Sexual Identity Differences in Tobacco (Re)Uptake: Testing Mediation by Internalizing and Externalizing Symptoms

Introduction: Tobacco use among gay, lesbian, and bisexual individuals is disproportionately higher than among heterosexual individuals. Identifying the mechanisms behind these differences can inform prevention and cessation efforts aimed at advancing health equity. Internalizing and externalizing symptoms as mediators of tobacco (re)uptake among sexual minority individuals was examined. Methods: Waves 4 and 5 of the Population Assessment of Tobacco and Health (2016-2019) study were analyzed in 2022. Adolescents aged >= 14 and adults years not using tobacco at Wave 4 (n=21,676) were included. Wave 4 sexual identity was categorized as heterosexual, gay/lesbian, bisexual, or something else. Associations of sexual identity with (re)uptake of cigarette use, E-ciga-rette use, and polytobacco use at Wave 5 were assessed, along with possible mediation of these asso-ciations by Wave 4-internalizing and-externalizing symptoms.Results: Internalizing and externalizing symptoms predicted tobacco (re)uptake regardless of sexual identity, particularly for female individuals. Gay/lesbian females (AOR=2.26; 95% CI=1.14, 4.48) and bisexual females (AOR=1.36; 95% CI=1.06, 1.74) had greater odds of E-cigarette (re)uptake than heterosexual females. High internalizing and externalizing symp-toms accounted for over one third of the difference in E-cigarette (re)uptake among bisexual compared with that among heterosexual females. Males who reported sexual identity as something-else had lower odds of cigarette (re)uptake than heterosexual males (AOR=0.19; 95% CI=0.06, 0.66); this association was not mediated by internalizing and externalizing symptoms. Conclusions: Internalizing and externalizing symptoms uniquely contribute to E-cigarette (re) uptake among bisexual females. Strategies that reduce sexual minority stressors and resulting psy-chological distress may help to reduce tobacco use disparities.Am J Prev Med 2023;64(6):824-833. (c) 2023 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.

Automated summary

Tobacco use is more prevalent among sexual minority individuals, especially females. Internalizing and externalizing symptoms mediate this association, particularly for bisexual females. Reducing stressors and psychological distress could help address tobacco disparities.