role of Menthol in Tobacco Use Inequalities for Sexual Minorities. Nicotine Tob Res 23, 1942-1946 (2021). 

16 Goodwin, R. D. et al. Menthol Cigarette Use Among Adults Who Smoke Cigarettes, 2008-2020: Rapid Growth and Widening Inequities in the United States. Nicotine Tob Res 25, 692-698 (2023). 

17 Abrahao, A. B. B. et al. The impact of discrimination on substance use disorders among sexual minorities. Int Rev Psychiatry 34, 423-431 (2022). 

18 Meyer, I. H. Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: conceptual issues and research evidence. Psychol Bull 129, 674-697 (2003). 

19 Evans-Polce, R. J., Kcomt, L., Veliz, P. T., Boyd, C. J. & McCabe, S. E. Alcohol, Tobacco, and Comorbid Psychiatric Disorders and Associations With Sexual Identity and Stress-Related Correlates. Am J Psychiatry 177, 1073-1081 (2020). 

20 McCabe, S. E., Bostwick, W. B., Hughes, T. L., West, B. T. & Boyd, C. J. The relationship between discrimination and substance use disorders among lesbian, gay, and bisexual adults in the United States. Am J Public Health 100, 1946-1952 (2010). 

21 McCabe, S. E. et al. Sexual Orientation Discrimination and Tobacco Use Disparities in the United States. Nicotine Tob Res 21, 523-531 (2019). 

22 Hughes, T., McCabe, S. E., Wilsnack, S. C., West, B. T. & Boyd, C. J. Victimization and substance use disorders in a national sample of heterosexual and sexual minority women and men. Addiction 105, 2130-2140 (2010). 

23 Blosnich, J., Lee, J. G. & Horn, K. A systematic review of the aetiology of tobacco disparities for sexual minorities. Tob Control 22, 66-73 (2013). 

24 Rosner, B., Neicun, J., Yang, J. C. & Roman-Urrestarazu, A. Substance use among sexual minorities in the US - Linked to inequalities and unmet need for mental health treatment? Results from the National Survey on Drug Use and Health (NSDUH). J Psychiatr Res 135, 107-118 (2021). 

25 Substance Abuse and Mental Health Services Administration. (2023). Lesbian, gay, and bisexual behavioral health: Results from the 2021 and 2022 National Surveys on Drug Use and Health. 

26 Shires, D. A. & Jaffee, K. D. Structural Discrimination is Associated With Smoking Status Among a National Sample of Transgender Individuals. Nicotine Tob Res 18, 1502-1508 (2016). 

27 Smith, E. A. & Malone, R. E. The outing of Philip Morris: advertising tobacco to gay men. Am J Public Health 93, 988-993 (2003). 

28 Stevens, P., Carlson, L. M. & Hinman, J. M. An analysis of tobacco industry marketing to lesbian, gay, bisexual, and transgender (LGBT) populations: strategies for mainstream tobacco control and prevention. Health Promot Pract 5, 129S-134S (2004). 

29 Emory, K., Buchting, F. O., Trinidad, D. R., Vera, L. & Emery, S. L. Lesbian, Gay, Bisexual, and Transgender (LGBT) View it Differently Than Non-LGBT: Exposure to Tobacco-related Couponing, E-cigarette Advertisements, and Anti-tobacco Messages on Social and Traditional Media. Nicotine Tob Res 21, 513-522 (2019). 

30 Casanova-Perez, R. et al. Broken down by bias: Healthcare biases experienced by BIPOC and LGBTQ+ patients. AMIA Annu Symp Proc 2021, 275-284 (2021).  

31 Matthews, P. A. et al. SBM recommends policy support to reduce smoking disparities for sexual and gender minorities. Transl Behav Med 8, 692-695 (2018). 

32 Tabaac, A. R. et al. Sexual orientation-related disparities in healthcare access in three cohorts of U.S. adults. Prev Med 132, 105999 (2020). 

33 Charlton, B. M. et al. Sexual orientation-related disparities in employment, health insurance, healthcare access and health-related quality of life: a cohort study of US male and female adolescents and young adults. BMJ Open 8, e020418 (2018). 

34 Schuler, M. S. & Evans-Polce, R. J. Perceived Substance Use Risks Among Never Users: Sexual Identity Differences in a Sample of U.S. Young Adults. Am J Prev Med 63, 987-996 (2022). 

35 Boynton, M. H., Gilbert, J., Shook-Sa, B. E. & Lee, J. G. L. Perceived Importance of Health Concerns Among Lesbian, Gay, Bisexual, and Transgender Adults in a National, Probability-Based Phone Survey, 2017. Health Promot Pract 21, 764-768 (2020). 

36 Max, W. B., Stark, B., Sung, H. Y. & Offen, N. Sexual Identity Disparities in Smoking and Secondhand Smoke Exposure in California: 2003-2013. Am J Public Health 106, 1136-1142 (2016). 

37 Fallin, A., Neilands, T. B., Jordan, J. W. & Ling, P. M. Secondhand smoke exposure among young adult sexual minority bar and nightclub patrons. Am J Public Health 104, e148-153 (2014). 

38 Eng, L. et al. Second-hand smoke as a predictor of smoking cessation among lung cancer survivors. J Clin Oncol 32, 564-570 (2014). 

39 Park-Lee, E. et al. Tobacco Product Use Among Middle and High School Students - United States, 2022. MMWR Morb Mortal Wkly Rep 71, 1429-1435 (2022). 

40 Evans-Polce, R. J., Veliz, P. T., Boyd, C. J., Hughes, T. L. & McCabe, S. E. Associations between sexual orientation discrimination and substance use disorders: differences by age in US adults. Soc Psychiatry Psychiatr Epidemiol 55, 101-110 (2020). 

41 Soneji, S. et al. Online tobacco marketing among US adolescent sexual, gender, racial, and ethnic minorities. Addict Behav 95, 189-196 (2019). 

42 Lovato, C., Watts, A. & Stead, L. F. Impact of tobacco advertising and promotion on increasing adolescent smoking behaviours. Cochrane Database Syst Rev 2011, CD003439 (2011). 

43 Newcomb, M. E., Heinz, A. J., Birkett, M. & Mustanski, B. A longitudinal examination of risk and protective factors for cigarette smoking among lesbian, gay, bisexual, and transgender youth. J Adolesc Health 54, 558-564 (2014). 

44 Duangchan, C., Matthews, A. K., Smith, A. U. & Steffen, A. D. Sexual minority status, school-based violence, and current tobacco use among youth. Tob Prev Cessat 8, 46 (2022). 

45 Rosario, M., Schrimshaw, E. W. & Hunter, J. Disclosure of sexual orientation and subsequent substance use and abuse among lesbian, gay, and bisexual youths: critical role of disclosure reactions. Psychol Addict Behav 23, 175-184 (2009). 

46 Hatzenbuehler, M. L., Wieringa, N. F. & Keyes, K. M. Community-level determinants of tobacco use disparities in lesbian, gay, and bisexual youth: results from a population-based study. Arch Pediatr Adolesc Med 165, 527-532 (2011). 

47 Eisenberg, M. E. et al. Supportive Community Resources Are Associated with Lower Risk of Substance Use among Lesbian, Gay, Bisexual, and Questioning Adolescents in Minnesota. J Youth Adolesc 49, 836-848 (2020). 

48 Street, R. L., Jr., O'Malley, K. J., Cooper, L. A. & Haidet, P. Understanding concordance in patient-physician relationships: personal and ethnic dimensions of shared identity. Ann Fam Med 6, 198-205 (2008). 

49 Health, F. Understanding the unique health needs of LGBTQIA+ employees.  (2023). 

50 Morris, M. et al. Training to reduce LGBTQ-related bias among medical, nursing, and dental students and providers: a systematic review. BMC Med Educ 19, 325 (2019). 

51 Schwappach, D. L. Smoking behavior, intention to quit, and preferences toward cessation programs among gay men in Zurich, Switzerland. Nicotine Tob Res 10, 1783-1787 (2008). 

52 Bruce Baskerville, N. et al. A qualitative study of tobacco interventions for LGBTQ+ youth and young adults: overarching themes and key learnings. BMC Public Health 18, 155 (2018). 

53 Vogel, E. A. et al. The Put It Out Project (POP) Facebook Intervention for Young Sexual and Gender Minority Smokers: Outcomes of a Pilot, Randomized, Controlled Trial. Nicotine Tob Res 22, 1614-1621 (2020). 

54 McQuoid, J. et al. Tobacco Cessation and Prevention Interventions for Sexual and/or Gender Minority-Identified People and the Theories That Underpin Them: A Scoping Review. Nicotine Tob Res 25, 1065-1073 (2023). 

55 Matthews, A. K. et al. Evaluation of a Randomized Clinical Trial Comparing the Effectiveness of a Culturally Targeted and Nontargeted Smoking Cessation Intervention for Lesbian, Gay, Bisexual, and Transgender Smokers. Nicotine Tob Res 21, 1506-1516 (2019). 

56 Skurka, C., Wheldon, C. W. & Eng, N. Targeted Truth: An Experiment Testing the Efficacy of Counterindustry Tobacco Advertisements Targeted to Black Individuals and Sexual and Gender Minority Individuals. Nicotine Tob Res 23, 1542-1550 (2021). 

57 Vogel, E. A., Thrul, J., Humfleet, G. L., Delucchi, K. L. & Ramo, D. E. Smoking cessation intervention trial outcomes for sexual and gender minority young adults. Health Psychol 38, 12-20 (2019). 

58 Grady, E. S. et al. Smoking cessation outcomes among sexual and gender minority and nonminority smokers in extended smoking treatments. Nicotine Tob Res 16, 1207-1215 (2014). 

59 Boman-Davis, M. C., Irvin, V. L. & Westling, E. Complete home smoking ban survey analysis: an opportunity to improve health equity among sexual minority adults in California, USA. BMC Public Health 22, 537 (2022). 

60 Wintemberg, J., McElroy, J. A., Ge, B. & Everett, K. D. Can Smoke-Free Policies Reduce Tobacco Use Disparities of Sexual and Gender Minorities in Missouri? Nicotine Tob Res 19, 1308-1314 (2017).