UCLA CENTER FOR &, Bla NW age A137 \ NO BR healthpolicy.ucla.edu California LGBTQ+ Adult Health Behaviors and Attitudes on Tobacco Use A report based on the California LGBTQ+ Tobacco Survey UCLA Center for Health Policy Research Funded by the California Tobacco Control Program, California Department of Health california aterelian interview ean CALIFORNIA LGBTQ+ ADULT HEALTH BEHAVIORS AND ATTITUDES ON TOBACCO A report based on the California LGBTQ+ Tobacco Survey June 2022 UCLA CENTER FOR ®. HEALTH POLICY RESEARCH, 6°; UCLA Center for Health Policy Research Funded by the California Tobacco Control Program, California Department of Public Health ABOUT Author Information Sean Tan, MPP is the Senior Public Administration Analyst at the UCLA Center for Health Policy Research. Suggested Citation Tan, S. California LGBTQ+ adult population health behaviors and attitudes on tobacco. 2022. Los Angeles, Calif.: UCLA Center for Health Policy Research. The UCLA Center for Health Policy Research (CHPR) is part of the UCLA Fielding School of Public Health and is affiliated with the UCLA School of Public Affairs. The views expressed in this report are those of the authors and do not necessarily represent those of the UCLA Center for Health Policy Research, the Regents of the University of California, or collaborating organizations or funders. Copyright © 2022 by the Regents of the University of California. All rights reserved. Editor-in-Chief: Ninez A. Ponce, PhD Phone: 310-794-0909 Fax: 310-794-2686 Email: chpr@ucla.edu healthpolicy.ucla.edu UCLA CENTER FOR HEALTH POLICY RESEARCH 05 ; e fit ACKNOWLEDGMENTS The California Lesbian, Gay, Bisexual, Transgender and Queer (LGBTQ+) Adult Health Behaviors and Attitudes on Tobacco report was funded and supported by the California Department of Public Health. The findings in this report are those of the author(s) and do not necessarily represent the views or opinions of the California Department of Public Health and the California Health and Human Services Agency. The author and UCLA CHPR would like to thank Xueying Zhang, Chief of Surveillance Unit, and Tam Vuong, Project Coordinator, of the California Tobacco Control Program for their support in the development of the California LGBTQ+ Tobacco Survey and this report. This project was conducted in collaboration with a Subject Matter Expert group including: Jody L. Herman, PhD, MA, UCLA Law Williams Institute Scout, PhD, MA, National LGBT Cancer Network Bianca D. M. Wilson, PhD, UCLA Law Williams Institute The author would like to thank the following individuals for their insightful review of the report: Amaya Wooding, LGBTQ Minus Tobacco Brian Davis, LGBTQ Minus Tobacco Bob Gordon, MPH, California LGBT Tobacco Education Partnership This project was also designed and conducted with significant contributions from the following staff members at the UCLA Center for Health Policy Research: Ninez Ponce, PhD, MPP, Director of UCLA Center for Health Policy Research & Principal Investigator of California Health Interview Survey (CHIS) Todd Hughes, Director of California Health Interview Survey Royce Park, MA, Associate Director of Survey Planning and Operations YuChing Yang, PhD, Director of Statistical Unit Andrew Juhnke, Compliance Officer and Data Product Manager Zebry Jiang, MA, Statistician The author thanks SSRS for conducting the data collection for this project. The author would also like to thank all of the respondents of the California LGBTQ+ Survey. | CONTENTS ADOUL......cccccccceseceeeeeesseeeeeeeeessneaeeeeeeessesaeeeessseesaaeeeesseseaeeeeeessesiseeeeessesneeeeesy 2 ACKNOWIECGMENMS ...........ccccseeeeceecceeeeeeeeesaeseeeeeesaaeeeeeeesaeeeeeessaaaaeeeeessaaeeeeseaees 3 EX@CUtIVE SUMM ALY .........ccccccccceeeeeeeeeceeeeeeeeeeeaaeeeeeesseasseeeeeeaaseeeeeseeaeeeessaaaeees 5 BaACKQPOUNG ............cccccccccceeeeeceeeeaeeeeeeceeeseeeeeeaeeeceeesseeseeeessaeseeeeeseeaseeeeseagaegs 8 MethOdOlogy .........cccccccccccesseeseeeeeeeceeceauaueeeeeeeeeeeeeeseaaaaaeeeeeeeeeessaaaaseeseseeeeeess 10 Demographic Profile................ccccccceccesssseeeeeeeeeeceeeeeaaeeseeeeeeeeesessaaaaaeseeseeeeeees 12 TODACCO USC 1.2.2... cece eee eee reer eee ene ee reassess eee aaenneeeeeeeeeeaaaaed 13 SECONKHANA EXPOS ...........cccccssececeseeeeceeeceteeseeecenscetseeeeeeueeeesegeeeesegeesagees 23 COSSALION 000 e cece eee cece eee cette eect cnet ee eeeeeeeeceeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeess 27 Attitudes About Tobacco and Smoke- And Vape-Free Policies................. 32 RECOMMENALMIONS .......... 00. c cece cece eect eee eet teeeee reer ee eee aaa a ene eeeeeeeeeeaaaaaaeeneeeeeeeees 36 List Of TOrMs ..........:ccceeeeeeeeeeee tee re nee 38 UCLA CENTER Far California LGBTQ+ Adult Population Health a ee Behaviors and Attitudes on Tobacco bende ak The California LGBTQ+ Tobacco Survey was developed by the UCLA Center for Health Policy Research to better understand tobacco and marijuana use, vaping, cessation efforts, secondhand smoke exposure, and tobacco-related attitudes among LGBTQ+ adults in California. Nearly EET)... EME...) : (38.1%) LGBTQ+ adults LGBTQ+ adults have : currently use used vaping products LGBTQ+ adults were exposed vaping products* in their lifetime** : ©& . to tobacco secondhand 4 a smoke or vapor in the past / 3.5K 2x j two weeks compared to higher than higher than; 26.6% of all California adults all California all California: a Xv adults (2.8%) adults (18.5%) Where were they exposed? S », | 69.1% 47.8% 19.4% Pine) (34%) : sidewalk home workplace LGBTQ+ adults currently use marijuana compared to 19.5% who --- use any tobacco product LGBTQ¢+ adults agree or strongly agree that apartment complexes should require all units to be ... a oa (80.1%) Cigarette smoke-free : and vape-free: f | LGBTQ+ smokers attempted a y_ | WS S SMOKING| to quit smoking at least once in their lifetime Nearly d What did smokers use to help quit smoking? Marijuana smoke-free: 46.8% vaping products Vs : Nearly * Os Nicotine replacement therapy (NRT) EET) 9 25./ % or prescription cessation medications -: ae Barriers to treatment LGBTQ¢+ adults who agree or strongly agree : that sales of tobacco should be banned to anyone born after 2025: 17 20K cost of NRT or prescription cessation medication 10.5% perceived unfair treatment due to : 60.8% 71.9% sexual orientation or gender identity AILGBTO+ LGBTQ+ young adults adults ages 18-24 Read the full report: https://ucla.in/3N7SHTc Source: California LGBTQ+ Survey, a California Health Interview Survey follow-on survey | EXECUTIVE SUMMARY The California LGBTQ+ Tobacco Survey, conducted in 2020-2021 by the UCLA Center for Health Policy Research with funding from the California Department of Public Health, is a survey of LGBTQ+ adults in California to support tobacco prevention and cessation programs focused on LGBTQ+ populations. This report provides data estimates on tobacco products and marijuana use, cessation efforts, secondhand smoke exposure, and attitudes among LGBTQ+ adults related to tobacco use as well as policies. Estimates on tobacco use and other health behaviors related tobacco are disaggregated by sexual and gender minority status, race and ethnicity, age, and education. Key Findings The key findings from this report are: Prevalence of current use (past 30 days) and ever use (lifetime) of e-cigarettes or other vaping products (hereafter referred to as vaping products) among LGBTQ+ adults is high when compared to the general California state and U.S. populations. Some of the findings that inform this are: e 9.8% of LGBTQ+ adults reported being current vaping products users, which is higher than the 2.8% prevalence of current use of vaping products among all California adults' e About 2 in 5 (39.0%) LGBTQ+ adults reported having ever used vaping products. In comparison, 18.5% of all California adults have used vaping products in their lifetimes.? In 2018, 14.9% of U.S. adults reported having used vaping products in their lifetimes.° e Among LGBTQ+ adults, about half (50.8%) of young adults (ages 18 to 24) and 42% of adults between the ages of 25 to 49 reported using vaping products in their lifetimes and were more likely to do so than adults between the ages of 50 to 64 (25.3%) and older adults (12.6%). e A majority (51.5%) of transgender or genderqueer adults reported having ever used vaping products, while 44.0% percent of bisexual adults and 31.9% of gay or lesbian adults also reported having ever used vaping products, but estimates are likely not statistically different. Lifetime use of vaping products was similar across racial or ethnic groups as well as by educational attainment. Reported marijuana use is higher than reported use of any tobacco products among LGBTQ+ adults. Some of the findings that inform this are e 34.0% of LGBTQ+ adults reported using marijuana in the past 30 days compared to 19.5% who reported using any tobacco product in the past 30 days. e Asian or Asian American LGBTQ+ adults (14.8%) were less likely to report using marijuana in the past 30 days than Black or African American (48.1%), White (37.8%), or Latinx (34.1%) LGBTQ adults. Current use of marijuana was similar across age, education, and sexual or gender minority status among LGBTQ+ adults. e 12.8% of LGBTQ+ adults reported current use of both cigarettes and marijuana compared to 4.6% of LGBTQ+ adults who reported current use of cigarettes and vaping products. LGBTQ+ adults reported higher exposure to tobacco secondhand smoke (SHS) and secondhand vape (SHV) than the California adult population. A large proportion of adults exposed to SHS or SHV reported being exposed in places such as in their home and on sidewalks. Some of the findings that inform this are: e Close to 2 in 5 (38.1%) LGBTQ+ adults reported being exposed to tobacco secondhand smoke or secondhand vape in the past two weeks compared to 26.6% of all California adults.1° SHS and SHV were similar across sexual or gender minority status, race, age, education, and housing status. e 47.8% of LGBTQ+ adults indicated that they were exposed to SHS or SHV at home in the past 2 weeks and close to 7 in 10 (68.1%) LGBTQ+ adults reported that they were exposed to SHS or SHV on the sidewalk in the past 2 weeks compared to 19.4% of LGBTQ+ adults who reported being exposed to SHS or SHV in the workplace. About 4 in 5 (80.1%) LGBTQ+ smokers reported attempting to quit smoking at least once in their lifetimes. LGBTQ+ adults who attempted to stop smoking in the past year reported using vaping products more than any other cessation method asked in the survey and indicated certain barriers to other methods of cessation such as cost. Some of the findings that inform this are: e 46.8% of LGBTQ+ smokers who tried to quit smoking cigarettes in the past year reported using vaping products to help quit smoking. About a quarter (25.7%) of adults who tried to quit also reported using a nicotine replacement therapy or prescription cessation medications, 13.0% reported use of a cessation helpline, 10.7% used a cessation services program serving the general population, and 10.6% used a cessation services program at an LGBTQ+ specific organization. e 17.2% of LGBTQ+ smokers indicated that they had delayed or did not get nicotine replacement therapy due to cost. e 10.5% of LGBTQ+ smokers reported that they had delayed or did not seek smoking cessation programs because of perceived unfair treatment due to their sexual orientation or gender identity. e While over a third (34.4%) of LGBTQ+ smokers reported not having any fears if they quit smoking for good, however, some barriers to cessation reported were fears of withdrawal symptoms such as increased stress or anxiety (29.3%), relapse or not being able to quit (14.9%), and had fears of weight gain (13.9%). A majority of LGBTQ+ adults agree that tobacco industries target LGBTQ+ communities, and support smoke-and vape-free policies but with strong disagreement for smoke- and vape-free policies in public LGBTQ+ events. Some of the findings that inform this are: e 65.0% of LGBTQ+ adults agree or strongly agree that apartment complexes should require all units to be tobacco smoke-free and vape-free. An even greater percentage (87.1%) of LGBTQ+ adults agree or strongly agree that apartment complexes should require all units to be marijuana smoke-free. e Only about a third (32.4%) of LGBTQ+ adults agree or strongly agree that public LGBTQ+ events should be cigarette smoke- or vape-free. A higher percentage of LGBTQ+ adults (46.9%) agree or strongly agree that public LGBTQ+ events should be marijuana smoke-free. e Close to three-quarters (73.4%) of LGBTQ+ adults agree or strongly agree that tobacco advertising targets the LGTBQ+ community. e 4in 5 (80.2%) LGBTQ+ adults agree or strongly agree that flavored vaping products and other flavored tobacco products are intentionally designed to appeal to young people. e Amajority (60.8%) of LGBTQ+ adults agree or strongly agree that the sales of tobacco should be banned to anyone born after 2025. About 7 in 10 (71.9%) LGBTQ+ young adults indicated that they agree or strongly agree on the sales ban policy. | BACKGROUND Research examining health behaviors related to tobacco use among LGBTQ+ populations is often lacking. In the United States, the American Lung Association found only 6 states had published reports on tobacco use by sexual orientation.? Data on tobacco use among LGBTQ+ adults are critically important as emerging tobacco products such as e-cigarettes, vapes, and other tobacco products are being strategically marketed by tobacco companies to LGBTQ+ communities, endangering decades of public policy and public health interventions aimed at eliminating cigarette smoking and tobacco use.* The 2019-2020 California Health Interview Survey (CHIS), one of the largest population health state surveys in the nation, estimated that around 3.3% of all adults in California are either gay or lesbian and another 3.6% are bisexual, while about 0.8% of California adults reported being transgender or nonbinary.>§ According to the Centers for Disease Control and Prevention (CDC), around 1 in 5 lesbian, gay or bisexual (LGB) adults in the U.S. smoked cigarettes in 2016, which is comparatively higher to heterosexual adults at 15.3%.' The 2020 CHIS estimated that the prevalence of current smokers in California among straight or heterosexual adults to be 6.4%, 6.4% among gay or lesbian adults, 8.4% among bisexual adults, and 9.7% among other sexual minority adults. The 2015 U.S. Transgender Survey, a non-representative sample of about 28,000 transgender adults, found that 22% of respondents were current smokers, which was similar to the proportion of current smokers in the U.S. general population at the time of the survey at 21%.® Similar analyses of the U.S. Transgender Survey have shown that transgender populations had significantly higher odds of tobacco use than cisgender populations.?"° While certain studies have shown that cigarette smoking rates are higher among LGBTQ+ populations compared to heterosexual or cisgender populations, a vast amount of research still needs to be undertaken to understand the use of other tobacco products and other substances among LGBTQ+ individuals and reasons why LGBTQ+ individuals use tobacco products. According to the 2018 National Survey on Drug Use and Health (NSDUH), 37.6% of sexual minority adults (18 and older) reported past year marijuana use, compared to 16.2% reported by the U.S. adult population.' Another study showed that about 11.0% of gay men and 7.9% of bisexual men reported everyday marijuana use, compared to 3.9% of heterosexual men.'? Furthermore, a study showed that lesbian or bisexual women had higher reported daily and past year marijuana use than heterosexual women, underscoring the need to further examine substance use and disparities in LGBTQ+ populations." The Tobacco Education and Research Oversight Committee treats the LGBTQ+ population as part of their priority populations in California defined as, "those that use tobacco at higher rates, experience greater secondhand smoke exposure, are disproportionately targeted by the [tobacco] industry, and/or have higher rates of tobacco- related disease". '4 Research into tobacco products use among LGBTQ+ individuals also takes priority as minority stress theory asserts that LGBTQ+ individuals experience excessive stress compared to heterosexual or cisgender individuals as a result of stressors such as stigma and discrimination as well as from fear of family and peer rejection, leading to certain health behaviors and poorer health outcomes. In certain cases, excessive stress experienced by LGBTQ+ individuals has been linked to tobacco use.'*'6A recent study also indicates that improvements in the past 50 years in the social and legal environment (e.g., stronger support for LGBTQ+ issues or constitutionality of same-sex marriage) of sexual or gender minority people have not represented a change in minority stressors experienced across various age cohorts.'" Ultimately, greater public health surveillance data on tobacco use and other health behaviors among LGBTQ+ populations is critical to the development of programs and policies that bolster pathways toward achieving health equity. This study's main goal is to gather disaggregated data on tobacco use, cessation, and secondhand exposure among the LGBTQ+ population. Data from this study is intended to be used to develop or improve tobacco prevention and cessation programs that are working in collaboration with the LGBTQ+ population in California. | METHODOLOGY The California LGBTQ+ Tobacco Survey (referred to in respondent materials as the "The California Health Attitudes and Behavior Survey" or CHABS) is a follow-on study that contacted adults residing in California who identify as lesbian, gay, bisexual, transgender as well as other sexual or gender minorities (_GBTQ+). The survey's goal was to capture tobacco use, cessation, and tobacco-related attitudes among LGBTQ+ populations in California. Participants were recruited from three sources: (1) 2019-2020 California Health Interview Survey (CHIS) (n = 1,086), (2) SRSS Weekly Telephone Omnibus Survey (n = 117), and (3) Dynata Online Panel Survey (n = 341). A total of 1,544 interviews were collected by telephone or by web between July 2020 and January 2021. Complete details regarding the study methodology including sample design, data collection, data processing and preparation, data collection results, survey weights and variance estimation can be found on a separate document entitled, California Health Attitudes and Behavior Survey - Methodology Report: October 2021. Interpretations and Limitations Cross-tabulation analysis between tobacco-related variables and demographic characteristics of interest were conducted to create the estimate tables. Statistically unstable estimates identified with an exclamation point (!) reflect estimates based on a sample size that may be too small to accurately reflect the behaviors, health conditions, or health services issues of the population. The coefficient of variation (CV) is calculated for each estimate to assess statistical stability. The CV is defined as the ratio between the standard error of the point estimate and the point estimate. A point estimate with a CV greater or equal to 30% is considered a statistically unstable estimate. If an estimate table has values followed by an exclamation point (!), the UCLA Center for Health Policy Research recommends interpreting these results with caution. Statistically unstable estimates are shown in the report to illustrate completeness of data collected and analyzed. Construction of Sexual and Gender Minority (SGM) Status Category Due to the small respondent sample size, responses from either transgender or genderqueer respondents were combined in the sexual or gender minority category as "transgender or genderqueer'" to improve statistical stability and power. In the sexual or gender minority category, lesbian or gay and bisexual respondents are cisgender, and transgender or genderqueer respondents varied in sexual orientation. 10 Marijuana Use The term marijuana, instead of cannabis, is used throughout this report, as participants were asked specifically about their marijuana use in the survey instrument. COVID-19 Pandemic and Stay-At-Home State Guidelines Because the California LGBTQ+ Tobacco survey was fielded between 2020 and 2021, the COVID-19 pandemic and stay-at-home guidelines may have had effects on reported exposure to SHS and SHV estimates. This report provides the weighted estimates for reported exposure rates among LGBTQ+ adults, but further investigation and analysis are needed to determine exactly how the COVID-19 pandemic affected secondhand exposure rates. 11 DEMOGRAPHIC PROFILE Table 1 shows that 48.8% of LGBTQ+ adults in California are cisgender gay or lesbian, 39.4% are cisgender bisexual, and 11.8% are transgender or genderqueer of any sexual orientation. About a quarter (23.3%) of respondents are young adults (between the ages of 18 to 24 years old) a majority (53.1%) are 25 to 49 years old, 14.8% are aging adults or between the age of 50 to 64 years old, and 8.8% are older adults (65 years old and older). Forty percent of respondents identify as Latinx, 39.2% are White, 4.0% are Black or African American, 9.9% are Asian or Asian American, and 6.8% reported some other race or ethnic group. Close to half of respondents (47.8%) reported having a college degree or post-secondary degree, 17.7% reported having some college education, 9.2% have a two-year associate's degree or an equivalent degree such as a trade or vocational degree, 19.3% having a high school diploma, and 6.0% have less than a high school education. Table I. Demographic Characteristics Percent (%) 95% Confidence Interval SGM status Transgender or Genderqueer 11.8 8.7 - 14.49 Gay or Lesbian 48.8 44.3 -- 53.3 Bisexual 39.4 34.9 - 43.9 100.0 Race or ethnicity Latinx 40.0 35.1 - 45.0 White (NL) 39.2 35.3 - 43.1 Black or African American (NL) 4.0 2.1-5.9 Asian or Asian American (NL) 9.9 7.3 -- 12.5 Other (NL) 6.8 4.6 -9.0 100.0 Age 18 to 24 23.3 19.0 - 27.5 25 to 49 53.1 48.7 - 57.5 50 to 64 14.8 12.2 --17.5 65 and over 8.8 7.1 - 10.6 100.0 Education Less than high school 6.0 3.1 -8.9 High school graduate 19.3 15.2 - 23.5 Associate's or equivalent degree 9.2 7.0 --11.4 Some college 17.7 14.4 - 20.9 College graduate or higher 47.8 43.2 - 52.5 100.0 ! = Statistically unstable estimate NL = Non-Latinx 12 | TOBACCO USE Use of Any Tobacco Product Current use of any tobacco product is defined here as past 30-day use of one of the following products: cigarettes, vaping products, chewing tobacco, snuff, snus, big cigars, cigarillos or little cigars, hookah, heated tobacco products, or nicotine pouches. Table II shows that 19.5% of LGBTQ+ adults reported current use of tobacco of any kind. Bisexual adults reported higher tobacco use than gay or lesbian adults (26.0% vs. 12.6%). Over a quarter (26.1%) of transgender adults also reported use of tobacco. Among LGBTQ+ adults, about 1 in 5 Latinx (19.2%), White (20.1%), as well as adults who indicated "other" as their racial or ethnic identity (22.8%) reported current use of tobacco. About 14.9% of Asian or Asian American LGBTQ+ adults also reported current use of tobacco. Across LGBTQ+ adult age groups, about 1 in 5 young adults (22.1%) and adults ages 25 to 49 (20.7%) reported current use of tobacco, while 16.7% of adults ages 50 to 64 and 9.8% of older adults also reported current use of tobacco. About a quarter (24.7%) of LGBTQ+ adults with high school diplomas, about 1 in 5 (19.9%) with some college, 31.6% with associate's or equivalent degree, and 14.2% with college diplomas reported current use of tobacco. Table Il. Prevalence of current use of any tobacco product by sexual or gender minority status, race/ethnicity, age, and educational attainment among LGBTQ+ adults Current Use of 95% Confidence Tobacco (%) Interval Overall LGBTQ+ Population 19.5 16.4 - 22.6 SGM Status Transgender or Genderqueer 26.1 15.2 - 37.1 Gay or Lesbian 12.6 8.4 - 16.7 Bisexual 26.0 20.3 - 31.8 Race or Ethnicity Latinx 19.2 12.8 - 25.5 White (NL) 20.1 15.3 - 24.9 Black or African American (NL) 22.2 (!) 7.4 - 36.9 Asian or Asian American (NL) 14.9 6.9 - 22.9 Other (NL) 22.8 10.3 - 35.3 Age 18 to 24 22.1 13.3 - 31.0 25 to 49 20.7 15.9 - 25.4 50 to 64 16.7 10.9 - 22.5 65 and over 9.8 5.3 - 14.4 13 Education Less than high school High school graduate Some college Two-year associate's or equivalent College graduate or higher ! = Statistically unstable estimate Current Smokers 25.3 (!) 2.1-48.5 24.7 14.2 - 35.1 19.9 13.4 - 26.5 31.6 18.3 --44.8 14.2 10.4 - 17.9 NL = Non-Latinx A current smoker refers to an adult who has had 100 or more cigarettes in their lifetimes, and smoke cigarettes some days or daily. Table Ill illustrates that 12.8% of LGBTQ+ adults reported being current smokers. About 1 in 10 (9.0%) gay or lesbian adults reported being a current smoker, while around 14.6% of transgender or genderqueer, and 16.9% of bisexual adults also reported being a current smoker. About 1 in 10 (11.5%) of Latinx LGBTQ+ adults, 14.8% of White adults and 13.7% of adults who indicated other as their racial or ethnic identity reported being a current smoker. About 14.3% of adults ages 25 to 49, 13.2% of adults 50 to 64, and 7.4% of older adults reported being a current smoker. About 1 in 10 (8.9%) of adults with a college degree or higher reported being a current smoker compared to over 1 in 5 (22.6%) of high school graduates. Table Ill. Percentages of current smokers by sexual or gender minority status, race/ethnicity, age, and educational attainment among LGBTQ+ adults Current Smokers (%) 95% Confidence Interval Overall LGBTQ+ Population SGM Status Transgender or Genderqueer Gay or Lesbian Bisexual Race or Ethnicity Latinx White (NL) Black or African American (NL) Asian or Asian American (NL) Other (NL) Age 18 to 24 25 to 49 50 to 64 65 and over Education Less than high school High school graduate Some college Associate's or equivalent 12.8 10.3 - 15.3 14.6 7.3-21.8 9.0 5.9-12.1 16.9 12.0 - 21.8 11.5 6.4- 16.6 14.8 11.0- 18.6 11.6 (!) 2.3-21.0 9.9 (!) 3.5 - 16.0 13.7 6.0-21.4 10.9 (!) 3.8 - 18.0 14.3 10.9- 17.8 13.2 7.8-18.6 7.4 3.5-11.4 6.5 (!) 0.0 - 13.7 22.6 12.2 - 32.9 11.8 7.2-16.5 12.0 9.2-26.8 14 College graduate or higher | 8.9 6.2 - 11.7 | ! = Statistically unstable estimate NL = Non-Latinx Age First Smoked a Whole Cigarette Half (50.7%) of LGBTQ+ adults reported having smoked their first cigarette when they were an adolescent (13 to 17 years old) and 3 in 10 (29.9%) as a young adult (18 to 24 years old). Around half of gay or lesbian (51.8%) and bisexual adults (50.8%) as well as 45.1% of transgender or genderqueer adults reported having their first cigarette as an adolescent. Around 3 in 5 (62.4%) current young adults, along with around half (49.0%) of adults between the ages of 25 to 49 indicated having had their first cigarette as an adolescent (See Appendix Table 1). Use of Vaping Products Table IV shows that 39.0% of LGBTQ+ adults reported having used vaping products in their lifetimes. A majority of (51.5%) of transgender or genderqueer adults reported ever using vaping products. Forty-four percent of bisexual adults and a close to a third (31.9%) of gay or lesbian adults also reported ever using vaping products. Close to 3 in 5 (58%) of LGBTQ+ adults who indicated "other" as their racial or ethnic identity reported ever using vaping products. Among LGBTQ+ adults, around 2 in 5 (41.4%) of Latinx, 37% of White, 30.8% of Black, and 27.3% of Asian or Asian American adults also reported ever using vaping products their lifetimes. LGBTQ+ older adults were less likely to indicate ever using vaping products in their lifetimes than LGBTQ+ young adults and LGBTQ+ adults between the ages 25 to 49 (12.6% vs. 50.8%, and 42.0%, respectively). A majority (51.6%) of LGBTQ+ adults with high school diplomas, 43.2% with some college, 36.7% with associate's or equivalent degree, and 34.0% with college degrees reported ever using vaping products. Table IV also shows that 9.8% of LGBTQ+ adults reported current use of vaping products. Bisexual adults were more likely to report current use of vaping products compared to gay or lesbian adults (15.0% vs. 4.3%). Around 1 in 10 (10.1%) White adults and 8.9% of Latinx adults reported current use of vaping products. Across LGBTQ+ age groups, 16.0% of young adults, 9.1% of adults between the ages 25 to 49 and 6.8% of adults between the ages 50 to 64 reported current use of vaping products. Across educational attainment categories, 8.4% of LGBTQ+ adults with high school diplomas, 13.5% with some college, 16.8% with an associate's degree, and 6.8% with college degrees reported current use of vaping products. 15 Table IV. Prevalence of current use of and ever using (lifetime) vaping products among LGBTQ+ adults Current Use Ever Used of Vaping 95% Vaping 95% products Confidence products Confidence (%) Interval (%) Interval Overall LGBTQ+ Population 9.8 7.4-12.2 39.0 34.6 - 43.3 SGM Status Transgender or Genderqueer 15.1(!) 6.1 - 24.0 51.5 38.6 - 64.3 Gay or Lesbian 4.3 1.8-6.8 31.9 25.8 - 38.1 Bisexual 15.0 10.3 - 19.7 44.0 37.0 - 51.0 Race or Ethnicity Latinx 8.9 4.4- 13.4 41.4 32.9 - 49.9 White (NL) 10.1 6.4 - 13.9 37.0 31.4 - 42.7 Black or African American (NL) 16.8 (!) 3.8 - 29.7 30.8 13.7 - 48.0 Asian or Asian American (NL) 8.8 (!) 2.7 - 15.0 27.3 16.1 - 38.4 Other (NL) 10.1 (!) 0.5 - 19.7 58.0 40.9 - 75.1 Age 18 to 24 16.0 8.3 - 23.8 50.8 39.2 - 62.4 25 to 49 9.1 5.8 - 12.4 42.0 35.7 - 48.3 50 to 64 6.8 3.2 - 10.5 25.3 18.0 - 32.6 65 and over 2.3 (!) 0.3-4.2 12.6 6.8 - 18.4 Education Less than high school 6.3 (!) 0.0 - 36.7 29.0 (!) 5.3 - 52.6 High school graduate 8.4 2.2 - 14.7 51.6 39.2 - 64.0 Some college 13.5 7.7 --19.4 43.2 33.9 - 52.4 Associate's or equivalent 16.8 4.4-29.2 36.7 23.1 - 50.3 College graduate or higher 6.8 3.9 - 9.7 34.0 28.1 - 39.9 ! = Statistically unstable estimate NL = Non-Latinx Use of Tobacco Products Other Than Cigarettes or Vaping Products Use of other tobacco products refer to products such as big cigars, little cigars, hookah, heated tobacco products, nicotine pouch, and smokeless tobacco products (i.e., chewing tobacco, snuff, or snus). Among LGBTQ+ adults, 3.8% reported current use of tobacco products other than cigarettes or vaping products. Among LGBTQ+ adults, 1.3% reported current use of big cigars, 1.4% reported current use of little cigars or cigarillos, 1.4% reported current use of hookah, 1.0% reported current use of heated tobacco products, 1.4% reported current use of smokeless tobacco products, and 1.0% reported current use of a nicotine pouch (see Appendix Table Il). 16 Use of Flavored Tobacco Products Flavored tobacco includes tobacco products that have flavors such as mint, fruit, candy or wine. Table VI shows that close to 1 in 5 (19.7%) transgender or genderqueer adults, 16.5% of bisexual adults and 7.1% of gay or lesbian adults reported current use of flavored tobacco products. Among LGBTQ+ adults, over 1 in 10 (12.5%) White LGBTQ+ adults and 12.1% Latinx adults reported current use of flavored tobacco products. Across LGBTQ+ adult age groups, 16.3% of young adults, 13.4% of adults between the ages of 25 to 49, and 7.4% of adults ages 65 and older reported current use of flavored tobacco products. Table VI. Prevalence of current use of flavored tobacco products by sexual and gender minority status, race/ethnicity, age groups, and educational attainment among LGBTQ+ adults. Current Use of Flavored Tobacco (%) 95% Confidence Interval Overall LGBTQ+ Population 12.3 9.4-15.2 SGM Status Transgender or Genderqueer 19.7 9.2 - 30.2 Gay or Lesbian 7.1 3.4 - 10.8 Bisexual 16.5 11.3 -21.7 Race or Ethnicity Latinx 12.5 7.0 - 18.1 White (NL) 12.1 7.8 - 16.5 Black or African American (NL) 19.4 (!) 5.6 - 33.2 Asian or Asian American (NL) 8.3 (!) 2.3 - 14.2 Other (NL) 13.2 (!) 2.1 - 24.4 Age 18 to 24 16.3 8.4-17.7 25 to 49 13.4 9.1-17.7 50 to 64 7.4 3.6 - 11.2 65 and over 3.2 (!) 0.7 -5.6 Education Less than high school 23.3 0.2 -- 46.5 High school graduate 15.0 6.4 - 23.5 Some college 13.6 7.9 - 19.3 Associate's or equivalent 19.0 (!) 6.1 - 31.9 College graduate or higher 8.0 4.8 - 11.2 ! = Statistically unstable estimate NL = Non-Latinx Table VII shows that among LGBTQ+ adults who reported current use of vaping products, 86.9% had vaping products in flavors such as mint, fruit, candy or wine. Almost all transgender or genderqueer adults (93.0%) who use vaping products reported using it with flavors. Similar percentages of gay or lesbian (85.4%) adults and 17 bisexual adults (85.5%) who use vaping products reported using it with flavors. Use of flavored vaping products were similar across SGM status, race or ethnicity, and age. Table Vil. Percentages of LGBTQ+ e-cigarette or vaping products users who reported using vaping products in flavors such as mint, fruit, candy, or wine by SGM status, race or ethnicity and age Current Use of Flavored Vaping Products (%) 95% Confidence Interval LGBTQ+ e-cigarette user population SGM Status Transgender or Genderqueer Gay or Lesbian Bisexual Race or Ethnicity Latinx White (NL) Black or African American (NL) Asian (NL) Other (NL) Age 18 to 24 25 to 49 50 to 64 65 and over ! = Statistically unstable estimate Use of Marijuana 86.9 76.1 - 97.6 93.0 80.8 - 100.0 85.4 72.9 - 97.8 85.5 68.3 - 100.0 82.4 57.2 - 100.0 86.6 76.5 - 96.7 100.0 (!) 100.0 - 100.0 94.2 81.6 - 100.0 89.1 63.0 - 100.0 97.7 94.4 - 100.0 79.3 60.1 - 98.5 90.2 78.4 - 100.0 50.4 (!) 5.0 - 95.7 NL = Non-Latinx Table VIII shows that 34.0% of LGBTQ+ adults reported current use of marijuana. Around 2 in 5 (38.7%) of transgender or genderqueer, 36.3% of bisexual and 31% of gay or lesbian adults reported current use of marijuana. About half (48.1%) of Black or African American LGBTQ+ adults reported current use of marijuana, followed by White adults (37.8%) and Latinx adults (34.1%), adults who specified other as their racial or ethnic identity (31.2%), and Asian or Asian American adults (14.8%). About a quarter (24.9%) of older adults indicated using marijuana in the past 30 days. Adult age groups under the age of 64 reported similar percentages of current marijuana use: 35.1% of young adults, 34.6% of adults aged 25 to 49, and 35.4% of aging adults. Around 3 in 10 (31.1%) of LGBTQ+ adults with high diplomas, 32.8% with some college, 45.0% with an associate's or equivalent degree, and 34.5% with college degrees. 18 Table Vill. Prevalence of current use of marijuana by sexual and gender minority status, race/ethnicity, age groups, and educational attainment among LGBTQ+ adults Current Use of Marijuana (%) 95% Confidence Interval Overall LGBTQ+ Population 34.0 29.9 - 38.1 SGM Status Transgender or Genderqueer 38.7 25.1 - 52.4 Gay or Lesbian 31.0 24.5 - 37.4 Bisexual 36.3 29.6 - 42.9 Race or Ethnicity Latinx 34.1 26.2 - 42.0 White (NL) 37.8 32.4 - 43.1 Black or African American (NL) 48.1 25.2 - 70.9 Asian or Asian American (NL) 14.8 7.5 - 22.0 Other (NL) 31.2 16.8 - 45.7 Age 18 to 24 35.1 24.4 - 45.8 25 to 49 34.6 29.0 - 40.2 50 to 64 35.4 26.2 - 44.5 65 and over 24.9 18.6 - 31.2 Education Less than high school 25.8 (!) 2.7 - 48.9 High school graduate 31.1 19.7 - 42.5 Some college 32.8 23.5 - 42.1 Associate's or equivalent 45.0 30.9 - 59.2 College graduate or higher 34.5 29.1 - 39.8 ! = Statistically unstable estimate NL = Non-Latinx Co-Use of Tobacco Products Table IX shows that among LGBTQ+ adults, 4.6% reported current co-use of cigarette and vaping products. Less than ten percent (7.1%) of bisexual adults and 2.0% of gay or lesbian adults reported current co-use of cigarettes and vaping products. Among LGBTQ+ adults, 6.5% of White adults reported current use both cigarettes and vaping products. Across LGBTQ+ adult age groups, 4.9% of adults aged 25 to 49 years old, 4.6% of adults aged 50 to 64 years old, and 1.2% of adults aged 65 years or older reported co-use of cigarettes and vaping products. Table IX also shows that among LGBTQ+ adults, 12.8% reported current co-use of cigarettes and marijuana. Across sexual and gender minorities, 16.9% of bisexual adults, 14.6% of transgender or genderqueer adults and 9% of gay or lesbian adults reported co-use of cigarettes and marijuana in the past 30 days. Across LGBTQ+ adult age groups, 14.3% of LGBTQ+ adults aged 25 to 49 and 13.2% of adults aged 50 to 64 19 reported co-use of cigarettes and marijuana. Over one-fifth (22.6%) of LGBTQ+ adults with only high school diploma used both cigarettes and marijuana, followed by LGBTQ+ adults with an associate's or equivalent degree at 18% (See Appendix Table). Table IX further shows that among LGBTQ+ adults, 5.8% reported co-use of vaping products and marijuana with 8.3% of bisexual adults reporting so. Among LGBTQ+ adults aged 25 to 49, 5.2% reported co-use of vaping products and marijuana. Among LGBTQ+ adults with high school diplomas, 3.8% reported co-use of vaping products and marijuana. Table IX further shows that among LGBTQ+ adults, 2.8% reported current use of cigarettes, vaping products, and marijuana. Among LGBTQ+ adults aged 25 to 49, 3.1% reported use of cigarette, vaping products and marijuana, and 2.3% of LGBTQ+ adults with college degrees reported use of all three products. Table IX. Percentages of LGBTQ+ adults who reported current co-use of cigarettes, vaping products, and cigarettes and marijuana by SGM status, race or ethnicity, age, and educational attainment Use All Use Both Use both (Cigarette, Cigarette & Use Both Vaping Vaping Vaping Cigarette & Products & Products, Products Marijuana Marijuana Marijuana) % % % % (95% (95% (95% (95% Confidence Confidence Confidence Confidence Interval) Interval) Interval) Interval) Overall LGBTQ+ Adult 4.6 12.8 5.8 2.8 Population (3.3 - 6.0) (10.3 - 15.3) (3.8 - 7.8) (1.9 - 3.6) SGM Status Transgender or 7.2 (!) 14.6 9.6 (!) 5.9 (!) Genderqueer (2.2 - 12.3) (7.3 - 21.8) (3.0 - 16.2) (1.5 - 10.4) Gay or Lesbian 2.0 9.0 2.8 (!) 1.0 (!) (0.9 - 3.0) (5.9 - 12.1) (0.5 - 5.2) (0.1 - 1.8) Bisexual 7.1 16.9 8.3 4.0 (4.1 - 10.2) (12.0 - 21.8) (4.9 - 11.7) (2.6 - 5.5) Race or Ethnicity Latinx 2.8 (!) 11.5 6.1 (!) 1.9 (!) (1.1 - 4.6) (6.4 - 16.6) (2.1 - 10.3) (0.6 - 3.2) White (NL) 6.5 14.8 4.9 3.5 (3.7 - 9.3) (11.0 - 18.6) (3.1 - 6.7) (2.0 - 5.1) Black or African 8.8 (!) 11.6 (1) 8.3 (!) 4.3 (!) American (NL) (0.8 - 16.7) (2.3 - 21.0 (0.0 - 16.7) (0.0 - 8.9) Asian (NL) 3.7 (!) 9.8 (!) 4.2 (!) 2.8 (!) (0.5 - 7.0) (3.5 - 16.0) (0.9 - 7.5) (0.2 - 5.4) 20 Other (NL) 3.2 (!) 13.7 9.4 (!) 2.4 (!) (0.0 - 6.6) (6.0 - 21.4) (0.0 - 18.8) (0.0 - 5.7) Age Groups 18 to 24 5.3 (!) 10.9 (!) 10.3 (!) 3.0 (!) (0.5 - 10.2) (3.8 - 18.0) (4.1 - 16.5) (0.7 - 5.3) 25 to 49 4.9 14.3 5.2 3.1 (3.3 - 6.4) (10.9 - 17.8) (2.8 - 7.6) (2.0 - 4.3) 50 to 64 4.6 13.2 3.0 (!) 1.9 (!) (1.3 - 8.0) (7.8 - 18.6) (0.2 - 5.9) (0.0 - 4.4) 65 and over 1.2 74 2.2 (!) 1.2 (!) (0.0 - 2.7) (3.5 - 11.4) (0.3 - 4.1) (0.0 - 2.6) Education Less than high school 45 (!) 6.5 (!) 28 (!) 28 (!) (0.0 - 10.2) (0.0 - 13.7) (0.0 - 7.0) (0.0 - 7.0) Some college 6.2 11.8 8.6 (!) 3.0 (!) (2.7 - 9.7) (7.2 - 16.5) (3.8 - 13.5) (1.3 - 3.4) High school graduate 7.2 (!) 226 3.8 32 (!) (1.1 - 13.2) (12.2 - 32.9) (0.9 - 6.7) (0.5 - 6.0) Associate's or 5.2 (!) 18.0 13.6 (!) 3.3 (1) equivalent degree (1.4 - 9.0) (9.2 - 26.8) (1.2 - 26.0) (0.5 - 6.1) College graduate or 2.9 8.9 4.4 2.3 higher (1.8 - 4.1) (6.2 - 11.7) (2.0 - 6.8) (1.3 - 3.4) ! = Statistically unstable estimate NL = Non-Latinx Alcohol Consumption Table X shows that 23.0% of LGBTQ+ adults who had any alcohol consumption in the past 30 days reported current use of tobacco products, compared to 12.6% of LGBTQ+t adults who had not consumed alcohol in the past 30 days. Seven percent of LGBTQ+ adults who had not consumed alcohol reported use of cigarettes, compared to 15.8% of LGBTQ+ adults who had consumed alcohol. Among LGBTQ+ adults who consumed alcohol, 11.7% reported current use of vaping products compared to 6.1% of LGBTQ+ adults who had not consumed alcohol. Six percent of LGBTQ+ adults who consumed alcohol reported current co-use of cigarettes and vaping products, compared to 2.0% of LGBTQ+ adults who had not consumed alcohol. Among LGBTQ+ adults who consumed alcohol, 14.6% reported use of flavored tobacco products compared to 7.8% of LGBTQ+ adults who had not consumed alcohol. Table X also shows that over 2 in 5 (42.9%) of LGBTQ+ adults who consumed alcohol reported current use of marijuana compared to 16.9% of LGBTQ+ adults who had not consumed alcohol. Among LGBTQ+ adults that consumed alcohol, 15.7% reported co- use of cigarettes and marijuana compared to 7.0% of LGBTQ+ adults who had not consumed alcohol. Eight percent of LGBTQ+ adults who consumed alcohol reported co- use of vaping products and marijuana compared to 1.6% of adults who had not consumed 21 alcohol. Among LGBTQ+ adults who consumed alcohol, 3.8% reported use of cigarettes, vaping products, and marijuana compared to 0.7% of LGBTQ+ adults who had not consumed alcohol. Table X. Prevalence of single and co-use of tobacco products between LGBTQ+ adults who have and have not had alcohol in the past 30 days Cigarettes & Any Tobacco Vaping Vaping Flavored Product Cigarettes Products Products Tobacco % (95% Cl) % (95% Cl) % (95% Cl) % (95% Cl) % (95% Cl ( No Alcohol 12.6 7.0 6.1 2.0 7.8 Use (7.8 - 17.5) (4.3 - 9.7) (2.2 -- 9.9) (0.6 - 3.5) (3.3 -- 12.2) Use of 23.0 15.8 11.7 6.0 14.6 Alcohol (18.4-27.6) (12.1 -- 19.5) (8.3 - 15.1) (3.8 - 8.1) (10.3 - 18.9) All Used (Cigarettes, Vaping Vaping Cigarettes & Products& Products & Marijuana Marijuana Marijuana Marijuana) % (95% Cl) % (95% Cl) % (95% Cl) % (95% Cl) No Alcohol 16.9 7.0 1.6 0.7 Use (11.4 - 22.3) (4.3 -- 9.7) (0.5 - 2.7) (0.0 - 1.3) Use of 42.9 15.7 8.0 3.8 Alcohol (37.2-48.5) (12.1 - 19.5) (5.1 - 10.8) (2.6 - 5.1) 22 | SECONDHAND EXPOSURE Tobacco and Marijuana Secondhand Smoke Exposure Table XI shows that 38.1% of LGBTQ+ adult reported having been exposed to tobacco and SHS and SHV in the past two weeks. Almost half (48.7%) of transgender or genderqueer adults, 34.1% of gay or lesbian adults and 39.8% of bisexual adults reported being exposed to tobacco SHS or SHV in the past two weeks. Among LGBTQ+ adults, around 2 in 5 Asians or Asian Americans (44.2%) and African Americans (40.2%) reported being exposed to tobacco SHS or SHV. Across LGBTQ+ adult age groups, 44% of young adults compared to 24.8% of older adults reported being exposed to tobacco SHS or SHV. A majority (56.0%) of LGBTQ+ adults who have less than a high school diploma reported being exposed to tobacco SHS or SHV compared to adults with associate's or equivalent degrees (44.7%), with a high school diploma (41.4%), with some college (37.3%) and with college diplomas (33.4%). Among LGBTQ+ adults, about half of adults who (49.2%) live in other arrangements categorized, 40.9% renting in a single- unit building (i.e., house or mobile home), 39.2% of those renting in a multi-unit building reported being exposed to tobacco SHS or SHV in the past two weeks, compared to 33.7% who are homeowners in a single-unit building and 27.7% who are homeowners in a multi-unit building. Table XI. Percentages of LGBTQ+ adults exposed to tobacco SHS or SHV and marijuana SHS by SGM status, race or ethnicity, age, education, and housing status Tobacco 95% 95% SHS or Confidence Marijuana Confidence SHV (%) Interval SHS (%) Interval Overall LGBTQ+ Population 38.1 33.8 - 42.3 48.4 43.6 - 53.2 SGM Status Transgender or Genderqueer 48.7 33.7 - 63.6 62.5 47.7 -77.2 Gay or Lesbian 34.1 27.9 - 40.3 45.9 39.1 - 52.6 Bisexual 39.8 32.9 - 46.7 47.4 39.7 - 55.1 Race or Ethnicity Latinx 38.7 30.1 - 47.4 55.8 47.1 - 64.6 White (NL) 35.6 30.0 - 41.1 42.1 35.9 - 48.2 Black or African American (NL) 40.2 17.2 - 63.1 37.7 17.3 - 58.1 Asian or Asian American (NL) 44.2 30.5 - 57.9 38.0 24.0 - 52.0 Other (NL) 38.1 23.1 - 53.0 63.1 47.3 - 78.9 Age 23 18 to 24 44.0 33.1 - 55.0 52.8 41.6 - 63.9 25 to 49 39.1 32.7 - 45.5 50.4 44.2 - 56.6 50 to 64 33.0 23.8 - 42.1 44.2 35.2 - 53.1 65 and over 24.8 14.1 -- 35.4 32.1 21.3 - 42.9 Education Less than high school 56.0 29.9 - 82.1 52.3 28.4 - 76.2 High school graduate 41.4 28.8 - 46.7 45.4 32.3 - 58.5 Some college 37.3 28.0 - 46.7 44.8 35.1 -- 54.5 Associate's or equivalent 44.7 30.1 - 59.2 55.7 42.1 - 69.4 College graduate or higher 33.4 27.6 - 39.3 49.1 43.6 - 54.6 Housing Status Renting in multi-unit buildings 39.2 31.4 - 46.9 55.5 47.2 - 63.7 Renting in single-unit building 40.9 30.7 - 51.0 51.0 40.3 - 61.6 Homeowner in multi-unit buildings 27.7 15.1 - 40.3 34.0 20.1 - 47.9 Homeowner in single-unit building 33.7 26.4 - 41.0 42.2 34.1 - 50.4 Living with other arrangements 49.2 35.2 - 63.3 48.4 32.1 - 64.8 ! = Statistically unstable estimate NL = Non-Latinx Table XI also shows that close to half (48.4%) of LGBTQ+ adults have been exposed to marijuana SHS in the past 2 weeks. About 3 in 5 (62.5%) of transgender or genderqueer adults, 47.4% of bisexual adults and 45.9% of gay or lesbian adults reported being exposed to marijuana SHS. A majority of (52.8%) LGBTQ+ young adults reported being exposed to marijuana SHS followed by about half (50.4%) of adults age 25 to 49 and compared to 44.2% of adults aged 50 to 64 years old and 32.1% of older adults. A majority of LGBTQ+ adults with associate's or equivalent degrees (55.7%) and with less than high school diplomas (52.3%) reported being exposed to marijuana SHS compared to close to half (49.1%) of adults with college degrees, 45.4% with high school diplomas, and 44.8% with some college. A majority of LGBTQ+ adults renting in multi-unit buildings (55.6%) and single-unit buildings (51.0%) reported being exposed to marijuana SHS compared to 48.4% of adults who are living with other arrangements, 42.2% of adults who are homeowners in single-unit buildings, and 34.0% who are homeowners in multi- unit buildings. Places Exposed to Tobacco SHS or SHV Table XII shows that among LGBTQ+ adults exposed to tobacco SHS or SHV in California in the past 2 weeks, about 7 in 10 (68.1%) reported exposure while on the sidewalk, while 47.8% reported exposure at home and 1 in 5 (19.4%) reported exposure in the workplace. Gay or lesbian adults exposed to SHS or SHV reported a higher level of exposure on the sidewalk (64.9%) and at home (45.4%) than in the workplace (20.5%). Close to 4 in 5 (78.0%) Black or African American LGBTQ+ adults exposed to SHS or SHV reported exposure on the sidewalk. About 7 in 10 (71.5%) Asian or Asian American LGBTQ+ adults 24 exposed to SHS or SHV reported exposure on the sidewalk and 46.8% reported exposure at home. Latinx LGBTQ+ adults exposed to SHS or SHV reported higher exposure on the sidewalk (78.2%) than at home (45.8%) or the workplace (29.8%). White LGBTQ+ adults reported less exposure in the workplace (10.5%) than at home (49.9%) or on the sidewalk (56.0%). LGBTQ+ young adults exposed to SHS reported higher exposure on the sidewalk than at home (81.2% vs. 40.5%). LGBTQ+ adults between the ages of 25 to 49 reported less exposure in the workplace (23.7%) than on the sidewalk (66.8%) and at home (51.0%). Similarly, older adults reported less exposure in the workplace (7.3%) than on the sidewalk (37.8%) and at home (61.1%). Table XII. Percentages of LGBTQ+ adults who were exposed to SHS or SHV in the past two weeks across reported places of exposure by SGM status, race or ethnicity, and age At Home In the Workplace On the Sidewalk % (95% Cl) % (95% Cl) % (95% Cl) Overall LGBTQ+ Population 47.8 19.4 68.1 (40.3 - 55.3) (13.2 - 25.5) (61.4 - 74.9) SGM Status Transgender or 60.8 27.0 (!) 82.1 Genderqueer (41.5 - 80.1) (8.9 - 45.0) (68.6 - 95.5) Gay or Lesbian 45.4 20.5 64.9 (33.3 - 57.6) (8.9 - 32.2) (54.6 - 75.3) Bisexual 45.5 15.3 66.4 (34.5 - 56.6) (8.3 - 66.4) (56.2 - 76.6) Race or Ethnicity Latinx 45.8 29.8 78.2 (33.4 - 58.1) (17.3 - 42.3) (67.4 - 89.0) White (NL) 49.9 10.5 56.0 (40.2 - 59.7) (6.0 - 14.9) (45.2 - 66.8) Black or African American 51.6 (!) 45.5 (!) 78.0 (NL) (10.7 - 92.4) (3.7 - 87.2) (51.4 - 100.0) Asian or Asian American 46.8 7.2 (!) 71.5 (NL) (24.8 - 68.9) (0.0 - 14.7) (55.3 - 87.7) Other (NL) 47.7 9.3 61.0 (24.5 - 70.9) (0.6 - 18.1) (39.3 - 82.8) Age 18 to 24 40.5 12.3 (!) 81.2 (25.2 - 55.7) (0.4 - 24.2) (69.8 - 92.8) 25 to 49 51.0 23.7 66.8 (40.7 - 61.4) (15.2 - 32.2) (57.9 - 75.8) 25 50 to 64 43.6 21.3 (!) 59.8 (27.4 - 59.8) (3.1 - 39.5) (42.5 - 77.0) 65 and over 61.1 7.3 37.8 (38.8 - 83.3) (0.0 - 17.3) (16.2 -- 59.5) ! = Statistically unstable estimate NL = Non-Latinx Table XIII shows that 12.2% of LGBTQ+ adults who were exposed to SHS or SHV reported that they were exposed outside an LGBTQ+ bar and 15.1% reported being exposed at a public LGBTQ+ event. Table XIll. Percentages of LGBTQ+ adults who were exposed to SHS or SHV in the past 2 weeks outside a LGBTQ+ bar and at a public LGBTQ+ event by SGM status, race or ethnicity, and age Outside a Public LGBTQ+ 95% LGBTQ+ 95% Bar Confidence Event Confidence (%) Interval (%) Interval Overall LGBTQ+ adults exposed 12.2 7.8-16.5 15.1 9.2 - 21.0 SGM status Transgender or Genderqueer 18.9 (!) 4.1-33.7 18.9(!) 4.0 -33.8 Gay or Lesbian 12.1 4.0-19.3 6.4(!) 0.0-12.9 Bisexual 9.7 54-141 7.7(!) 1.1-14.4 Race or ethnicity Latinx 9.2 (!) 2.9-15.4 11.6 (!) 2.9 - 20.3 White (NL) 15.4 7.7 -23.1 8.3 (!) 1.2-15.4 Black or African American (NL) 31.5 (!) 0.1 - 63.0 15.2 (!) 0.0 - 36.0 Asian (NL) 5.7 (!) 0.0-11.8 1.9 (!) 0.0-5.3 Other (NL) 11.4 (!) 1.6-21.2 3.1 (!) 0.0-6.7 Age 18 to 24 5.2 (!) 0.6 - 5.9 2.8 (!) 0.0 -6.1 25 to 49 11.2 5.9-16.5 10.2 (!) 4.0-16.3 50 to 64 16.0 (!) 6.1 - 26.0 7.2 (!) 0.0 - 15.0 65 and over 45.3 (!) 16.9 - 73.7 28.0 (!) 0.0 - 62.1 ! = Statistically Unstable Estimate 26 NL = Non-Latinx | CESSATION Attempts to Quit Smoking Table XIV shows that 19.9% of LGBTQ+ past 12-month smokers had never tried to quit smoking in their lifetimes with around 15.9% of gay or lesbian smokers reporting that they had never tried to quit smoking. About 4 in 5 (79.5%) bisexual past 12-month smokers had tried to quit at least once in their lifetimes. Among LGBTQ+ past 12-month smokers, about 3 in 5 (60.7%) Black or African American smokers, 57.3% of Asian or Asian American smokers and 46.7% of White smokers had attempted to quit smoking between 1 to 3 times in their lifetimes. 37.6% of Latinx LGBTQ+ past 12-month smokers and 35.8% of White LGBTQ+ past 12-month smokers attempted to quit 4 or more times in their lifetimes. Table XIV. Percentages of LGBTQ+ past 12-month smokers across the number of times tried to quit smoking in their lifetimes by SGM status, race or ethnicity, and age Never 1 to 3 Times 4 Times or More % (95% Cl) % (95% Cl) % (95% Cl) LGBTQ+ Smokers 19.9 44.0 36.1 (12.1 - 24.7) (33.8 - 54.3) (27.6 - 44.5) SGM Status Transgender or 29.6 (!) 28.0 (!) 42.4 (!) Genderqueer (7.6 - 51.6) (9.5 - 46.5) (20.8 - 64.0) Gay or Lesbian 15.9 42.8 41.3 (6.8 - 25.0) (28.1 - 57.5) (26.9 - 55.7) Bisexual 20.5 (!) 49.2 30.3 (7.5 - 33.4) (34.0 - 64.5) (19.0 - 41.6) Race or Ethnicity Latinx 25.1 (!) 37.3 (!) 37.6 (7.8 - 42.4) (14.4 - 60.1) (18.4 - 56.9) White (NL) 17.5 46.7 35.8 (8.6 - 26.4) (34.1 - 59.3) (24.9 - 46.8) Black or African American 3.6 (!) 60.7 35.8 (!) (NL) (0.0 - 12.1) (31.6 - 89.9) (7.3 - 64.1) Asian or Asian American 16.1 (!) 57.3 26.6 (!) (NL) (0.0 - 42.6) (29.0 - 85.6) (1.6 - 51.5) Other (NL) 22.4 (!) 38.6 (!) 39.0 (!) (3.8 - 41.1) (13.6 - 63. 6) (15.5 - 62.4) Age 18 to 24 46.3 (!) 36.7 (!) 17.0 (!) (13.9 - 78.7) (5.1 - 68.3) (0.0 - 35.3) 27 25 to 49 13.4 48.0 38.6 (7.9 - 19.0) (35.7 - 60.2) (27.4 - 49.8) 50 to 64 12.3 (!) 35.1 52.6 (2.7 - 21.9) (18.0 - 52. 1) (34.3 - 71.0) 65 and over 31.1 (!) 45.9 23.0 (!) (5.0 - 57.1) (21.8 - 70.1) (6.9 - 39.1) ! = Statistically unstable estimate NL = Non-Latinx Relatedly, over a third (36.0%) of LGBTQ+ smokers reported that they do not have plans to quit smoking, 44.1% reported that they do plan to quit within the next 6 months and over 63.9% planned to quit within the next year (See Appendix Table Ill). Cessation Methods Table XV shows that among LGBTQ+ smokers who had tried to quit in the past 12 months, 46.8% reported using vaping products to help quit smoking. About 47.8% of gay or lesbian adults and 46.9% of bisexual adults who tried to quit used vaping products. Only a quarter (25.7%) of LGBTQ+ adults who tried to quit smoking in the past 12 months reported using nicotine replacement therapy (NRT) or prescription cessation medication. About 1 in 10 (10.7%) reported using cessation services programs at a non-LGBTQ+ specific organization. Also, about 1 in 10 (10.6%) reported using cessation services at an LGBTQ+ specific organization. Table XV. Percentages of LGBTQ+ smokers who tried to quit in the past 12 months based on cessation method used. 95% Confidence Percent (%) Interval Nicotine Replacement Therapy or Prescription Cessation Medication 25.7 15.0 - 36.4 Cessation Services Programs (LGBTQ+ Specific Org) 10.6 5.4 - 15.8 Cessation Services Programs (Non- LGBTQ+ Specific Org) 10.7 3.9 -- 17.5 Cessation Helpline 13.0 (!) 5.2 - 20.9 E-cigarettes and other Vaping Products 46.8 32.4 - 61.1 ! = Statistically Unstable Estimate Relatedly, Table XVI shows that 3 in 5 (59.3%) LGBTQ+ smokers reported that there would be no difference in their level of comfort with receiving cessation services with LGBTQ+ organizations over non-LGBTQ+ organizations, while 37.4% reported that they 28 would be more comfortable with receiving cessation services with LGBTQ+ organizations over non-LGBTQ+ organizations, and 3.3% reported they would be less comfortable. Table XVI. Percentages of LGBTQ+ smokers on level of comfort receiving cessation services with LGBTQ+ organizations over non-LGBTQ+ organizations by SGM status, race or ethnicity, and age More Comfortable Less Comfortable No Difference % (95% Cl) % (95% Cl) % (95% Cl) LGBTQ+ smokers 37.4 3.3 59.3 (27.2 - 47.2) (0.8 - 5.8) (49.3 - 69.3) SGM Status Transgender or 72.1 1.3 (!) 26.5 (!) Genderqueer (49.9 - 94.3) (0.0 - 4.5) (4.6 - 48.4) Gay or Lesbian 33.0 1.6 (!) 65.4 (19.5 - 46.6) (0.0 - 3.8) (51.8 - 79.0) Bisexual 30.6 4.9 (!) 64.5 (16.9 - 44.3) (0.5 - 9.3) (50.1 - 78.9) Race or Ethnicity Latinx 35.0 1.5 (!) 63.5 (15.1 - 55.0) (0.0 - 4.0) (43.2 - 83.8) White (NL) 32.8 4.1 (!) 63.0 (20.3 - 45.4) (0.0 - 8.6) (49.4 - 76.2) Black or African 59.6 23 (!) 38.1 (!) American (NL) (27.4 - 91.7) (0.0 - 9.1) (5.4 - 70.8) Asian (NL) 45.3 (!) 6.8 (!) 47.9 (!) (10.8 - 79.9) (0.0 - 2.3) (13.6 - 82.2) Other (NL) 55.0 3.0 (!) 42.1 (!) (27.8 - 82.2) (0.0 - 8.5) (15.4 - 68.7) Age 18 to 24 46.4 (!) 0.9 (!) 52.6 (!) (12.2 - 80.7) (0.0 - 3.1) (18.1 - 87.2) 25 to 49 36.5 4.4 (!) 59.1 (23.9 - 49.1) (0.4 - 8.4) (46.3 - 71.9) 50 to 64 37.3 0.7 (!) 62.0 (18.1 - 56.4) (0.0 - 2.2) (42.7 - 81.3) 65 and over 12.0 (!) 8.9 (!) 79.2 (0.0 - 30.7) (0.0 - 26.0) (57.3 - 100.0) ! = Statistically unstable estimate NL = Non-Latinx Barriers to Cessation In Table XVII, 17.2% of LGBTQ+ smokers indicated that they delayed or did not get NRT due to its cost in the past 12 months. Among gay or lesbian smokers, 15.9% reported cost as reason for delaying or not getting NRT and 15.8% of bisexual adults also reported cost of NRT as a barrier. About 1 in 10 (10.5%) LGBTQ+ smokers indicated that they delayed or did not seek smoking cessation programs because of perceived unfair treatment due to their sexual orientation or gender identity. Table XVII. Percentages of LGBTQ+ past-year smokers who had delayed or did not get nicotine replacement therapy due to cost or delayed or did not seek smoking cessation programs in the past year by SGM status, race or ethnicity, and age Delayed/Did Not Get Nicotine Delayed/Did Not Seek Smoking Cessation Programs Because of Perceived Unfair Replacement 95% Treatment Due to 95% Therapy Due Confidence Sexual Orientation or Confidence to Cost (%) Interval Gender Identity (%) Interval Overall LGBTQ+ Past-Year Smokers 17.2 11.9 -- 22.5 10.5 6.7 - 14.4 SGM Status Transgender or Genderqueer 26.2 (!) 7.6 - 44.8 25.6 (!) 7.3 - 43.9 Gay or Lesbian 15.9 6.9 - 24.9 4.0(!) 0.3 - 7.7 Bisexual 15.8 7.8 - 23.7 11.7 5.5 --17.8 Race or Ethnicity Latinx 16.1 (!) 5.5 - 26.8 14.5 (!) 4.6 -- 24.3 White (NL) 18.7 10.1 - 27.3 8.6 4.1-13.1 Black or African American (NL) 18.0 (!) 0.0 - 40.1 18.0 (!) 0.0 - 40.1 Asian or Asian American (NL) 23.3 (!) 0.0 - 47.9 9.1 (!) 0.0 - 23.3 Other (NL) 8.2 (!) 0.0 - 17.7 3.4 (!) 0.0 -7.9 Age 18 to 24 11.4 (!) 0.0 - 26.9 7.5 (!) 0.0 - 16.0 25 to 49 19.3 12.0 - 26.6 11.8 6.6 - 16.9 50 to 64 18.2 (!) 5.3 - 31.1 8.8 (!) 0.3 -17.3 65 and over 7.9 (!) 0.0 -17.3 10.5 (!) 0.0 - 26.3 ! = Statistically Unstable Estimate NL = Non-Latinx 30 Fears Regarding Cessation Table XVIII shows that over a third (34.4%) of LGBTQ+ smokers indicated that they had no fears regarding quitting smoking for good. About 3 in 10 (29.3%) smokers indicated concerns about withdrawal symptoms such as increased stress or anxiety, and 13.9% indicated they had fears about weight gain. Less than 10% reported they had fears regarding relapse or not being able to quit (See Appendix Table IV for Complete Table). Table XVIII. Top fears among LGBTQ+ smokers when quitting for good 95% Confidence Percent (%) Interval No Fears 34.4 24.3 - 44.5 Withdrawal Symptoms (i.e., Increased Stress or Anxiety 29.3 18.9 - 39.7 Weight Gain 13.9 8.6 - 19.2 Relapse / Not Being Able to Reach Cessation 7.1 3.3 - 10.9 Use or Increased Use of Other Substances 6.3 1.8 - 10.9 Decrease in Social Interaction with Peers 6.2 0.0 - 14.9 Other Fears 2.9 0.0 - 5.80 31 ATTITUDES ABOUT TOBACCO AND SMOKE- AND VAPE-FREE POLICIES Tobacco Products are Intentionally Designed to Appeal to Youth Table XIX shows that about 4 in 5 (80.2%) LGBTQ+ adults agree or strongly agree that flavored vaping products and other flavored tobacco products are intentionally designed to appeal to young people with 86.0% of LGBTQ+ young adults indicating agreement or strongly agreement to this statement. Table XIX. Percentage of LGBTQ+ adults who agree or strongly agree and disagree or strongly disagree whether flavored e-cigarettes and other flavored tobacco products are intentionally designed to appeal to youth by SGM status and age Agree or 95% Disagree or 95% Strongly Confidence Strongly Confidence Agree (%) Interval Disagree (%) Interval Overall LGBTQ+ Population 80.2 76.4 - 83.9 19.7 16.0 - 23.5 SGM Status Transgender or Genderqueer 83.7 73.6 - 93.8 16.3 (!) 6.2 - 26.4 Gay or Lesbian 82.1 77.0 - 87.3 17.8 12.7 - 22.9 Bisexual 76.6 69.7 - 83.6 23.2 16.2-30.1 Age 18 to 24 86.0 78.0 - 94.0 14.0 6.0 - 22.0 25 to 49 75.4 69.8 - 81.1 24.5 18.9 - 30.1 50 to 64 84.9 78.6 - 91.3 14.7 8.4 - 21.0 65 and over 84.7 73.2 - 96.3 15.0 (!) 3.5 - 26.6 ! = Statistically Unstable Estimate Banning Sales of Tobacco In Table XX, about 3 in 5 (60.8%) LGBTQ+ adults agree or strongly agree that sales of tobacco should be banned to anyone born after 2025. About 7 in 10 (71.9%) current LGBTQ+ young adults agree or strongly agree with the sales ban, followed by 58.5% of adults ages 25 to 49, 55.7% of adults ages 50 to 64, and 53.7% of older adults. 32 Table XX. Percentages of agreement and disagreement among LGBTQ+ adults regarding a sales ban on tobacco to anyone born after 2025 by SGM status and age groups Agree or 95% Disagree or 95% Strongly Confidence Strongly Confidence Agree (%) Interval Disagree (%) Interval Overall LGBTQ+ Population 60.8 56.1 -- 65.5 38.6 34.0 - 43.3 SGM Status Transgender or Genderqueer 64.7 56.1 - 65.5 35.3 21.8 - 48.9 Gay or Lesbian 63.5 57.3 - 69.8 36.3 30.0 - 42.5 Bisexual 56.2 48.3 - 64.1 42.6 34.8 - 50.3 Age Groups 18 to 24 71.9 62.6 - 81.1 28.1 18.9 - 37.4 25 to 49 58.5 51.9 - 65.1 40.6 34.1 - 47.1 50 to 64 55.7 46.8 - 64.6 44.0 35.1 - 52.9 65 and over 53.7 44.3 - 63.0 45.7 36.1 - 55.1 Tobacco Smoke- or Vape-Free and Marijuana Smoke-Free Policies In Table XXI, 65.0% of LGBTQ+ adults agree or strongly agree that apartment complexes should require all units to be cigarette smoke- and vape-free. Among those living in multi-unit buildings, about three-quarters (75.8%) of gay or lesbian adults agree or strongly agree that all apartment units should be smoke- and vape-free. About 65.4% of transgender or genderqueer adults and 58.6% of bisexual adults living in multi-unit housing also indicated they agree on such a policy. Table XXI. Percentages of agreement or disagreement among LGBTQ+ adults regarding whether apartment complexes should be tobacco smoke- and vape-free or marijuana smoke-free Apartments Should Be Smoke- and Vape-Free Apartments Should Be Marijuana-Smoke Free Overall LGBTQ+ Population SGM status Transgender or Genderqueer Agree or Disagree or Agree or Disagree or Strongly Strongly Strongly Strongly Agree Disagree Agree Disagree % (95% Cl) % (95% Cl) % (95% Cl) % (95% Cl) 65.0 34.7 87.1 12.8 (60.7 - 69.3) (30.4 - 39.0) (83.9 - 90.2) (9.6 - 15.9) 55.5 44.5 90.7 9.3 (!) (40.9 - 70.1) (29.9 - 59.1) (84.8 - 96.6) (3.4 - 15.2) 33 Gay or Lesbian 69.8 29.9 90.3 9.4 (63.7 - 75.8) (23.9 - 36.0) (86.5 - 94.1) (5.6 - 13.1) Bisexual 62.0 37.6 82.0 18.0 (55.0 - 69.0) (30.6 - 44.6) (75.6 - 88.3) (11.7 - 24.3) LGBTQ+ renters or homeowners in 67.9 32.0 84.3 15.7 multi-unit buildings (60.3 - 75.4) (24.4 - 39.5) (78.8 - 89.8) (10.2 - 21.2) SGM status Transgender or 65.4 34.6 91.8 8.2 Genderqueer (44.2 - 86.6) (13.4 - 55.8) (83.6 - 100.0) (0.0 - 16.4) Gay or Lesbian 75.8 24.0 89.1 10.8 (67.8 - 83.8) (16.0 - 32.0) (83.0 - 95.3) (4.7 - 17.0) Bisexual 58.6 41.2 75.7 24.3 (46.1 - 71.0) (28.7 - 53.7) (64.1 - 87.3) (12.7 - 35.9) Table XXI also shows that a larger proportion of LGBTQ+ adults agree or strongly agree that apartment complexes should require all units to be marijuana smoke-free compared to the proportion who support a tobacco smoke-free policy. About 9 in 10 transgender or genderqueer adults living in multi-unit complexes agree or strongly agree that apartment units should be required to be marijuana smoke-free. Around 9 in 10 gay or lesbian adults and about three-quarters (75.7%) of bisexual adults living in multi-unit complexes also agree or strongly agree on a marijuana smoke-free policy for all apartment units. Public LGBTQ+ Events Should be Free of Tobacco SHS or SHV and Marijuana SHS Table XXII shows that about a third (32.4%) of LGBTQ+ adults agree or strongly agree that public LGBTQ+ events should be cigarette smoke-free and vape-free. A higher percentage of LGBTQ+ adults (46.9%) agree or strongly agree that public LGBTQ+ events should be marijuana smoke-free and vape-free. Table XII. Percentages of LGBTQ adults who agree or strongly and disagree or strongly disagree that public LGBTQ+ events should be tobacco smoke- or vape- free and marijuana smoke-free Public LGBTQ+ Events Should Be Tobacco Smoke- and Vape-Free Public LGBTQ+ Events Should Be Marijuana Smoke-Free Disagree or Disagree or Agree or Strongly Agree or Strongly Strongly Agree Disagree Strongly Agree Disagree % (95% Cl) % (95% Cl) % (95% Cl) % (95% Cl) 34 Overall LGBTQ+ Population SGM Status Transgender or Genderqueer Gay or Lesbian Bisexual Other Attitudes About Tobacco 32.4 65.4 46.9 52.6 (28.0 - 36.7) (60.9 - 69.9) (42.4 - 51.5) (48.0 - 57.1) 33.2 63.2 36.5 63.1 (19.5 - 46.8) (49.2 - 77.2) (23.6 - 49.3) (50.2 - 76.0) 38.8 58.3 52.8 47.0 (32.5 - 45.0) (52.1 - 64.6) (46.4 - 59.2) (40.6 - 53.4) 24.2 74.8 42.8 56.3 (30.1 - 74.8) (69.0 - 80.7) (35.4 - 50.2) (48.9 - 63.7) The survey found that about 73.4% of LGBTQ+ adults agree or strongly agree that tobacco advertising targets the LGTBQ+ community. A majority (52.8%) of LGBTQ+ adults agree or strongly agree that LGBTQ+ individuals have higher smoking rates than the general population. About 56.5% of LGBTQ+ adults agree or strongly agree that vaping, "Juuling", and vaping products are a health threat to the LGBTQ+ community (See Appendix Table V). 35 | RECOMMENDATIONS Future Data Collection Collecting additional years of data will enable pooling of data and assist in analysis of other tobacco products aside from cigarettes or vaping products. For example, other tobacco products such as big cigars, little cigars, heated tobacco products, smokeless tobacco products, and hookah yielded statistically unstable estimates when data estimates were disaggregated by SGM status, race/ethnicity, or other variables of interest. Also, additional years of data may also provide larger samples of transgender, genderqueer, and nonbinary individuals, which can provide greater understanding of the experiences of gender minorities and tobacco use. The COVID-19 pandemic and governmental policies that were implemented to slow the spread of the COVID-19 outbreak may have impacted data related to secondhand exposure and location of exposure. Collecting data post-pandemic would provide better understanding of tobacco use and secondhand exposure with in-person social interactions returning to pre-pandemic levels. Modifications or Additional Questions to Consider for Future Data Collection e Alcohol Consumption: number of days having at least 1 drink in the past 30 days can be further elaborated with a question that captures the intensity of drinking (e.g., heavy drinkers vs. light drinkers) such as the number of drinks had in a day or number of days at least 1 drink in the past two weeks, in order to understand the relationship between tobacco produce use and use of other substances. e Mental Health: additional questions regarding mental health aside from "thinking about your mental health, which includes stress, depression, and problems with emotions, how many days during the past 30 days was your mental health not good?", can provide more in-depth analysis of the type of mental health stressors that may be associated with tobacco uses. e Marijuana Use: additional questions regarding the type of ways marijuana was used such as the use of vape pens or by ingestion may also provide greater 36 understanding of the relationship between tobacco and marijuana use, especially among young adults. Stigma or Discrimination: questions about stigma or discrimination experienced such as fear of coming out due to rejection from family or peers as well as ever experiencing discrimination due to sexual orientation or gender identity may provide greater understanding of stress experienced by LGBTQ+ individuals and its role in tobacco use and other health behaviors. 37 | LIST OF TERMS The definitions regarding sexual orientation and gender identity are based on the survey questionnaire. These definitions may not exhaust the full scope of terms as used by all members of the LGBTQ+ communities. Sexual Orientation Lesbian: A person who identifies as lesbian; a term used to describe someone who is attracted to women or the same gender. Gay: A person who identifies as gay; a term used to describe someone who is attracted to a man or the same gender. Bisexual: A person who identifies as bisexual; a term used to describe a person who is attracted to both men and women. Gender Gender: a multidimensional construct that links gender identity, gender expression, and social and cultural expectations about status, characteristics and behaviors with sex traits. Transgender: A person who identifies as transgender. A term used to describe a person whose current gender identity differs from the sex they were assigned at birth. Genderqueer: A person who identifies as genderqueer. A term used to describe a person who does not follow gender norms. Cisgender: A term used to describe person whose gender identity corresponds to the sex they were assigned at birth. Adult Age Groups Young adults: adults between the ages of 18 to 24 years old. Older adults: adults who are 65 years or older. Tobacco Products Big cigars: tobacco wrapped in tobacco leaf. Little cigars or cigarillos (LCC): tobacco wrapped in tobacco leaf or brown paper. Hookah: Water pipe used to smoke tobacco or something else. Heated tobacco products: tobacco in the form of heat-sticks or capsules that is heated, instead of being combusted or burned, using an electronic device. Chewing tobacco: loose leaf or ground tobacco leaves that come in a large pouch (bag) or in tins. 38 e Vapes: electronic devices like vape pens, vaping products, e-hookah, hookah pens, e- vaporizers, tanks, pods or mods used to inhale a vapor. Product Use Description e Current use: use of tobacco or other products in the past 30 days. e Ever used: use of tobacco or other products in one's lifetime. e Co-use: Use of cigarettes and at least one tobacco product within the past 30 days OR use of marijuana or some other product and at least one tobacco product within the last 30 days. e Poly-use: Use of two or more tobacco products within the past the past 30 days. Health Behavior Description e Tobacco use: use of cigarettes, vaping products or other tobacco products in the past 30 days. e Current smoker: respondent has had 100 or more cigarettes in their lifetime and smokes cigarettes daily or some days o Notacurrent smoker: smoked less than (<)100 cigarettes in lifetime or not smoke daily. 39 Endnotes 1. 10. 11. 12. 13. UCLA Center for Health Policy research. ASkCHIS 2020: current e-cigarette user status (California - adults). httos://ask.chis.ucla.edu/. Exported on March 18, 2022. UCLA Center for Health Policy Research. ASkCHIS 2020: ever smoked an e-cigarette (California - adults). https://ask.chis.ucla.edu/. Exported on March 18, 2022. American Lung Association. The LGBT community: a priority population for tobacco control. Last Updated January 11, 2022. Accessed February 3, 2022. httos://www.lung.org/policy- advocacy/tobacco/reports-resources. Tobacco Free CA. The Story of LGBTQ+. October 27, 2020. 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State-level marijuana policies and marijuana use and marijuana use disorder among a nationally representative sample of adults in the United 40 14. 15. 16. 17. 18. States, 2015-2017: sexual identity and gender matter. 2019. Drug and Alcohol Dependence 204. https://doi.org/10.1016/j.drugalcdep.2019.06.009. Tobacco Education and Research Oversight Committee. Achieving health equity: toward a commercial tobacco-free California. 2021. Accessed February 3, 2022. https://www.cdph.ca.gov/Programs/CCDPHP/DCDIC/CTCB/Pages/TEROCMasterPlan.aspx. Jannat-Khah D, Dill LJ, Reynolds AS, et. al. Stress, socializing, and other motivations for smoking among the lesbian, gay, bisexual, transgender, and queer community in New York city. 2017. American Journal of Health Promotion 32 (5):1178-1186. https://doi.org/10.1177/0890117117694449. Wolford-Clevenger C, Hill S, and Cropsey K. Correlates of tobacco and nicotine use among transgender and gender diverse people: a systematic review guided by the minority stress model. 2022. Nicotine Tob Res 24(4): 444-452. 10.1093/ntr/ntab159. Meyer IH, Russell ST, Hammack PL, et. al. Minority Stress, distress, and suicide attempts in three cohorts of sexual minority adults: a US probability sample. 2021. PLOS ONE 16(3). https://doi.org/10.137 1/journal.pone.0246827. UCLA Center for Health Policy Research. ASkCHIS 2020: ever been exposed to secondhand tobacco smoke or e-cig vapor in the last 2 weeks (California - adults). httos://ask.chis.ucla.edu/. Exported on March 18, 2022. 41