Smoking-Attributable Doctor Visits and Emergency Room Utilization and Costs by California's Lesbian, Gay, and Bisexual Community.

The lesbian, gay, and bisexual (LGB) community is known to smoke at greater rates than the general population, but there has been no study estimating the impact of cigarette smoking on healthcare utilization and costs in the LGB population. Using data from the 2005-2014 California Health Interview Surveys, we determine smoking-attributable healthcare utilization and costs among California's LGB-identified community. Our findings indicate that lesbian/bisexual women who smoke incur excess doctor visits and emergency room visits compared to their never smoking counterparts. No statistically significant differences were found for gay/bisexual men. Annual smoking-attributable costs were $58.3 million for the California LGB community (2019 dollars).

Deaths from smoking and from HIV/AIDS among gay and bisexual men in California, 2005-2050.

INTRODUCTION: Deaths from HIV/AIDS have long been of concern to the gay community, but less attention has focused on smoking-attributable deaths despite the relatively high smoking rates among gay and bisexual men. This study compared deaths from HIV/AIDS with smoking-attributable deaths among California gay and bisexual men from 2005 to 2050. METHODS: Smoking-attributable fractions (SAFs) were estimated using smoking prevalence for gay and bisexual men from the 2011-2014 California Health Interview Surveys and published relative risks of death. Smoking-attributable deaths were calculated by multiplying the SAFs by deaths among gay and bisexual men. Deaths from HIV/AIDS among men who have sex with men was obtained from the California Department of Public Health. Future deaths from smoking and HIV/AIDS were projected using regression equations based on time trends. RESULTS: From 2005 to 2014, smoking caused over 6800 deaths among gay and bisexual men, while nearly 9500 died from HIV/AIDS. Mortality from both causes has been falling, but deaths from HIV/AIDS have been falling more rapidly. Projections suggest that in the mid-2040s, more gay/bisexual men will die from smoking than from HIV/AIDS. CONCLUSION: Smoking will surpass HIV/AIDS as a cause of death among gay and bisexual men in California within a few decades. The lesbian, gay, bisexual and transgender (LGBT) community was highly effective in drawing attention and resources to the fight against HIV/AIDS, saving untold lives by hastening effective treatments. Lessons learnt in the fight against AIDS should be used to help fight the tobacco epidemic.

Sexual Identity Disparities in Smoking and Secondhand Smoke Exposure in California: 2003-2013.

OBJECTIVES: To determine smoking prevalence, smoking behavior, and secondhand smoke (SHS) exposure of lesbian, gay, and bisexual (LGB)-identified Californians; compare these with that of heterosexuals; and analyze changes over time. METHODS: We analyzed self-reported variables from 111 965 heterosexual, 1667 lesbian, and 1706 bisexual women, and 79 881 heterosexual, 2505 gay, and 911 bisexual men, aged 18 to 70 years, in the 2003-2013 California Health Interview Surveys. RESULTS: Sexual minority women had higher smoking prevalence, and female bisexual smokers were less likely to be light smokers, than heterosexuals. Smoking prevalence was higher among sexual minority men, and gay smokers were more likely to be daily smokers than were heterosexuals; and male bisexual smokers were more likely to be light smokers than were gay or heterosexual smokers. Sexual minority adults were more likely to have SHS exposure at home than were heterosexuals. Current smoking prevalence decreased annually 4% and 7% for lesbian and bisexual women, and 5% and 6% for gay and bisexual men, respectively. Exposure to SHS fell an average of 11% annually for sexual minority men and women. CONCLUSIONS: Sexual identity disparities in smoking and SHS exposure exist in California, with bisexuals particularly at risk.

Smoking or My Job? US Media Coverage of Nonsmoker-Only Hiring Policies.

OBJECTIVES: Media advocacy plays a critical role in tobacco control, shaping the content of news in ways that generate public support for tobacco control. We examined US media coverage of nonsmoker-only hiring policies, which have little US public support, exploring the extent to which tobacco control advocates and experts have engaged the media on this controversial issue. METHODS: We searched online media databases (Lexis Nexis, Access World News, and Proquest) for articles published from 1995-2013, coding retrieved items through a collaborative, iterative process. We analyzed the volume, type, provenance, prominence, content and slant of coverage. RESULTS: We found 1,159 media items on nonsmoker-only hiring policies, most published in local newspapers in regions where such policies were enacted. The most common reason given for implementing such policies was to reduce healthcare costs. Most news items offered reasons both to support and oppose such policies; thus, the slant of the majority of news items was neutral or mixed. Tobacco control advocates or experts were infrequently cited or quoted in news items, and rarely authored opinion pieces. Those who expressed opinions were more likely to support than oppose nonsmoker-only hiring policies, for economic and health reasons. Ethical concerns about the policies were seldom raised. CONCLUSIONS: As presented in the media, nonsmoker-only hiring policies were primarily framed in terms of business cost savings and had little connection to health initiatives. Tobacco control advocates were rarely quoted and their positions were not consistent. Given their intrusiveness and the lack of strong evidence that such business policies actually do improve worker health, tobacco control advocates may feel that the status quo is preferable to engaging on a policy that the majority of Americans dislike.

"Tired of watching customers walk out the door because of the smoke": a content analysis of media coverage of voluntarily smokefree restaurants and bars.

BACKGROUND: News media are key sources of information regarding tobacco issues, and help set the tobacco control policy agenda. We examined US news coverage of voluntarily smokefree restaurants and bars in locales without mandatory policies to understand how such initiatives are perceived. METHODS: We searched three online media databases (Access World News, Lexis Nexis, and Proquest) for all news items, including opinion pieces, published from 1995 to 2011. We coded retrieved items quantitatively, analyzing the volume, type, provenance, prominence, and content of news coverage. RESULTS: We found 986 news items, most published in local newspapers. News items conveyed unambiguous support for voluntarily smokefree establishments, regardless of venue. Mandatory policies were also frequently mentioned, and portrayed positively or neutrally. Restaurant items were more likely to mention health-related benefits of going smokefree, with bar items more likely to mention business-related benefits. CONCLUSION: Voluntary smokefree rules in bars and restaurants are regarded by news media as reasonable responses to health and business-based concerns about worker and customer exposure to secondhand smoke. As efforts continue to enact comprehensive smokefree policies to protect all in such venues, the media are likely to be supportive partners in the advocacy process, helping to generate public and policymaker support.

"A breath of fresh air worth spreading": media coverage of retailer abandonment of tobacco sales.

OBJECTIVES: Media play an important role in the diffusion of innovations by spreading knowledge of their relative advantages. We examined media coverage of retailers abandoning tobacco sales to explore whether this innovation might be further diffused by media accounts. METHODS: We searched online media databases (Lexis Nexis, Proquest, and Access World News) for articles published from 1995 to 2011, coding retrieved items through a collaborative process. We analyzed the volume, type, provenance, prominence, and content of coverage. RESULTS: We found 429 local and national news items. Two retailers who were the first in their category to end tobacco sales received the most coverage and the majority of prominent coverage. News items cited positive potential impacts of the decision more often than negative potential impacts, and frequently referred to tobacco-caused disease, death, or addiction. Letters to the editor and editorials were overwhelmingly supportive. CONCLUSIONS: The content of media coverage about retailers ending tobacco sales could facilitate broader diffusion of this policy innovation, contributing to the denormalization of tobacco and moving society closer to ending the tobacco epidemic. Media advocacy could increase and enhance such coverage.

"They're going to die anyway": smoking shelters at veterans' facilities.

Military personnel and veterans are disadvantaged by inadequate tobacco control policies. We conducted a case study of a Department of Veterans Affairs (VA) effort to disallow smoking and tobacco sales in VA facilities. Despite strong VA support, the tobacco industry created a public relations-focused grassroots veterans' opposition group, eventually pushing the US Congress to pass a law requiring smoking areas in every VA health facility. Arguing that it would be unpatriotic to deny veterans this "freedom" they had ostensibly fought for and that banning smoking could even harm veterans' health, industry consultants exploited veterans' organizations to protect tobacco industry profits. Civilian public health advocates should collaborate with veterans to expose the industry's manipulation, reframe the debate, and repeal the law.

Forcing the Navy to sell cigarettes on ships: how the tobacco industry and politicians torpedoed Navy tobacco control.

In 1986, the US Navy announced the goal of becoming smoke-free by 2000. However, efforts to restrict tobacco sales and use aboard the USS Roosevelt prompted tobacco industry lobbyists to persuade their allies in Congress to legislate that all naval ships must sell tobacco. Congress also removed control of ships' stores from the Navy. By 1993, the Navy abandoned its smoke-free goal entirely and promised smokers a place to smoke on all ships. Congressional complicity in promoting the agenda of the tobacco industry thwarted the Navy's efforts to achieve a healthy military workforce. Because of military lobbying constraints, civilian pressure on Congress may be necessary to establish effective tobacco control policies in the armed forces.

"Willful misconduct": how the US government prevented tobacco-disabled veterans from obtaining disability pensions.

In this descriptive case study, we analyze the unsuccessful struggle to access disability pensions by veterans sickened by tobacco use begun during service. Drawing on tobacco industry documents and other material, we show how the US government, tobacco industry, and veterans' organizations each took inconsistent positions to protect their interests. Congress and Department of Veterans Affairs leadership, concerned about costs, characterized veterans' smoking as "willful misconduct," thereby contradicting the government's position in a federal lawsuit that tobacco companies addicted smokers. Veterans' groups supported the pensions, despite previously defending smoking as a "right." The tobacco industry wavered, fearing liability. Securing pensions was complicated by the notion that smoking is primarily a personal choice. The US government should compensate veterans fairly and should abolish military practices that encourage tobacco addiction.

"If you know you exist, it's just marketing poison": meanings of tobacco industry targeting in the lesbian, gay, bisexual, and transgender community.

In the public health literature, it is generally assumed that the perception of "targeting" as positive or negative by the targeted audience depends on the product or message being promoted. Smoking prevalence rates are high among lesbian, gay, bisexual, and transgender (LGBT) individuals, but little is known about how they perceive tobacco industry targeting. We conducted focus groups with LGBT individuals in 4 US cities to explore their perceptions. Our findings indicated that focus group participants often responded positively to tobacco company targeting. Targeting connoted community visibility, legitimacy, and economic viability. Participants did not view tobacco as a gay health issue. Targeting is a key aspect of corporate-community interaction. A better understanding of targeting may aid public health efforts to counter corporate disease promotion.

Is tobacco a gay issue? Interviews with leaders of the lesbian, gay, bisexual and transgender community.

This study examined the extent of tobacco industry funding of lesbian, gay, bisexual and transgender (LGBT) organisations and whether leaders of these organisations thought tobacco was a priority health issue for their community. We interviewed leaders of 74 LGBT organisations and publications in the USA, reflecting a wide variety of groups. Twenty-two percent said they had accepted tobacco industry funding and few (24%) identified tobacco as a priority issue. Most leaders did not perceive tobacco as an issue relevant to LGBT identity. They saw smoking as a personal choice and individual right rather than as a health crisis fuelled by industry activities. As such, they were reluctant to judge a legal industry, fearing it might lead to having to evaluate other potential funders. They saw tobacco control as divisive, potentially alienating their peers who smoke. The minority who embraced tobacco control saw the industry as culpable and viewed their own roles as protecting the community from all harms, not just those specific to the gay community. Lesbian, gay, bisexual and transgender tobacco-control advocates should reframe smoking as an unhealthy response to the stresses of homophobia to persuade leaders that tobacco control is central to LGBT health.

Pictures worth a thousand words: noncommercial tobacco content in the lesbian, gay, and bisexual press.

Smoking prevalence in the lesbian, gay, and bisexual (LGB) community is higher than in the mainstream population. The reason is undetermined; however, normalization of tobacco use in the media has been shown to affect smoking rates. To explore whether this might be a factor in the LGB community, we examined noncommercial imagery and text relating to tobacco and smoking in LGB magazines and newspapers. Tobacco-related images were frequent and overwhelmingly positive or neutral about tobacco use. Images frequently associated smoking with celebrities. Text items unrelated to tobacco were often illustrated with smoking imagery. Text items about tobacco were likely to be critical of tobacco use; however, there were three times as many images as text items. The number of image items was not accounted for by the number of text items: nearly three quarters of all tobacco-related images (73.8%) were unassociated with relevant text. Tobacco imagery is pervasive in LGB publications. The predominant message about tobacco use in the LGB press is positive or neutral; tobacco is often glamorized. Noncommercial print images of smoking may normalize it, as movie product placement does. Media advocacy approaches could counter normalization of smoking in LGB-specific media.

What makes an ad a cigarette ad? Commercial tobacco imagery in the lesbian, gay, and bisexual press.

OBJECTIVES: To determine the extent of commercial tobacco imagery in the lesbian, gay, and bisexual (LGB) press. METHODS: Content analysis of all advertising containing tobacco related text or imagery in 20 LGB community periodicals, published between January 1990 and December 2000. RESULTS: 3428 ads were found: 689 tobacco product ads, 1607 ads for cessation products or services, 99 ads with a political message about tobacco, and 1033 non-tobacco ads that showed tobacco (NAST). Although cessation ads were numerically dominant, tobacco product ads and NAST occupied more space and were more likely to use images. NAST almost never had an anti-tobacco message. Formal sponsorship between tobacco and other companies was very rare. Lesbian periodicals had proportionally more NAST and fewer cessation ads. CONCLUSIONS: Cigarette ads were outnumbered by NAST. Although these ads do not usually show brands, and are unlikely to be the result of formal sponsorship agreements, they may be "selling" smoking. Tobacco control advocates should persuade editors to refuse tobacco product ads and those with gratuitous tobacco imagery.