GREENWOOD ET AL. RESPOND

Abstract

We agree that disparities in health (e.g., physical, behavioral, mental) can indeed be thought of in terms of sexual orientation and gender identification as well as in terms of race/ethnicity. The data reported by Archer and colleagues are consistent with other studies showing that lesbian, gay, bisexual, and transgendered (LGBT) populations experience higher rates of smoking than others.1 Beyond measuring the prevalence of tobacco use, however, we have few data on consumption patterns and rates of tobacco cessation for LGBT populations similar to those that are available for the general population. To address such questions large-scale data sets are typically needed, particularly when they take into account the intersections of race, class, and access to health care to model smoking and cessation outcomes for LGBT populations. The addition of sexual orientation and gender identification questions to ongoing large-scale tobacco use surveys is an essential first step toward addressing LGBT disparities in tobacco use. Furthermore, as Archer and colleagues note, tobacco misuse is just one of a cluster of comorbid conditions that appear to be more prevalent in LGBT populations than in the general population: depression,2 substance abuse,3 HIV/AIDS,4 victimization,5 and childhood trauma.6 These health conditions are known not only to coexist but to interact and amplify each other’s effects in classic syndemic fashion.7 It is possible that reducing the prevalence of these co-occurring problems in LGBT populations might result in a parallel decline in prevalence of tobacco use. At a minimum, it is important that national, state, and local tobacco control efforts work in partnership with LGBT populations to take full advantage of current best-practice models of effective tobacco control programs,8 which include multilevel efforts designed to reduce tobacco-related morbidity and mortality. Finally, in addition to the influence of the tobacco industry’s targeting of LGBT populations, it is important to identify other risk and protective factors associated with smoking and quitting for LGBT smokers. For example, tobacco (and other health) disparities in the LGBT population are likely related to high levels of societal discrimination and daily stress.9 Research is needed to uncover how identity (gender, sexual, and ethnic), socioeconomic status, and other key individual, interpersonal, social, and environmental factors combine to contribute to tobacco use and cessation. In addition, we need to know more about the resilience that helps some LGBT individuals remain smoke-free.