Family Rejection and Cigarette Smoking Among Sexual and Gender Minority Adolescents in the USA

  • Kristi E. GamarelEmail author
  • Ryan J. Watson
  • Raha Mouzoon
  • Christopher W. Wheldon
  • Jessica N. Fish
  • Nancy L. Fleischer
Full length manuscript



Sexual and gender minority (SGM) adolescents are more likely than their heterosexual and cisgender peers to smoke cigarettes. Family rejection has been associated with adverse health outcomes; however, few studies have examined whether SGM-specific family rejection is associated with cigarette smoking among SGM adolescents.


A non-probability sample of 11,005 SGM adolescents (M = 15.58, SD = 1.27) completed an online cross-sectional survey. Bivariate and multivariable analyses were conducted to examine associations between SGM-specific family rejection, sociodemographic variables, and smoking.


Approximately 7% of the sample currently smoked cigarettes. Pansexual, asexual, trans boys, and non-binary assigned female at birth adolescents had the highest SGM family rejection scores. In multivariable regression analyses, SGM-specific family rejection was independently associated with smoking after adjusting for covariates (AOR = 1.15, 95% CI 1.04, 1.28). Family support (AOR = 0.80, 95% CI 0.73, 0.88) and experiencing violence (AOR = 1.64, 95% CI 1.49, 1.82) were also associated with smoking in multivariable models. Adolescents who identified as bisexual versus gay/lesbian (AOR = 1.50, 95% CI 1.21, 1.85) and trans boys versus cisgender girls (AOR = 2.05, 95% CI 1.13, 3.71) had an increased odds of smoking. Those who disclosed their sexual orientation identity to most (AOR = 1.95, 95% CI 1.45, 2.63) and all (AOR = 1.60, 95% CI 1.21, 2.11) of their family/parents had increased odds of smoking.


Our findings underscore the importance of attending to the role of SGM-specific family rejection and distinctions with SGM adolescents in tobacco prevention and smoking cessation efforts.


Sexual and gender minorities Adolescents Smoking Family rejection 



This research uses data from the LGBTQ Teen Study, designed by Ryan J. Watson and Rebecca M. Puhl in collaboration with the Human Rights Campaign, and supported by the Office for Vice President of Research at the University of Connecticut. The authors acknowledge the intensive efforts of Ellen Kahn, Gabe Murchison, and Liam Miranda in their support, conceptualization, and management related to the LGBTQ Teen Study.

Funding Information

Dr. Gamarel and Dr. Fleischer were supported by R37CA214787. Dr. Fish received support from the Eunice Kennedy Shriver National Center for Child Health and Human Development grant P2CHD041041, Maryland Population Research Center. Dr. Watson received support from the National Institute of Drug Abuse, K01DA047918.

Compliance with Ethical Standards

All procedures were reviewed and approved by the Intuitional Review Board who granted permission for parental consent to be waived, indicating parental consent would potentially place youth at more risk than waiving the consent.

Conflict of Interest

The authors declare that they have no conflict of interest.

Supplementary material

12529_2019_9846_MOESM1_ESM.docx (38 kb)
ESM 1 (DOCX 38 kb)


  1. 1.
    Marshal MP, et al. Individual trajectories of substance use in lesbian, gay and bisexual youth and heterosexual youth. Addiction. 2009;104(6):974–81.PubMedPubMedCentralCrossRefGoogle Scholar
  2. 2.
    Corliss HL, et al. Sexual orientation and drug use in a longitudinal cohort study of US adolescents. Addict Behav. 2010;35(5):517–21.PubMedPubMedCentralCrossRefGoogle Scholar
  3. 3.
    Fish JN, et al. Smoking behaviours among heterosexual and sexual minority youth? Findings from 15 years of provincially representative data. Drug and Alcohol Review. 2019;38(1):101–10.PubMedPubMedCentralGoogle Scholar
  4. 4.
    Khuder SA, Dayal HH, Mutgi AB. Age at smoking onset and its effect on smoking cessation. Addict Behav. 1999;24(5):673–7.PubMedCrossRefPubMedCentralGoogle Scholar
  5. 5.
    Watson RJ, et al. Sexual minority youth continue to smoke cigarettes earlier and more often than heterosexuals: findings from population-based data. Drug Alcohol Depend. 2018;184:64–70.PubMedCrossRefPubMedCentralGoogle Scholar
  6. 6.
    Dai H. Tobacco product use among lesbian, gay, and bisexual adolescents. Pediatrics. 2017;139(4):e20163276.PubMedCrossRefPubMedCentralGoogle Scholar
  7. 7.
    Remafedi G, Jurek AM, Oakes JM. Sexual identity and tobacco use in a venue-based sample of adolescents and young adults. Am J Prev Med. 2008;35(6):S463–70.PubMedCrossRefPubMedCentralGoogle Scholar
  8. 8.
    Johnson SE, et al. Tobacco product use among sexual minority adults: findings from the 2012–2013 National Adult Tobacco Survey. Am J Prev Med. 2016;50(4):e91–e100.PubMedCrossRefPubMedCentralGoogle Scholar
  9. 9.
    Wheldon CW, et al. Tobacco use among adults by sexual orientation: findings from the Population Assessment of Tobacco and Health. LGBT Health. 2018;5(1):33–44.PubMedPubMedCentralCrossRefGoogle Scholar
  10. 10.
    Hoffman L, et al. Sexual and gender minority cigarette smoking disparities: an analysis of 2016 Behavioral Risk Factor Surveillance System data. Prev Med. 2018;113:109–15.PubMedCrossRefPubMedCentralGoogle Scholar
  11. 11.
    Gamarel KE, et al. Sexual orientation disparities in smoking vary by sex and household smoking among US adults: findings from the 2003–2012 National Health and Nutrition Examination Surveys. Prev Med. 2016;82:1–6.PubMedCrossRefGoogle Scholar
  12. 12.
    Vogel EA, et al. Smoking cessation intervention trial outcomes for sexual and gender minority young adults. Health Psychol. 2019;38(1):12.PubMedCrossRefGoogle Scholar
  13. 13.
    Pachankis JE, Westmaas JL, Dougherty LR. The influence of sexual orientation and masculinity on young men’s tobacco smoking. J Consult Clin Psychol. 2011;79(2):142.PubMedCrossRefGoogle Scholar
  14. 14.
    Emory K, et al. Intragroup variance in lesbian, gay, and bisexual tobacco use behaviors: evidence that subgroups matter, notably bisexual women. Nicotine Tob Res. 2015;18(6):1494–501.PubMedPubMedCentralCrossRefGoogle Scholar
  15. 15.
    Day JK, et al. Transgender youth substance use disparities: results from a population-based sample. J Adolesc Health. 2017;61(6):729–35.PubMedPubMedCentralCrossRefGoogle Scholar
  16. 16.
    Wheldon, C.W. and K.P. Wiseman, Tobacco use among transgender and gender non-conforming adults in the United States. Tobacco Use Insights, in press.Google Scholar
  17. 17.
    Corliss HL, et al. Sexual orientation disparities in adolescent cigarette smoking: intersections with race/ethnicity, gender, and age. Am J Public Health. 2014;104(6):1137–47.PubMedPubMedCentralCrossRefGoogle Scholar
  18. 18.
    Wheldon, C., et al., Cigarette smoking among youth at the intersection of sexual orientation and gender identity. LGBT Health, in press.Google Scholar
  19. 19.
    Meyer IH. Minority stress and mental health in gay men. J Health Soc Behav. 1995:38–56.PubMedCrossRefPubMedCentralGoogle Scholar
  20. 20.
    Hendricks ML, Testa RJ. A conceptual framework for clinical work with transgender and gender nonconforming clients: an adaptation of the Minority Stress Model. Prof Psychol Res Pract. 2012;43(5):460.CrossRefGoogle Scholar
  21. 21.
    Goldbach JT, et al. Minority stress and substance use in sexual minority adolescents: a meta-analysis. Prev Sci. 2014;15(3):350–63.PubMedCrossRefPubMedCentralGoogle Scholar
  22. 22.
    Almeida J, et al. Emotional distress among LGBT youth: the influence of perceived discrimination based on sexual orientation. Journal of Youth and Adolescence. 2009;38(7):1001–14.PubMedPubMedCentralCrossRefGoogle Scholar
  23. 23.
    Bontempo DE, d’Augelli AR. Effects of at-school victimization and sexual orientation on lesbian, gay, or bisexual youths’ health risk behavior. J Adolesc Health. 2002;30(5):364–74.PubMedCrossRefPubMedCentralGoogle Scholar
  24. 24.
    Bouris A, et al. Effects of victimization and violence on suicidal ideation and behaviors among sexual minority and heterosexual adolescents. LGBT health. 2016;3(2):153–61.PubMedPubMedCentralCrossRefGoogle Scholar
  25. 25.
    Goldbach JT, Gibbs JJ. A developmentally informed adaptation of minority stress for sexual minority adolescents. J Adolesc. 2017;55:36–50.PubMedCrossRefPubMedCentralGoogle Scholar
  26. 26.
    Katz-Wise SL, Rosario M, Tsappis M. LGBT youth and family acceptance. Pediatrics Clinical North America. 2016;63(6):1011–25.CrossRefGoogle Scholar
  27. 27.
    Newcomb ME, Heinz AJ, Mustanski B. Examining risk and protective factors for alcohol use in lesbian, gay, bisexual, and transgender youth: a longitudinal multilevel analysis. Journal of Studies on Alcohol and Drugs. 2012;73(5):783–93.PubMedPubMedCentralCrossRefGoogle Scholar
  28. 28.
    Ryan C, et al. Family acceptance in adolescence and the health of LGBT young adults. Journal of Child and Adolescent Psychiatric Nursing. 2010;23(4):205–13.PubMedPubMedCentralCrossRefGoogle Scholar
  29. 29.
    Padilla YC, Crisp C, Rew DL. Parental acceptance and illegal drug use among gay, lesbian, and bisexual adolescents: results from a national survey. Soc Work. 2010;55(3):265–75.PubMedCrossRefPubMedCentralGoogle Scholar
  30. 30.
    Rosario M, Schrimshaw EW, 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. 2009;23(1):175.PubMedPubMedCentralCrossRefGoogle Scholar
  31. 31.
    Russell ST, et al. Adolescent health and harassment based on discriminatory bias. Am J Public Health. 2012;102(3):493–5.PubMedPubMedCentralCrossRefGoogle Scholar
  32. 32.
    Watson RJ, Wheldon CW, Puhl RM. Evidence of diverse identities in a large national sample of sexual and gender minority adolescents. J Res Adolesc. 2019.Google Scholar
  33. 33.
    Puhl RM, Himmelstein MS, Watson RJ. Weight-based victimization among sexual and gender minority adolescents: findings from a diverse national sample. Pediatric Obesity. 2019:e12514.PubMedCrossRefPubMedCentralGoogle Scholar
  34. 34.
    Ryan C, et al. Family rejection as a predictor of negative health outcomes in white and Latino lesbian, gay, and bisexual young adults. Pediatrics. 2009;123(1):346.PubMedCrossRefGoogle Scholar
  35. 35.
    Gamarel KE, Mitchell JW. Comparisons between smoking patterns among sexual minority females and males in romantic relationships. Health Educ Behav. 2019;46(1):176–84.PubMedCrossRefGoogle Scholar
  36. 36.
    Brener, N.D., et al., Centers for Disease Control and Prevention (CDC). Methodology of the youth risk behavior surveillance system–2013. MMWR Recomm Rep, 2013. RR-1: p. 1–20.Google Scholar
  37. 37.
    Procidano ME, Heller K. Measures of perceived social support from friends and from family: three validation studies. Am J Community Psychol. 1983;11(1):1–24.PubMedCrossRefGoogle Scholar
  38. 38.
    Thompson JK, et al. The perception of teasing scale (POTS): a revision and extension of the physical appearance related teasing scale (PARTS). J Pers Assess. 1995;65(1):146–57.PubMedCrossRefGoogle Scholar
  39. 39.
    Friedman MS, et al. A meta-analysis of disparities in childhood sexual abuse, parental physical abuse, and peer victimization among sexual minority and sexual nonminority individuals. Am J Public Health. 2011;101(8):1481–94.PubMedPubMedCentralCrossRefGoogle Scholar
  40. 40.
    Hawkins JD, Catalano RF, Miller JY. Risk and protective factors for alcohol and other drug problems in adolescence and early adulthood: implications for substance abuse prevention. Psychol Bull. 1992;112(1):64.PubMedCrossRefPubMedCentralGoogle Scholar
  41. 41.
    Buchting, F.O., W.L. Furmanski, and J.G. Lee, MPOWERED: best and promising practices for LGBT tobacco prevention and control document. 2012, Ft. Lauderdale, FL: The Network for LGBT Health Equity.Google Scholar
  42. 42.
    Stevens P, Carlson LM, Hinman JM. An analysis of tobacco industry marketing to lesbian, gay, bisexual, and transgender (LGBT) populations: strategies for mainstream tobacco control and prevention. Health Promot Pract. 2004;5(suppl 3):129S–34S.PubMedCrossRefPubMedCentralGoogle Scholar
  43. 43.
    Washington HA. Burning love: big tobacco takes aim at LGBT youths. Am J Public Health. 2002;92(7):1086–95.PubMedPubMedCentralCrossRefGoogle Scholar
  44. 44.
    Remafedi G. Lesbian, gay, bisexual, and transgender youths: who smokes, and why? Nicotine Tob Res. 2007;9(Suppl 1):S65–71.PubMedCrossRefPubMedCentralGoogle Scholar
  45. 45.
    Newcomb ME, La Sala BA, Mustanski B, Prado G, Schrager SM, Huebner DM. The influence of families on LGBTQ youth health: a call to action for innovation in research and intervention development. LGBT Health. 2019;1(4):139–45.CrossRefGoogle Scholar
  46. 46.
    Gamarel KE, Meriesh EH, Manning D, Iwamoto M, Operario D, Nemoto T. Minority stress, smoking patterns, and cessation attempts: findings from a community-sample of transgender women in the San Francisco Bay Area. Nicotine Tob Res. 2015;18(3):306–13.PubMedPubMedCentralCrossRefGoogle Scholar
  47. 47.
    Gamarel KE, Neilands TB, Dilworth SE, Taylor JM, Johnson MO. Smoking, internalized heterosexism, and HIV disease management among male couples. AIDS Care. 2015;75(5):649–54.CrossRefGoogle Scholar
  48. 48.
    Das JK, Salam RA, Finkelstein Y, Bhutta ZA. Interventions for adolescent substance abuse: an overview of systematic reviews. J Adolesc Health. 2016;59(4):S61–75.PubMedPubMedCentralCrossRefGoogle Scholar
  49. 49.
    Van Ryzin MJ, Roseth CJ, Fosco GM, Lee Y-K, Chen I-C. A component-centered mental-analysis of family-based prevention programs for adolescent substance use. Clin Psychol Rev. 2016;45:72–80.PubMedPubMedCentralCrossRefGoogle Scholar
  50. 50.
    Stephenson, R, Todd, K., Kahle, E., Sullivan, S.P., Miller-Perusse, M., Sharma, A., Horvath, K., Project Moxie: results of a feasibility study of a telehealth intervention to increase HIV testing among binary and nonbinary transgender youth. AIDS and Behavior, 2019.Google Scholar

Copyright information

© International Society of Behavioral Medicine 2020

Authors and Affiliations

  1. 1.Department of Health Behavior & Health EducationUniversity of Michigan School of Public HealthAnn ArborUSA
  2. 2.Department of Human Development and Family StudiesUniversity of ConnecticutStorrsUSA
  3. 3.Department of EpidemiologyUniversity of Michigan School of Public HealthAnn ArborUSA
  4. 4.Department of Social and Behavioral SciencesTemple University College of Public HealthPhiladelphiaUSA
  5. 5.Department of Family ScienceUniversity of Maryland School of Public HealthCollege ParkUSA

Personalised recommendations