Elsevier

Health & Place

Volume 58, July 2019, 102069
Health & Place

Tobacco use in the sexual borderlands: The smoking contexts and practices of bisexual young adults

https://doi.org/10.1016/j.healthplace.2018.12.010Get rights and content

Highlights

  • Bisexual people use tobacco at particularly high rates.

  • We explored the everyday smoking contexts and practices of bisexual young adults.

  • Real-time surveys, location tracking, and map-led interviews were employed.

  • Spatio-temporal patterns and situational predictors of smoking were described.

  • The meaning and roles of smoking in differently sexualized spaces were revealed.

Abstract

Little is known about why bisexual people use tobacco at higher rates than any other sexual identity group. Non-binary sexualities, such as bisexuality, exist within the socially constructed borderland between homosexuality and heterosexuality. Exploration of the everyday smoking contexts and practices of bisexual individuals may reveal unique mechanisms driving tobacco use. We employed a novel mixed method, integrating real-time, smartphone-administered surveys of (non)smoking situations, location tracking, spatial visualization of participant data, and subsequent map-led interviews. Participants (n = 17; ages 18–26, California) identified as bisexual, pansexual, and/or queer. Most were cisgender women. Survey smoking patterns and situational predictors were similar to other young adults’. However, interviews revealed unique roles of tobacco use in participants’ navigation of differently sexualized spaces in everyday life: 1) stepping away from uncomfortable situations related to bisexual identity; 2) facilitating belonging to LGBTQ+ community; and 3) recovering from bisexual identity perception management. Similar studies can examine the place-embedded practices and spatio-temporal patterns of other substance use and other stigmatized identity experiences.

Introduction

Little is known about why bisexual people are more likely to use tobacco than any other sexual identity group. A recent national United States survey found that 42% of bisexual individuals use at least one tobacco product, compared to 25% of heterosexuals, 30% of gay men, and 30% of lesbian women (Emory et al., 2016). These disparities are present also for cigarette use alone, with 20% of heterosexuals, 29% of gay men, 27% of lesbian women, and 37% of bisexuals reporting cigarette smoking (Emory et al., 2016). A growing body of health disparities research has found persistently high rates of tobacco use among bisexual adolescents and adults (Boehmer et al., 2012, Corliss et al., 2013, Fallin et al., 2015a, Fallin et al., 2015b). Bisexuals start smoking at younger ages than other sexual identity groups (Corliss et al., 2013), and disparities in tobacco and alcohol use between sexual minority and heterosexual youth appear to not only persist but escalate as they transition from adolescence into young adulthood (Marshal et al., 2012). Among bisexuals, women and girls have especially pronounced risk for tobacco use and other risky behaviors (e.g., binge drinking) (Fallin et al., 2015a, Fallin et al., 2015b). Attending to the tobacco use behaviors of young bisexual women and girls is particularly pressing, as disparities in tobacco use for sexual minority girls appear to be widening over time rather than closing, as observed among sexual minority boys (Watson et al., 2018).

Bisexuality is the fastest growing sexual identity in the United States, especially among younger populations (Copen et al., 2016). It is crucial to address tobacco use among young adults, as this age group has higher smoking rates (28%) than the general American population (24%) (Jamal et al., 2014), and quitting smoking before age 30 avoids most health consequences of tobacco use (U.S. Department of Health and Human Services, 2014). Among young American adults, sexual minorities are more likely to report smoking than their heterosexual young adult peers (Li et al., 2018). Furthermore, bisexual women under age 50 have greater odds of smoking than those over age 50 (Boehmer et al., 2012). Although a variety of sexual identities are used by individuals to express their attraction to more than one gender (e.g., pansexual, queer, fluid), we employ the term ‘bisexual’ in this paper to refer to all non-binary sexual identities so as to avoid confusion with non-binary gender identity (e.g., gender queer).

Smoking disparities among bisexuals exemplify the increasing concentration of tobacco use and associated health risks within socio-economically disadvantaged and/or stigmatized groups and places (Pearce et al., 2012). There is growing interest in understanding the role of context in the persistence of these “smoking islands” (Thompson et al., 2007) that remain after decades of broad anti-tobacco interventions (Barnett et al., 2017). Calls have been made for examining not only area-level effects on tobacco use, (e.g., Moon,'s et al., 2012 study on residential segregation), but also the social contexts, social practices, and meanings of tobacco use from the perspectives of smokers themselves (e.g., Blue et al., 2016; Poland et al., 2006; Frohlich et al., 2002; Tan, 2012). Nonetheless, the unique drivers of tobacco use for bisexuals have largely gone uninvestigated (Blosnich et al., 2013), and bisexuality has received little attention in geographies of sexualities (see, as exceptions, Hemmings, 2002; Weier, 2018; McLean, 2003; Maliepaard, 2015).

In-depth understanding of how and why high rates of smoking persist among bisexual people is needed to develop interventions to reduce associated health disparities (Blosnich et al., 2013, Lee et al., 2009). Explanations for the persistence of high smoking rates among sexual and gender minorities as a group, in other words lesbian, gay, bisexual, transgender, queer (LGBTQ) individuals, include: having smokers in one's peer network (Remafedi, 2007), the role of bars in sexual and gender minority communities and the reinforcing effects of alcohol and nicotine (Blosnich et al., 2013, McKee et al., 2004), tobacco retail and marketing density in neighborhoods with concentrations of same-sex couples (Lee et al., 2016), and targeted tobacco marketing campaigns (Stevens et al., 2004). The minority stress model (Meyer, 2003) has been particularly influential in LGBTQ tobacco research (Blosnich et al., 2013). It focuses on processes through which prejudice, stigma, and discrimination contribute to poor mental health, including experience of prejudice events, expectations of rejection, hiding and concealing, internalized homophobia, and ameliorative coping processes. These types of events link to smoking, as smokers often report experiencing smoking as a helpful way to cope with stressful events (Antin et al., 2017). In addition to understanding tobacco initiation among LGBTQ+ individuals, reasons for continuing to smoke warrant attention, particularly among young adults, whose light and intermittent smoking is highly influenced by social context (Thrul et al., 2014; Glenn et al., 2017; Nichter et al., 2010).

The unique experiences of people with non-binary sexual identities, like bisexuality, in navigating everyday contexts may help explain their higher smoking rates. The metaphor of the “sexual borderland” is helpful in this regard (Callis, 2014). Popular views of sexuality in Western societies have long maintained a firm binary construction wherein sexualities are either normal (heterosexual; attracted only to the opposite sex) or abnormal (homosexual; attracted only to the same sex) (Brown et al., 2007). Recently, more individuals are stepping outside monosexual identity categories to claim labels that better align with their attraction to more than one gender, such as bisexual, pansexual, queer, fluid, and ambisexual (Copen et al., 2016).

A growing body of literature outside geography has documented experiences of navigating the “ambiguous both-and-neither-place” (Callis, 2014) at the border between heterosexual and homosexual identities (Davidson et al., 1997, Shokeid, 2002, Lingel, 2009). This literature highlights how bisexual people risk social invisibility as their identity is often misread as gay or straight in different settings due to assumptions that everyone is attracted either to men or women. Within academic literature, bisexual identities (as well as transgender and gender non-conforming identities) are most often subsumed into a general ‘sexual and gender minority’ group along with lesbian and gay individuals, rendering the experiences of these groups invisible (see, for example, a recent review of scholarship concerning tobacco use among sexual and gender minorities by Blosnich et al., 2013). The absence of a ‘bisexual community’ that is felt by many bisexual individuals compounds these experiences of invisibility (McLean, 2003, Weier, 2018).

Many bisexual individuals experience a ‘twice rejection’ from both the straight population for being ‘too homosexual’, and from the gay/lesbian population for being ‘too straight’, and are exposed to stereotypes of bisexual identities, such as being closeted homosexuals or attention-seeking heterosexuals, diseased (in the case of bisexual men), and untrustworthy ‘lesbian heartbreakers’ (in the case of bisexual women) (see, for overview, Callis, 2013; Callis, 2014).

Building on largely theoretical work on bisexual identities and space (Maliepaard, 2015, Hemmings, 2002), geographers have recently begun to explore the experiences of bisexual individuals as they move through space and time in everyday life and interact with various contexts (McLean, 2003, Weier, 2018). These studies have drawn inspiration from work on geographies of sexualities that examines how spaces and places are sexualized, and how norms and categories of gender, sex, and sexuality are deployed and performed within different spaces (Browne, 2006, Oswin, 2008, Brown et al., 2007, Binnie, 1997, Namaste, 1996). The tensions between power and sexuality and the (self-) disciplining of the individual to conform to social norms underpins many of these works (Foucault, 1978). A case study of the everyday geographies of bisexual Canadian men (McLean, 2003) found that experiences and practices associated with sexual identity were compartmentalized and shifted across space and time depending on the normative expectations of heterosexual versus homosexual settings. Some of these men felt that their identity was contingently ‘fixed’ to either homosexuality or heterosexuality depending on the gender of their current partner. A case study of young bisexual individuals (ages 19–35) in the American Midwest (Weier, 2018) highlighted the undesirability and/or invisibility of bisexuality within gay spaces due to the ‘policing’ of these spaces for homonormative ideals.

These studies provide insight into the everyday social contexts of bisexual individuals, and suggest ways in which tobacco use practices (Blue et al., 2016) interplay with navigation of everyday life. Studies of tobacco use practices have found that individuals use tobacco to create a protected time to rest and reflect during everyday routines, transition from one context or activity to another, ease social interactions, self-soothe, and cope with crisis (McQuoid et al., 2018a; Graham, 1993; Antin et al., 2017; Gough et al., 2009; Keane, 2002). The relationship between experiences of acute stress and desire to smoke is also acknowledged in accounts of smoking practices (e.g., Antin et al., 2017). These everyday affordances of tobacco use may lend tobacco to helping bisexually-identified individuals negotiate and transition between homosexual/heterosexual spaces, given their unique position on the sexual borderlands between straight and gay/lesbian identities.

This article works toward explaining why bisexuals’ smoking rates are even higher than their gay and lesbian counterparts’ by exploring the everyday smoking contexts and practices of bisexual young adults. We employed a novel mixed method that integrates collection of real-time surveys of (non)smoking situations, spatial visualization of participant data, and in-depth interviews guided by maps of participants’ own data (see McQuoid et al., 2018b). Our study included 17 young adults (ages 18–26) in the San Francisco Bay Area who identify as bisexual, pansexual, and/or queer and regularly use cigarettes. Most were cisgender female identified. We asked: 1) Where are participants’ smoking and craving episodes concentrated in everyday life? 2) What contextual factors and place-based practices drive spatial and temporal patterns of smoking? and 3) How, if at all, does bisexual identity interplay with these contextual factors and place-based practices of smoking?

Section snippets

Study design

We piloted a geographically explicit ecological momentary assessment (GEMA) mixed method (McQuoid et al., 2018b). Ecological momentary assessment (EMA) methods employ “repeated collection of real-time data on subjects' behavior and experience in their natural environments,” (Shiffman et al., 2008, 3). A variety of data collection tools are used, including written diaries and cell phones, with which participants repeatedly report on factors such as their current state, activities, and

Patterns of tobacco use

The GEMA data provided a sketch of the situations in which the sample as a whole most often smoked (Table 2). Participants contributed a total of 961 cigarette reports (avg. 56.6 per participant). Most of these were reported in the evening or at night, followed by afternoons, and mornings.

Cigarette reports resulted in 445 completed smoking surveys (avg. 26.2 per participant). Most surveys were completed at home. Other frequent locations included other's homes, vehicles, and the workplace.

Discussion

This study offers initial insight into the mechanisms driving high tobacco use rates among people with bisexual identities by examining the everyday smoking contexts and practices of a group of bisexual, pansexual, and queer-identified young adults in the San Francisco Bay Area. The geographically explicit ecological momentary assessment (GEMA) mixed method (McQuoid et al., 2018b) allowed us to ‘accompany’ participants as they moved through space and time in their everyday routines and provided

Conclusion

Tobacco use appears to play a unique role in navigating everyday journeys through space and time for many young bisexually-identified people. This study is among the first to work toward explaining and contextualizing bisexual smoking disparities. Future research should further examine the interplay between place-embedded tobacco use practices and sexual identity in other settings, compare bisexual tobacco use experiences and patterns with those of heterosexuals and gays/lesbians to better

Acknowledgements

We are grateful to the individuals who participated in this study and Carson Benowitz-Fredericks for research coordination. This work was supported by the National Cancer Institute under Grant T32 CA113710 and Grant U01 CA154240, and the California Tobacco Related Disease Research Program under Grant TRDRP 25FT-0009.

Declaration of interest

Dr. Ramo has consulted to Carrot, Inc which makes a tobacco cessation device.

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