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



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


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


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


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

This is a preview of subscription content, access via your institution.


  1. 1.

    Marshal MP, et al. Individual trajectories of substance use in lesbian, gay and bisexual youth and heterosexual youth. Addiction. 2009;104(6):974–81.

    PubMed  PubMed Central  Google Scholar 

  2. 2.

    Corliss HL, et al. Sexual orientation and drug use in a longitudinal cohort study of US adolescents. Addict Behav. 2010;35(5):517–21.

    PubMed  PubMed Central  Google Scholar 

  3. 3.

    Fish JN, et al. Smoking behaviours among heterosexual and sexual minority youth? Findings from 15 years of provincially representative data. Drug and Alcohol Review. 2019;38(1):101–10.

    PubMed  Google Scholar 

  4. 4.

    Khuder SA, Dayal HH, Mutgi AB. Age at smoking onset and its effect on smoking cessation. Addict Behav. 1999;24(5):673–7.

    CAS  PubMed  Google Scholar 

  5. 5.

    Watson RJ, et al. Sexual minority youth continue to smoke cigarettes earlier and more often than heterosexuals: findings from population-based data. Drug Alcohol Depend. 2018;184:64–70.

    PubMed  Google Scholar 

  6. 6.

    Dai H. Tobacco product use among lesbian, gay, and bisexual adolescents. Pediatrics. 2017;139(4):e20163276.

    PubMed  Google Scholar 

  7. 7.

    Remafedi G, Jurek AM, Oakes JM. Sexual identity and tobacco use in a venue-based sample of adolescents and young adults. Am J Prev Med. 2008;35(6):S463–70.

    PubMed  Google Scholar 

  8. 8.

    Johnson SE, et al. Tobacco product use among sexual minority adults: findings from the 2012–2013 National Adult Tobacco Survey. Am J Prev Med. 2016;50(4):e91–e100.

    PubMed  Google Scholar 

  9. 9.

    Wheldon CW, et al. Tobacco use among adults by sexual orientation: findings from the Population Assessment of Tobacco and Health. LGBT Health. 2018;5(1):33–44.

    PubMed  PubMed Central  Google Scholar 

  10. 10.

    Hoffman L, et al. Sexual and gender minority cigarette smoking disparities: an analysis of 2016 Behavioral Risk Factor Surveillance System data. Prev Med. 2018;113:109–15.

    PubMed  Google Scholar 

  11. 11.

    Gamarel KE, et al. Sexual orientation disparities in smoking vary by sex and household smoking among US adults: findings from the 2003–2012 National Health and Nutrition Examination Surveys. Prev Med. 2016;82:1–6.

    PubMed  Google Scholar 

  12. 12.

    Vogel EA, et al. Smoking cessation intervention trial outcomes for sexual and gender minority young adults. Health Psychol. 2019;38(1):12.

    PubMed  Google Scholar 

  13. 13.

    Pachankis JE, Westmaas JL, Dougherty LR. The influence of sexual orientation and masculinity on young men’s tobacco smoking. J Consult Clin Psychol. 2011;79(2):142.

    PubMed  Google Scholar 

  14. 14.

    Emory K, et al. Intragroup variance in lesbian, gay, and bisexual tobacco use behaviors: evidence that subgroups matter, notably bisexual women. Nicotine Tob Res. 2015;18(6):1494–501.

    PubMed  PubMed Central  Google Scholar 

  15. 15.

    Day JK, et al. Transgender youth substance use disparities: results from a population-based sample. J Adolesc Health. 2017;61(6):729–35.

    PubMed  PubMed Central  Google Scholar 

  16. 16.

    Wheldon, C.W. and K.P. Wiseman, Tobacco use among transgender and gender non-conforming adults in the United States. Tobacco Use Insights, in press.

  17. 17.

    Corliss HL, et al. Sexual orientation disparities in adolescent cigarette smoking: intersections with race/ethnicity, gender, and age. Am J Public Health. 2014;104(6):1137–47.

    PubMed  PubMed Central  Google Scholar 

  18. 18.

    Wheldon, C., et al., Cigarette smoking among youth at the intersection of sexual orientation and gender identity. LGBT Health, in press.

  19. 19.

    Meyer IH. Minority stress and mental health in gay men. J Health Soc Behav. 1995:38–56.

  20. 20.

    Hendricks ML, Testa RJ. A conceptual framework for clinical work with transgender and gender nonconforming clients: an adaptation of the Minority Stress Model. Prof Psychol Res Pract. 2012;43(5):460.

    Google Scholar 

  21. 21.

    Goldbach JT, et al. Minority stress and substance use in sexual minority adolescents: a meta-analysis. Prev Sci. 2014;15(3):350–63.

    PubMed  Google Scholar 

  22. 22.

    Almeida J, et al. Emotional distress among LGBT youth: the influence of perceived discrimination based on sexual orientation. Journal of Youth and Adolescence. 2009;38(7):1001–14.

    PubMed  PubMed Central  Google Scholar 

  23. 23.

    Bontempo DE, d’Augelli AR. Effects of at-school victimization and sexual orientation on lesbian, gay, or bisexual youths’ health risk behavior. J Adolesc Health. 2002;30(5):364–74.

    PubMed  Google Scholar 

  24. 24.

    Bouris A, et al. Effects of victimization and violence on suicidal ideation and behaviors among sexual minority and heterosexual adolescents. LGBT health. 2016;3(2):153–61.

    PubMed  PubMed Central  Google Scholar 

  25. 25.

    Goldbach JT, Gibbs JJ. A developmentally informed adaptation of minority stress for sexual minority adolescents. J Adolesc. 2017;55:36–50.

    PubMed  Google Scholar 

  26. 26.

    Katz-Wise SL, Rosario M, Tsappis M. LGBT youth and family acceptance. Pediatrics Clinical North America. 2016;63(6):1011–25.

    Google Scholar 

  27. 27.

    Newcomb ME, Heinz AJ, Mustanski B. Examining risk and protective factors for alcohol use in lesbian, gay, bisexual, and transgender youth: a longitudinal multilevel analysis. Journal of Studies on Alcohol and Drugs. 2012;73(5):783–93.

    PubMed  PubMed Central  Google Scholar 

  28. 28.

    Ryan C, et al. Family acceptance in adolescence and the health of LGBT young adults. Journal of Child and Adolescent Psychiatric Nursing. 2010;23(4):205–13.

    PubMed  Google Scholar 

  29. 29.

    Padilla YC, Crisp C, Rew DL. Parental acceptance and illegal drug use among gay, lesbian, and bisexual adolescents: results from a national survey. Soc Work. 2010;55(3):265–75.

    PubMed  Google Scholar 

  30. 30.

    Rosario M, Schrimshaw EW, Hunter J. Disclosure of sexual orientation and subsequent substance use and abuse among lesbian, gay, and bisexual youths: critical role of disclosure reactions. Psychol Addict Behav. 2009;23(1):175.

    PubMed  PubMed Central  Google Scholar 

  31. 31.

    Russell ST, et al. Adolescent health and harassment based on discriminatory bias. Am J Public Health. 2012;102(3):493–5.

    PubMed  PubMed Central  Google Scholar 

  32. 32.

    Watson RJ, Wheldon CW, Puhl RM. Evidence of diverse identities in a large national sample of sexual and gender minority adolescents. J Res Adolesc. 2019.

  33. 33.

    Puhl RM, Himmelstein MS, Watson RJ. Weight-based victimization among sexual and gender minority adolescents: findings from a diverse national sample. Pediatric Obesity. 2019:e12514.

  34. 34.

    Ryan C, et al. Family rejection as a predictor of negative health outcomes in white and Latino lesbian, gay, and bisexual young adults. Pediatrics. 2009;123(1):346.

    PubMed  Google Scholar 

  35. 35.

    Gamarel KE, Mitchell JW. Comparisons between smoking patterns among sexual minority females and males in romantic relationships. Health Educ Behav. 2019;46(1):176–84.

    PubMed  Google Scholar 

  36. 36.

    Brener, N.D., et al., Centers for Disease Control and Prevention (CDC). Methodology of the youth risk behavior surveillance system–2013. MMWR Recomm Rep, 2013. RR-1: p. 1–20.

  37. 37.

    Procidano ME, Heller K. Measures of perceived social support from friends and from family: three validation studies. Am J Community Psychol. 1983;11(1):1–24.

    CAS  PubMed  Google Scholar 

  38. 38.

    Thompson JK, et al. The perception of teasing scale (POTS): a revision and extension of the physical appearance related teasing scale (PARTS). J Pers Assess. 1995;65(1):146–57.

    CAS  PubMed  Google Scholar 

  39. 39.

    Friedman MS, et al. A meta-analysis of disparities in childhood sexual abuse, parental physical abuse, and peer victimization among sexual minority and sexual nonminority individuals. Am J Public Health. 2011;101(8):1481–94.

    PubMed  PubMed Central  Google Scholar 

  40. 40.

    Hawkins JD, Catalano RF, Miller JY. Risk and protective factors for alcohol and other drug problems in adolescence and early adulthood: implications for substance abuse prevention. Psychol Bull. 1992;112(1):64.

    CAS  PubMed  Google Scholar 

  41. 41.

    Buchting, F.O., W.L. Furmanski, and J.G. Lee, MPOWERED: best and promising practices for LGBT tobacco prevention and control document. 2012, Ft. Lauderdale, FL: The Network for LGBT Health Equity.

  42. 42.

    Stevens P, Carlson LM, Hinman JM. An analysis of tobacco industry marketing to lesbian, gay, bisexual, and transgender (LGBT) populations: strategies for mainstream tobacco control and prevention. Health Promot Pract. 2004;5(suppl 3):129S–34S.

    PubMed  Google Scholar 

  43. 43.

    Washington HA. Burning love: big tobacco takes aim at LGBT youths. Am J Public Health. 2002;92(7):1086–95.

    PubMed  PubMed Central  Google Scholar 

  44. 44.

    Remafedi G. Lesbian, gay, bisexual, and transgender youths: who smokes, and why? Nicotine Tob Res. 2007;9(Suppl 1):S65–71.

    PubMed  Google Scholar 

  45. 45.

    Newcomb ME, La Sala BA, Mustanski B, Prado G, Schrager SM, Huebner DM. The influence of families on LGBTQ youth health: a call to action for innovation in research and intervention development. LGBT Health. 2019;1(4):139–45.

    Google Scholar 

  46. 46.

    Gamarel KE, Meriesh EH, Manning D, Iwamoto M, Operario D, Nemoto T. Minority stress, smoking patterns, and cessation attempts: findings from a community-sample of transgender women in the San Francisco Bay Area. Nicotine Tob Res. 2015;18(3):306–13.

    PubMed  PubMed Central  Google Scholar 

  47. 47.

    Gamarel KE, Neilands TB, Dilworth SE, Taylor JM, Johnson MO. Smoking, internalized heterosexism, and HIV disease management among male couples. AIDS Care. 2015;75(5):649–54.

    Google Scholar 

  48. 48.

    Das JK, Salam RA, Finkelstein Y, Bhutta ZA. Interventions for adolescent substance abuse: an overview of systematic reviews. J Adolesc Health. 2016;59(4):S61–75.

    PubMed  PubMed Central  Google Scholar 

  49. 49.

    Van Ryzin MJ, Roseth CJ, Fosco GM, Lee Y-K, Chen I-C. A component-centered mental-analysis of family-based prevention programs for adolescent substance use. Clin Psychol Rev. 2016;45:72–80.

    PubMed  PubMed Central  Google Scholar 

  50. 50.

    Stephenson, R, Todd, K., Kahle, E., Sullivan, S.P., Miller-Perusse, M., Sharma, A., Horvath, K., Project Moxie: results of a feasibility study of a telehealth intervention to increase HIV testing among binary and nonbinary transgender youth. AIDS and Behavior, 2019.

Download references


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


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

Author information



Corresponding author

Correspondence to Kristi E. Gamarel.

Ethics declarations

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

Conflict of Interest

The authors declare that they have no conflict of interest.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Electronic Supplementary Material


(DOCX 38 kb)

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Gamarel, K.E., Watson, R.J., Mouzoon, R. et al. Family Rejection and Cigarette Smoking Among Sexual and Gender Minority Adolescents in the USA. Int.J. Behav. Med. 27, 179–187 (2020).

Download citation


  • Sexual and gender minorities
  • Adolescents
  • Smoking
  • Family rejection