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research-article2014
JAPXXX10.1177/1078390314546952Journal of the American Psychiatric Nurses AssociationSivadon et al.
Research Paper
Social Integration, Psychological Distress, and Smoking Behaviors in a Midwest LGBT Community
Journal of the American Psychiatric Nurses Association 2014, Vol. 20(5) 307–314 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1078390314546952 jap.sagepub.com
Angela Sivadon1, Alicia K. Matthews2, and Kevin M. David3
Abstract BACKGROUND: Lesbian, gay, bisexual, and transgender (LGBT) populations have smoking rates twice that of their heterosexual counterparts. To design effective outreach, prevention, and treatments for these individuals, a comprehensive understanding of associated factors is needed. OBJECTIVE: To increase understanding of how social integration and psychological distress are related to smoking behaviors among LGBT populations. DESIGN: A cross-sectional, descriptive study of 135 LGBT adults using an online data collection strategy. Multivariate analyses were performed to examine factors associated with current smoking status. RESULTS: Social integration was not significantly related to smoking behaviors in this LGBT population, although psychological distress was higher among smokers than nonsmokers. CONCLUSIONS: Although social support has been reported to have an impact on health behaviors in the general population, the present findings suggest that the benefits of social support may not apply to the smoking activities of LGBT individuals. Keywords LGBT, social support, psychological distress, smoking, social integration Smoking is the most preventable cause of premature death in the United States (U.S. Department of Health and Human Services [HHS], 2014). Each year more than 450,000 Americans die prematurely from diseases related to tobacco smoke (HHS, 2014), and that number will increase to more than 9 million by the year 2030 if current trends remain unchanged (Yanbaeva, Dentener, Creutzberg, Wesseling, & Wouters, 2007). Diseases that result from the effects of smoking include lung, larynx, and tongue cancer; chronic obstructive pulmonary disease; and cardiovascular disease (HHS, 2014). Women who smoke can expect to live 14.5 years less than female nonsmokers whereas male smokers decrease their life expectancy by 13.2 years (American Lung Association, 2010). Public knowledge about the health risks associated with smoking has increased significantly (Benowitz, 2010). Although smoking rates have seen a slight decline overall among adults in the United States, lesbian, gay, bisexual, and transgender (LGBT) populations continue to have a high prevalence of tobacco use (Lehavot & Simoni, 2011b). Currently, 25 states have begun to include sexual orientation questions in their Behavioral Risk Factor Surveillance System (BRFSS), the largest random-digit–dialed health survey conducted annually in every U.S. state (http://www.cdc.gov/brfss/). A pooled data analysis of BRFSS data from the 2010 survey in 10
states revealed higher smoking rates among gay men (22.9%), bisexual men (33.3%), lesbians (19.1%), and bisexual women (29.7%) when compared with heterosexual men (15.8%) and women (11.7%; Blosnich, Farmer, Lee, Silenzio, & Bowen, 2014). Other large-scale health surveys consistently report smoking rates among LGBT individuals to be 1.5 to 2.5 times higher than heterosexuals (Blosnich, Lee, & Horn, 2013; Johns et al., 2013; B. A. King, Dube, & Tynan, 2012; Rath, Villanti, Rubenstein, & Vallone, 2012). In a systematic review, Blosnich et al. (2013) suggested that factors such as depression, anxiety, and stress contribute to this high prevalence of smoking among LGBT communities. LGBT populations are at an increased risk of psychological distress in the form of depression, anxiety, mood disorders, and psychological disorders (Carter, Van der Deen, Wilson, & Blakely, 2012). Fear of revealing 1
Angela Sivadon, PhD, RN, University of Missouri–Kansas City, Kansas City, MO, USA 2 Alicia K. Matthews, PhD, University of Illinois, Chicago, IL, USA 3 Kevin M. David, PhD, Tulsa Community College, Tulsa, OK, USA Corresponding Author: Angela Sivadon, Allied Health Services Division, Tulsa Community College, 909 S. Boston Avenue, Tulsa, OK 74119, USA. Email: [email protected]
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their sexual orientation to health care providers, previous poor experiences with health professionals, and the absence of health insurance coverage create barriers to preventive health services for these individuals (Weisz, 2009). Moreover, advertisement and financial sponsorships by the tobacco industry target the LGBT community, creating a sense of inclusion and a positive influence for continued smoking (National Cancer Institute, 2008; Smith, Thompson, Offen, & Malone, 2008). The LGBT population has lacked the focused attention that other vulnerable groups have received to address their unique needs in order to successfully stop smoking. The majority of smoking studies conducted in LGBT populations in the United States have targeted those who live in coastal and larger cities, with little attention given to those who live in smaller cities and towns. Often, the very different social norms and negative attitudes about sexual minority populations in these towns, especially those in states that have passed anti–gay marriage laws, can result in a greater prevalence of psychological distress (Balsam, Lehavot, Beadnell, & Circo, 2010; Hatzenbuehler, McLaughlin, Keyes, & Hasin, 2010). Another factor that may influence smoking decisions is social integration. In general, individuals with a marginalized social status experience lower levels of social support (Fluskerud & Winslow, 1998). Research suggests that an individual’s connectivity to others is significant for achieving and maintaining a healthy lifestyle, and poor health outcomes are associated with social isolation (Weinert, 2003). The presence of social integration, described as belonging to community organizations or groups, has been correlated with both improved mental and physical health (Cohen & Syme, 1985). Furthermore, community connectedness has been identified as a protective factor against psychological distress, decreasing the likelihood of smoking (Johns et al., 2013) Positive health behaviors, such as not smoking, can often result from the disclosure of one’s sexual identity, or outness, depending on the circumstances (Legate, Ryan, & Weinstein, 2012). Each of these aspects of social integration has been recognized as a key element in successful smoking cessation (Burns, Fu, & Joseph, 2014). More research is needed to understand the association of social integration components to smoking behaviors among LGBT populations, particularly for those living in smaller communities. The purpose of the current study was to determine if social integration differed among smokers and nonsmokers in an LGBT population in Oklahoma, a Midwest state that is predominantly conservative, does not offer any government-supported services to the LGBT population, does not recognize same-sex couples, and does not provide basic civil rights such as same-sex partner benefits or protection through antidiscrimination laws. Based on prior work, we hypothesized that smokers in the LGBT
population would have lower levels of social integration and higher levels of psychological distress than nonsmokers.
Method Participants A convenience sample was recruited from the LGBT population in Oklahoma in a number of ways. Postcards with survey information were distributed at the Tulsa Pride picnic and in five of the gay bars in Tulsa. Announcements were posted in a variety of LGBT-targeted domains: the Oklahomans for Equality (OkEq) web page, the OkEq e-newsletter, and the social media pages of several LGBT organizations. The announcements displayed a web-based Survey Monkey® link for individuals to access via a matrix barcode (QR code) as well as the uniform resources locator (URL) web address. A total of 152 participants completed portions of the survey, and 135 participants completed it in its entirety. A final N of 135 was used for smoking status analysis. The mean age of participants was 33.99 years (SD = 12.94, range 18-75 years). The majority of the sample was White (79.5%), employed full-time (64.4%), and well-educated (54.6%). More than three fourths of participants reported having health insurance (79.2%). Gender identity was evenly distributed among participants, with 49.3% identifying as female, 48.6% identifying as male, and 2.1% identifying as “something else.” Approximately 9% identified as transgender. The majority of the sample (87.3%) identified as homosexual (lesbian or gay male), 11.8% identified as bisexual, and 1.9% reported they were pansexual (attracted to all genders and biological sexes; A. R. King, 2011).
Procedure Participants completed a 59-item questionnaire online via Survey Monkey that measured demographics, smoking behaviors, social support, community connectedness, outness, and psychological distress variables. At the conclusion of the survey, participants could choose to be entered into a random drawing for a $100.00 Amazon gift card.
Measurement of Study Variables Demographics. Demographic questions included age, race/ethnicity, gender, sexual orientation, relationship status, education, employment status, income level, and health insurance status. Table 1 presents statistics for the demographic variables. Smoking Behaviors. Standardized questions were selected from the BRFSS to determine smoking behaviors. To
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Sivadon et al. Table 1. Sample Characteristics, N = 152. n (%) Race/ethnicity African American/Black Latino White Other Age (years) M (SD) Range ≤30 >30 Employment Employed full-time Employed part-time Unemployed Student Retired Disabled Education High school or less Technical school Some college College graduate Postgraduate or Professional degree Income ($) 75,000 Gender identity Female Male Something else Transgender Yes, male to female Yes, female to male Yes, neither male nor female Sexual identity Homosexual (gay or lesbian) Bisexual Pansexual Health insurance Yes No Not sure
7 (4.8) 22 (15.1) 116 (79.5) 1 (.7) 33.99 (12.94) 18-75 81(53.3) 71 (46.7) 96 (64.4) 13 (8.7) 5 (3.4) 19 (12.8) 8 (5.4) 8 (5.4) 18 (11.8) 10 (6.6) 41 (27) 52 (34.2) 31 (20.4)
31 (20.4) 32 (21) 49 (32.2) 40 (26.3) 73 (49.3) 72 (48.6) 3 (2) 9 (5.9) 4 (2.6) 1 (0.7) 124 (87.3) 18 (11.8) 3 (1.9) 118 (79.2) 27 (18.1) 4 (2.7)
establish smoking status, participants were asked, “Have you smoked at least 100 cigarettes in your entire life?” (yes = 1, no = 0) and “Do you now smoke cigarettes every day, on some days, or not at all?” (one response selected). Current smokers were asked, “About how many cigarettes do you smoke each day?” “On how many days have
you smoked in the past 30 days?” and “Do you usually smoke menthol cigarettes?” (always, occasionally, never). The Fagerstrom Test for Nicotine Dependence was also used to measure the level of nicotine addiction among participants who smoke. The Fagerstrom Test items are also used to indicate one’s ability to stop smoking (Fagerstrom, Heatherton, & Kozlowski, 1990). To measure the intention of current smokers to quit smoking, three items from the BRFSS were used: (a) “Would you like to quit smoking one day?” (b) “Are you seriously considering quitting smoking in the next 6 months?” and (c) “Are you seriously considering quitting smoking in the next 30 days?” All responses were recorded as yes = 1 and no = 0. Participants were also asked if they had attempted to quit smoking for at least one day within the past 12 months (yes =1, no = 0) and if they had been advised by a health care provider to quit smoking during the previous 12 months (yes = 1, no = 0). Current smoking was reported by 30.3%, and almost half (48.8%) reported always smoking menthol cigarettes. The mean number of cigarettes smoked daily was 11.59, and the mean number of days for smoking was 22.73 of the past 30 days. Of the participants who reported current smoking, 87% responded they would like to quit smoking one day, and when asked if they were seriously considering quitting smoking in the next 6 months, 62% responded yes. More than half the sample (60.0%) reported stopping smoking 1 day or longer during the previous 12 months because they were trying to quit. Only 32.5% reported being advised by a health care provider that they should quit smoking. The Fagerstrom measure indicated a moderate level of nicotine dependency for 40.0% of the sample (M = 3.08, SD = 2.52). Descriptive statistics for smoking behaviors are presented in Table 2. Social Integration. The scales described below were used to measure three aspects of social integration: social support, community connectedness, and outness. Social support. The Personal Resource Questionnaire instrument uses 15 positively worded questions (e.g., “There is someone I feel close to who makes me feel secure”) answered with a 7-point Likert-type scale ranging from 1 = strongly disagree to 7 = strongly agree. The items were summed for a total Social Support score (15105) with higher numbers indicating a higher level of perceived social support in the domains of self-worth, social integration, intimacy, nurturance, and assistance (Weinert & Brandt, 1987). Reliability of this scale reflected strong internal consistency (Cronbach’s α = .94) Community connectedness. The Connectedness to the LBGT Community of New York City scale, which was adapted from the Urban Men Health Study, was used as a
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Table 2. Smoking Behaviors.
all responses and reported as a mean score for Overall Outness. Possible scores ranged from 0 to 7, with higher scores indicating that the participants were more open about their sexual orientation or gender identity than those with lower scores. The instrument had excellent internal consistency with Cronbach’s α = .92.
n (%) Current smoker Yes No Age first cigarette smoked (years) M (SD) Range Number of cigarettes smoked daily M (SD) Range Number of days smoking in past 30 days M (SD) Range Usually smoke menthol cigarettes Always Occasionally Never Fagerstrom Test for Nicotine Dependence Low dependence (1-2) Low-moderate dependence (3-4) Moderate dependence (5-7) High dependence (8+)
41 (30.3) 94 (69.6) 15.68 (4.13) 7-32 11.59 (9.95) 0-35 22.73 (10.05) 1-30 20 (48.8) 7 (17.1) 14 (34.1) 17 (42.5) 7 (17.5) 16 (40) 0 (0)
measure of community affiliation (Frost & Meyer, 2012). This scale consisted of eight items asking participants to indicate the extent to which they agreed with each statement regarding community connectedness (e.g., “You feel you are part of the LGBT community”). Responses were measured on a 4-point Likert-type scale ranging from 1 = strongly agree to 4 = strongly disagree. A mean score was calculated after reverse coding of all items, with higher scores being equivalent to greater feelings of connectedness. The reliability coefficient was Cronbach’s α = .89. Outness. The Outness Inventory scale was originally designed to provide an assessment of the level of outness in varying areas of an individual’s life (Mohr & Fassinger, 2000) and has been widely used to measure the extent of outness in LGBT populations (Carvalho, Lewis, Derlega, Winstead, & Vigianno, 2011; Knoble & Linville, 2010; Sanchez, Meacher, & Beil, 2005; Solomon, Rothblum, & Balsalm, 2004). The scale consists of 11 items, divided into three areas of functioning: Out to Family, Out to World, and Out to Religion (Mohr & Fassinger, 2000). Each item represented someone in the participants’ life, such as mother, father, coworkers, members of religious community, and so on, and was measured by a 7-point Likert-type scale (1 = definitely does NOT know about sexual orientation status to 7 = definitely knows about orientation status and it is openly talked about) with an additional response of 0 = not applicable, no such person or group in your life. An average was calculated for
Psychological Distress. Three scales were used to measure different aspects of psychological distress: depression, perceived stress, and anxiety. Depression. Depression was measured using the Center for Epidemiological Studies Depression Scale (Irwin, Haydari, & Oxman, 1999). This 10-item scale asked participants how often in the past week they have felt a range of specific symptoms. Likert-type scale responses were scored ranging from 0 = rarely or none of the time to 3 = most of the time. Eight of the items were positive predictors of depression if experienced more often and the remaining 2 reflected lack of depression symptoms. The 2 latter items were reverse coded prior to calculation of sum depressions scores for each participant ranging from 0 to 30, with higher scores more indicative of depression. Test reliability of the 10-item Center for Epidemiological Studies Depression Scale showed good internal consistency (Cronbach’s α = .89). Perceived stress. The short four-item scale of the Perceived Stress Scale was used for this study (Cohen, 1994). The PSS4 uses a 5-point Likert-type scale and asks participants how frequently they have felt or thought about the listed items. A sample item is “In the last month, how often have you felt that you were unable to control important things in your life?” Possible responses range from 0 = never to 4 = very often and were summed for a total perceived stress score of 0 to 16 after the two positively stated items (Item 1s and 2) were reverse scored. This four-item version of the PSS had good internal consistency (Cronbach’s α = .81). Anxiety. The seven-item Generalized Anxiety Disorder Scale was used to measure anxiety (Spitzer, Kroenke, Williams, & Lowe, 2006). This seven-item Likert-type scale demonstrated excellent internal consistency in the current study (α = .93) and has been used in numerous research settings targeting LGBT individuals (Balsam et al., 2010; Lehavot & Simoni, 2011a; Litt, Lewis, Blayney, & Kaysen, 2013). The items inquired how often participants were bothered by a range of anxietyrelated feelings during the previous 2 weeks and response choices were 0 = not at all, 1 = several days, 2 = more than half the days, and 3 = nearly every day (Spitzer et al., 2006). Scores from all items were summed for a generalized anxiety score (0-21). Higher scores were predictive of generalized anxiety in participants (Spitzer et al., 2006).
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Sivadon et al. Table 3. Correlations Among Social Integration and Psychological Distress Variables. Social support 1. Social support 2. Connectedness 3. Outness 4. Depression 5. Perceived stress 6. Anxiety
Connectedness
— .30** .37*** −.48*** −.45*** −.32***
— .18* −.21* −.23** −.20*
Outness
— −.29** −.31*** −.13
Depression
— .75*** .73***
Perceived stress
Anxiety
— .66***
—
*p < .05. **p < .01. ***p < .001.
Results Data Analytic Plan After the survey was closed, responses were exported from Survey Monkey into SPSS 19.0 for analysis. Descriptive statistics were used to characterize the sample, and inferential statistics were used to identify relationships between variables. Initial analysis involved calculating Pearson’s correlation coefficients among each of the measures of social integration and psychological distress. The correlations were followed by a principal components analysis (PCA) to determine the factor structure among the integration and distress variables. To determine the sample size needed for factor analysis, researchers have suggested using the ratio of participants to variables analyzed (see MacCallum, Widaman, Zhang, & Hong, 1999, for a review). For example, Gorsuch (1983) recommended a minimum ratio of 5:1 (i.e., 5 participants for each variable analyzed), and Everitt (1975) suggested that a ratio of 10:1 is adequate for estimating and producing reliable factors. The ratio of participants to variables analyzed for the PCA conducted in the present study was 22:1, exceeding both Gorsuch’s (1983) and Everitt’s (1975) suggested minimum requirements. A multivariate analysis of variance was then conducted to examine mean differences between smokers and nonsmokers on the broad factors from the PCA.
Correlations and Principal Components Analysis The correlation coefficients indicating the linear relations among the social integration and psychological distress variables are presented in Table 3. In general, the social integration variables (social support, community connectedness, and outness) were significantly and positively correlated with each other, and the psychological distress measures (depression, perceived stress, and anxiety) were significantly and positively related to one another. However, there were also a number of significant correlations across these groups of variables.
To obtain a better understanding of the factor structure underlying these six variables, a PCA with a varimax rotation was conducted on all of these measures. The PCA revealed two factors with eigenvalues above 1.0, with the following loadings: (a) Social Support (.66), Community Connectedness (.67), and Outness (.76); and (b) Depression (.89), Perceived Stress (.85), and Anxiety (.90). Thus, the scores loading on the first factor were standardized and averaged to form a Social Integration composite that was used in subsequent analysis. Higher scores on this composite reflected higher levels of support, connectedness with the LGBT community, and level of outness with family and others. Scores loading on the second factor were standardized and averaged to create a Psychological Distress composite that was used in subsequent analyses; higher scores on this composite indicated higher levels of depression, perceived stress, and anxiety. Because the scores averaged for each factor came from different questionnaires with varying response scales, each scale score was first standardized before creating the factor composite scores, resulting in factor scores that have a mean of zero. The Social Integration and Psychological Distress factors were significantly and negatively correlated, r(133) = −.44, p < .001.
Smoking Behaviors as a Function of Social Integration and Psychological Distress To examine the extent to which Social Integration and Psychological Distress are associated with smoking behaviors, a multivariate analysis of variance was conducted with current smoker as the independent variable (yes = 1 and no = 0) and the Social Integration and Psychological Distress factors as the multiple dependent measures. The omnibus test was statistically significant, F(2, 132) = 7.20, p = .001. Univariate tests revealed that smokers (M = .40, SD = .95) had significantly higher levels of Psychological Distress than did nonsmokers (M = −.18, SD = .82), F(1, 133) = 12.90, p < .001. Although smokers (M = −.04, SD = .82) had a slightly lower mean on Social Integration than did nonsmokers
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(M = .02, SD = .69), the univariate test for this measure indicated that this difference was not statistically significant, F(1, 133) = .23, p = .63.
cigarettes, and lacked advisement by medical care providers to quit smoking. However, a majority of smokers expressed interest in quitting and had previously attempted to quit in the past 12 months. By identifying positive social influences and focusing on decreasing psychological distress in LGBT individuals, practitioners can increase successful smoking cessation in this community.
Discussion Although the Institute of Medicine (2011) identified social influences as a priority research area among LGBT populations, specific types that affect smoking and smoking cessation have yet to be established (Burns et al., 2014). Based on the literature, it was expected that facets of social support would be related to health behavior choices, such as smoking, in this marginalized group (Weinert & Brandt, 1987). Previous studies have shown a positive correlation of social integration and health behaviors and health outcomes (Kelly et al., 2012). However, in this study, there were no significant differences in the levels of perceived social support, community connectedness, or the extent of outness among smokers and nonsmokers. Many of the participants who reported being current smokers had the highest level of social integration scores just as various individuals who reported not smoking had particularly low social integration scores. It is noteworthy that similar results were found when smokers and nonsmokers were compared on the individual scales representing social integration (i.e., social support, community connectedness, and outness). Smokers and nonsmokers had similar levels of social support, involvement in the LGBT community, and openness about their sexual orientation. Consistent with expectations, the psychological distress variables (depression, generalized anxiety, and perceived stress) were significantly associated with smoking. Participants who reported higher scores on these subscales were more likely to smoke than those with lower scores. Overall, psychological distress was a greater predictor of smoking behaviors than social support, community connectedness, or outness in this LGBT population. There is a well-established link between psychological distress and smoking in the general population (Purnell et al., 2012), so this was not a new or surprising finding. Nevertheless, the present study confirms the strong relationship between psychological distress and smoking in a population that experiences increased levels of distress, especially in a state without protection laws for LGBT individuals (Hatzenbuehler, Keyes, & Hasin, 2009).
Implications for Practitioners This study provides health care workers a research-based foundation for developing patient education programs and clinical interventions targeting smoking cessation in the Oklahoma LGBT population. Participants who reported being current smokers in this sample were moderately dependent on nicotine, had a high use of mentholated
Limitations and Future Research This study was subject to two important limitations. First, recruitment was primarily in LGBT community venues. To be aware of the survey, participants had to be involved with the LGBT community in some manner, even if it was simply by being on a mailing list for OkEq. Since Oklahoma does not include sexual orientation on any state questionnaires, convenience sampling is the most common option for surveying this hard-to-reach population. Second, participants were not asked about smoking behaviors of their social networks. An individual’s relationship with only the nightclub or bar community, as opposed to the Equality Center or LGBT specific support programs, may play a role in the type of social support available. For instance, those individuals who are actively involved in programs at the Equality Center may receive more positive support to not smoke than someone whose social integration is primarily through the bars where alcohol intake and tobacco use are the norm. Further investigation to determine the characteristics of social networks of Oklahoma’s LGBT community can help us better understand the complex ways in which social integration and psychological distress are linked with smoking behaviors in this population.
Conclusion These results add to the developing literature encompassing social influences and tobacco use in the LGBT population. The findings show that psychological distress is associated with smoking in this stigmatized community and that social integration does not necessarily provide a protective factor against smoking among Oklahoma LGBT individuals. Implementing targeted tobacco use education, psychological counseling opportunities, and smoking cessation interventions can have a vast impact on the health and welfare of this community. Author Roles Dr. Sivadon conducted this study as part of her doctoral dissertation and prepared the article for publication. Dr. Matthews provided consultation on study design, measurement, and analysis of study results and guided the article preparation. Dr. David assisted in data analysis and provided guidance for the interpretation of study results.
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Sivadon et al. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research project was funded in part by a research award from the Lambda Phi Chapter of Sigma Theta Tau International.
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Smith, E. A., Thompson, K., Offen, N., & Malone, R. E. (2008). “If you know you exist, it’s just marketing poison”: Meanings of tobacco industry targeting the lesbian, gay, bisexual, and transgender community. American Journal of Public Health, 98, 996-1003. doi:10.2105/ AJPH.2007.118174 Solomon, S., Rothblum, E., & Balsalm, K. (2004). Pioneers in partnership: Lesbian and gay male couples in civil unions compared with those not in civil unions and married heterosexuals. Journal of Family Psychology, 18, 275-286. doi:10.1037/0893-3200.18.2.275 Spitzer, R., Kroenke, K., Williams, J., & Lowe, B. (2006). A brief measure for assessing generalized anxiety disorder. Archives of Internal Medicine, 166, 1092-1097. doi:10.1001/archinte.166.10.1092 U.S. Department of Health and Human Services. (2014). The health consequences of smoking—50 years of progress. A report of the surgeon general. Atlanta, GA: Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health. Weinert, C. (2003). Measuring social support: PRQ2000. In O. Strickland & C. DiIorio (Eds.), Measurement of nursing outcomes: Vol. 3. Self-care and coping (pp. 161-172). New York, NY: Springer. Weinert, C., & Brandt, P. A. (1987). Measuring social support with the Personal Resource Questionnaire. Western Journal of Nursing Research, 9, 589-602. doi:10.1177/019394598700900411 Weisz, V. K. (2009). Social justice considerations for lesbian and bisexual women’s health care. Journal of Obstetric Gynecological and Neonatal Nursing, 38, 81-87. doi:10.1111/j.1552-6909.2008.00306 Yanbaeva, D. G., Dentener, M. A., Creutzberg, E. C., Wesseling, G., & Wouters, E. F. (2007). Systemic effects of smoking. Chest, 131, 1557-1566. doi:10.1378./chest.06-2179
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research-article2014
JAPXXX10.1177/1078390314546952Journal of the American Psychiatric Nurses AssociationSivadon et al.
Research Paper
Social Integration, Psychological Distress, and Smoking Behaviors in a Midwest LGBT Community
Journal of the American Psychiatric Nurses Association 2014, Vol. 20(5) 307–314 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1078390314546952 jap.sagepub.com
Angela Sivadon1, Alicia K. Matthews2, and Kevin M. David3
Abstract BACKGROUND: Lesbian, gay, bisexual, and transgender (LGBT) populations have smoking rates twice that of their heterosexual counterparts. To design effective outreach, prevention, and treatments for these individuals, a comprehensive understanding of associated factors is needed. OBJECTIVE: To increase understanding of how social integration and psychological distress are related to smoking behaviors among LGBT populations. DESIGN: A cross-sectional, descriptive study of 135 LGBT adults using an online data collection strategy. Multivariate analyses were performed to examine factors associated with current smoking status. RESULTS: Social integration was not significantly related to smoking behaviors in this LGBT population, although psychological distress was higher among smokers than nonsmokers. CONCLUSIONS: Although social support has been reported to have an impact on health behaviors in the general population, the present findings suggest that the benefits of social support may not apply to the smoking activities of LGBT individuals. Keywords LGBT, social support, psychological distress, smoking, social integration Smoking is the most preventable cause of premature death in the United States (U.S. Department of Health and Human Services [HHS], 2014). Each year more than 450,000 Americans die prematurely from diseases related to tobacco smoke (HHS, 2014), and that number will increase to more than 9 million by the year 2030 if current trends remain unchanged (Yanbaeva, Dentener, Creutzberg, Wesseling, & Wouters, 2007). Diseases that result from the effects of smoking include lung, larynx, and tongue cancer; chronic obstructive pulmonary disease; and cardiovascular disease (HHS, 2014). Women who smoke can expect to live 14.5 years less than female nonsmokers whereas male smokers decrease their life expectancy by 13.2 years (American Lung Association, 2010). Public knowledge about the health risks associated with smoking has increased significantly (Benowitz, 2010). Although smoking rates have seen a slight decline overall among adults in the United States, lesbian, gay, bisexual, and transgender (LGBT) populations continue to have a high prevalence of tobacco use (Lehavot & Simoni, 2011b). Currently, 25 states have begun to include sexual orientation questions in their Behavioral Risk Factor Surveillance System (BRFSS), the largest random-digit–dialed health survey conducted annually in every U.S. state (http://www.cdc.gov/brfss/). A pooled data analysis of BRFSS data from the 2010 survey in 10
states revealed higher smoking rates among gay men (22.9%), bisexual men (33.3%), lesbians (19.1%), and bisexual women (29.7%) when compared with heterosexual men (15.8%) and women (11.7%; Blosnich, Farmer, Lee, Silenzio, & Bowen, 2014). Other large-scale health surveys consistently report smoking rates among LGBT individuals to be 1.5 to 2.5 times higher than heterosexuals (Blosnich, Lee, & Horn, 2013; Johns et al., 2013; B. A. King, Dube, & Tynan, 2012; Rath, Villanti, Rubenstein, & Vallone, 2012). In a systematic review, Blosnich et al. (2013) suggested that factors such as depression, anxiety, and stress contribute to this high prevalence of smoking among LGBT communities. LGBT populations are at an increased risk of psychological distress in the form of depression, anxiety, mood disorders, and psychological disorders (Carter, Van der Deen, Wilson, & Blakely, 2012). Fear of revealing 1
Angela Sivadon, PhD, RN, University of Missouri–Kansas City, Kansas City, MO, USA 2 Alicia K. Matthews, PhD, University of Illinois, Chicago, IL, USA 3 Kevin M. David, PhD, Tulsa Community College, Tulsa, OK, USA Corresponding Author: Angela Sivadon, Allied Health Services Division, Tulsa Community College, 909 S. Boston Avenue, Tulsa, OK 74119, USA. Email: [email protected]
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their sexual orientation to health care providers, previous poor experiences with health professionals, and the absence of health insurance coverage create barriers to preventive health services for these individuals (Weisz, 2009). Moreover, advertisement and financial sponsorships by the tobacco industry target the LGBT community, creating a sense of inclusion and a positive influence for continued smoking (National Cancer Institute, 2008; Smith, Thompson, Offen, & Malone, 2008). The LGBT population has lacked the focused attention that other vulnerable groups have received to address their unique needs in order to successfully stop smoking. The majority of smoking studies conducted in LGBT populations in the United States have targeted those who live in coastal and larger cities, with little attention given to those who live in smaller cities and towns. Often, the very different social norms and negative attitudes about sexual minority populations in these towns, especially those in states that have passed anti–gay marriage laws, can result in a greater prevalence of psychological distress (Balsam, Lehavot, Beadnell, & Circo, 2010; Hatzenbuehler, McLaughlin, Keyes, & Hasin, 2010). Another factor that may influence smoking decisions is social integration. In general, individuals with a marginalized social status experience lower levels of social support (Fluskerud & Winslow, 1998). Research suggests that an individual’s connectivity to others is significant for achieving and maintaining a healthy lifestyle, and poor health outcomes are associated with social isolation (Weinert, 2003). The presence of social integration, described as belonging to community organizations or groups, has been correlated with both improved mental and physical health (Cohen & Syme, 1985). Furthermore, community connectedness has been identified as a protective factor against psychological distress, decreasing the likelihood of smoking (Johns et al., 2013) Positive health behaviors, such as not smoking, can often result from the disclosure of one’s sexual identity, or outness, depending on the circumstances (Legate, Ryan, & Weinstein, 2012). Each of these aspects of social integration has been recognized as a key element in successful smoking cessation (Burns, Fu, & Joseph, 2014). More research is needed to understand the association of social integration components to smoking behaviors among LGBT populations, particularly for those living in smaller communities. The purpose of the current study was to determine if social integration differed among smokers and nonsmokers in an LGBT population in Oklahoma, a Midwest state that is predominantly conservative, does not offer any government-supported services to the LGBT population, does not recognize same-sex couples, and does not provide basic civil rights such as same-sex partner benefits or protection through antidiscrimination laws. Based on prior work, we hypothesized that smokers in the LGBT
population would have lower levels of social integration and higher levels of psychological distress than nonsmokers.
Method Participants A convenience sample was recruited from the LGBT population in Oklahoma in a number of ways. Postcards with survey information were distributed at the Tulsa Pride picnic and in five of the gay bars in Tulsa. Announcements were posted in a variety of LGBT-targeted domains: the Oklahomans for Equality (OkEq) web page, the OkEq e-newsletter, and the social media pages of several LGBT organizations. The announcements displayed a web-based Survey Monkey® link for individuals to access via a matrix barcode (QR code) as well as the uniform resources locator (URL) web address. A total of 152 participants completed portions of the survey, and 135 participants completed it in its entirety. A final N of 135 was used for smoking status analysis. The mean age of participants was 33.99 years (SD = 12.94, range 18-75 years). The majority of the sample was White (79.5%), employed full-time (64.4%), and well-educated (54.6%). More than three fourths of participants reported having health insurance (79.2%). Gender identity was evenly distributed among participants, with 49.3% identifying as female, 48.6% identifying as male, and 2.1% identifying as “something else.” Approximately 9% identified as transgender. The majority of the sample (87.3%) identified as homosexual (lesbian or gay male), 11.8% identified as bisexual, and 1.9% reported they were pansexual (attracted to all genders and biological sexes; A. R. King, 2011).
Procedure Participants completed a 59-item questionnaire online via Survey Monkey that measured demographics, smoking behaviors, social support, community connectedness, outness, and psychological distress variables. At the conclusion of the survey, participants could choose to be entered into a random drawing for a $100.00 Amazon gift card.
Measurement of Study Variables Demographics. Demographic questions included age, race/ethnicity, gender, sexual orientation, relationship status, education, employment status, income level, and health insurance status. Table 1 presents statistics for the demographic variables. Smoking Behaviors. Standardized questions were selected from the BRFSS to determine smoking behaviors. To
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Sivadon et al. Table 1. Sample Characteristics, N = 152. n (%) Race/ethnicity African American/Black Latino White Other Age (years) M (SD) Range ≤30 >30 Employment Employed full-time Employed part-time Unemployed Student Retired Disabled Education High school or less Technical school Some college College graduate Postgraduate or Professional degree Income ($) 75,000 Gender identity Female Male Something else Transgender Yes, male to female Yes, female to male Yes, neither male nor female Sexual identity Homosexual (gay or lesbian) Bisexual Pansexual Health insurance Yes No Not sure
7 (4.8) 22 (15.1) 116 (79.5) 1 (.7) 33.99 (12.94) 18-75 81(53.3) 71 (46.7) 96 (64.4) 13 (8.7) 5 (3.4) 19 (12.8) 8 (5.4) 8 (5.4) 18 (11.8) 10 (6.6) 41 (27) 52 (34.2) 31 (20.4)
31 (20.4) 32 (21) 49 (32.2) 40 (26.3) 73 (49.3) 72 (48.6) 3 (2) 9 (5.9) 4 (2.6) 1 (0.7) 124 (87.3) 18 (11.8) 3 (1.9) 118 (79.2) 27 (18.1) 4 (2.7)
establish smoking status, participants were asked, “Have you smoked at least 100 cigarettes in your entire life?” (yes = 1, no = 0) and “Do you now smoke cigarettes every day, on some days, or not at all?” (one response selected). Current smokers were asked, “About how many cigarettes do you smoke each day?” “On how many days have
you smoked in the past 30 days?” and “Do you usually smoke menthol cigarettes?” (always, occasionally, never). The Fagerstrom Test for Nicotine Dependence was also used to measure the level of nicotine addiction among participants who smoke. The Fagerstrom Test items are also used to indicate one’s ability to stop smoking (Fagerstrom, Heatherton, & Kozlowski, 1990). To measure the intention of current smokers to quit smoking, three items from the BRFSS were used: (a) “Would you like to quit smoking one day?” (b) “Are you seriously considering quitting smoking in the next 6 months?” and (c) “Are you seriously considering quitting smoking in the next 30 days?” All responses were recorded as yes = 1 and no = 0. Participants were also asked if they had attempted to quit smoking for at least one day within the past 12 months (yes =1, no = 0) and if they had been advised by a health care provider to quit smoking during the previous 12 months (yes = 1, no = 0). Current smoking was reported by 30.3%, and almost half (48.8%) reported always smoking menthol cigarettes. The mean number of cigarettes smoked daily was 11.59, and the mean number of days for smoking was 22.73 of the past 30 days. Of the participants who reported current smoking, 87% responded they would like to quit smoking one day, and when asked if they were seriously considering quitting smoking in the next 6 months, 62% responded yes. More than half the sample (60.0%) reported stopping smoking 1 day or longer during the previous 12 months because they were trying to quit. Only 32.5% reported being advised by a health care provider that they should quit smoking. The Fagerstrom measure indicated a moderate level of nicotine dependency for 40.0% of the sample (M = 3.08, SD = 2.52). Descriptive statistics for smoking behaviors are presented in Table 2. Social Integration. The scales described below were used to measure three aspects of social integration: social support, community connectedness, and outness. Social support. The Personal Resource Questionnaire instrument uses 15 positively worded questions (e.g., “There is someone I feel close to who makes me feel secure”) answered with a 7-point Likert-type scale ranging from 1 = strongly disagree to 7 = strongly agree. The items were summed for a total Social Support score (15105) with higher numbers indicating a higher level of perceived social support in the domains of self-worth, social integration, intimacy, nurturance, and assistance (Weinert & Brandt, 1987). Reliability of this scale reflected strong internal consistency (Cronbach’s α = .94) Community connectedness. The Connectedness to the LBGT Community of New York City scale, which was adapted from the Urban Men Health Study, was used as a
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Table 2. Smoking Behaviors.
all responses and reported as a mean score for Overall Outness. Possible scores ranged from 0 to 7, with higher scores indicating that the participants were more open about their sexual orientation or gender identity than those with lower scores. The instrument had excellent internal consistency with Cronbach’s α = .92.
n (%) Current smoker Yes No Age first cigarette smoked (years) M (SD) Range Number of cigarettes smoked daily M (SD) Range Number of days smoking in past 30 days M (SD) Range Usually smoke menthol cigarettes Always Occasionally Never Fagerstrom Test for Nicotine Dependence Low dependence (1-2) Low-moderate dependence (3-4) Moderate dependence (5-7) High dependence (8+)
41 (30.3) 94 (69.6) 15.68 (4.13) 7-32 11.59 (9.95) 0-35 22.73 (10.05) 1-30 20 (48.8) 7 (17.1) 14 (34.1) 17 (42.5) 7 (17.5) 16 (40) 0 (0)
measure of community affiliation (Frost & Meyer, 2012). This scale consisted of eight items asking participants to indicate the extent to which they agreed with each statement regarding community connectedness (e.g., “You feel you are part of the LGBT community”). Responses were measured on a 4-point Likert-type scale ranging from 1 = strongly agree to 4 = strongly disagree. A mean score was calculated after reverse coding of all items, with higher scores being equivalent to greater feelings of connectedness. The reliability coefficient was Cronbach’s α = .89. Outness. The Outness Inventory scale was originally designed to provide an assessment of the level of outness in varying areas of an individual’s life (Mohr & Fassinger, 2000) and has been widely used to measure the extent of outness in LGBT populations (Carvalho, Lewis, Derlega, Winstead, & Vigianno, 2011; Knoble & Linville, 2010; Sanchez, Meacher, & Beil, 2005; Solomon, Rothblum, & Balsalm, 2004). The scale consists of 11 items, divided into three areas of functioning: Out to Family, Out to World, and Out to Religion (Mohr & Fassinger, 2000). Each item represented someone in the participants’ life, such as mother, father, coworkers, members of religious community, and so on, and was measured by a 7-point Likert-type scale (1 = definitely does NOT know about sexual orientation status to 7 = definitely knows about orientation status and it is openly talked about) with an additional response of 0 = not applicable, no such person or group in your life. An average was calculated for
Psychological Distress. Three scales were used to measure different aspects of psychological distress: depression, perceived stress, and anxiety. Depression. Depression was measured using the Center for Epidemiological Studies Depression Scale (Irwin, Haydari, & Oxman, 1999). This 10-item scale asked participants how often in the past week they have felt a range of specific symptoms. Likert-type scale responses were scored ranging from 0 = rarely or none of the time to 3 = most of the time. Eight of the items were positive predictors of depression if experienced more often and the remaining 2 reflected lack of depression symptoms. The 2 latter items were reverse coded prior to calculation of sum depressions scores for each participant ranging from 0 to 30, with higher scores more indicative of depression. Test reliability of the 10-item Center for Epidemiological Studies Depression Scale showed good internal consistency (Cronbach’s α = .89). Perceived stress. The short four-item scale of the Perceived Stress Scale was used for this study (Cohen, 1994). The PSS4 uses a 5-point Likert-type scale and asks participants how frequently they have felt or thought about the listed items. A sample item is “In the last month, how often have you felt that you were unable to control important things in your life?” Possible responses range from 0 = never to 4 = very often and were summed for a total perceived stress score of 0 to 16 after the two positively stated items (Item 1s and 2) were reverse scored. This four-item version of the PSS had good internal consistency (Cronbach’s α = .81). Anxiety. The seven-item Generalized Anxiety Disorder Scale was used to measure anxiety (Spitzer, Kroenke, Williams, & Lowe, 2006). This seven-item Likert-type scale demonstrated excellent internal consistency in the current study (α = .93) and has been used in numerous research settings targeting LGBT individuals (Balsam et al., 2010; Lehavot & Simoni, 2011a; Litt, Lewis, Blayney, & Kaysen, 2013). The items inquired how often participants were bothered by a range of anxietyrelated feelings during the previous 2 weeks and response choices were 0 = not at all, 1 = several days, 2 = more than half the days, and 3 = nearly every day (Spitzer et al., 2006). Scores from all items were summed for a generalized anxiety score (0-21). Higher scores were predictive of generalized anxiety in participants (Spitzer et al., 2006).
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Sivadon et al. Table 3. Correlations Among Social Integration and Psychological Distress Variables. Social support 1. Social support 2. Connectedness 3. Outness 4. Depression 5. Perceived stress 6. Anxiety
Connectedness
— .30** .37*** −.48*** −.45*** −.32***
— .18* −.21* −.23** −.20*
Outness
— −.29** −.31*** −.13
Depression
— .75*** .73***
Perceived stress
Anxiety
— .66***
—
*p < .05. **p < .01. ***p < .001.
Results Data Analytic Plan After the survey was closed, responses were exported from Survey Monkey into SPSS 19.0 for analysis. Descriptive statistics were used to characterize the sample, and inferential statistics were used to identify relationships between variables. Initial analysis involved calculating Pearson’s correlation coefficients among each of the measures of social integration and psychological distress. The correlations were followed by a principal components analysis (PCA) to determine the factor structure among the integration and distress variables. To determine the sample size needed for factor analysis, researchers have suggested using the ratio of participants to variables analyzed (see MacCallum, Widaman, Zhang, & Hong, 1999, for a review). For example, Gorsuch (1983) recommended a minimum ratio of 5:1 (i.e., 5 participants for each variable analyzed), and Everitt (1975) suggested that a ratio of 10:1 is adequate for estimating and producing reliable factors. The ratio of participants to variables analyzed for the PCA conducted in the present study was 22:1, exceeding both Gorsuch’s (1983) and Everitt’s (1975) suggested minimum requirements. A multivariate analysis of variance was then conducted to examine mean differences between smokers and nonsmokers on the broad factors from the PCA.
Correlations and Principal Components Analysis The correlation coefficients indicating the linear relations among the social integration and psychological distress variables are presented in Table 3. In general, the social integration variables (social support, community connectedness, and outness) were significantly and positively correlated with each other, and the psychological distress measures (depression, perceived stress, and anxiety) were significantly and positively related to one another. However, there were also a number of significant correlations across these groups of variables.
To obtain a better understanding of the factor structure underlying these six variables, a PCA with a varimax rotation was conducted on all of these measures. The PCA revealed two factors with eigenvalues above 1.0, with the following loadings: (a) Social Support (.66), Community Connectedness (.67), and Outness (.76); and (b) Depression (.89), Perceived Stress (.85), and Anxiety (.90). Thus, the scores loading on the first factor were standardized and averaged to form a Social Integration composite that was used in subsequent analysis. Higher scores on this composite reflected higher levels of support, connectedness with the LGBT community, and level of outness with family and others. Scores loading on the second factor were standardized and averaged to create a Psychological Distress composite that was used in subsequent analyses; higher scores on this composite indicated higher levels of depression, perceived stress, and anxiety. Because the scores averaged for each factor came from different questionnaires with varying response scales, each scale score was first standardized before creating the factor composite scores, resulting in factor scores that have a mean of zero. The Social Integration and Psychological Distress factors were significantly and negatively correlated, r(133) = −.44, p < .001.
Smoking Behaviors as a Function of Social Integration and Psychological Distress To examine the extent to which Social Integration and Psychological Distress are associated with smoking behaviors, a multivariate analysis of variance was conducted with current smoker as the independent variable (yes = 1 and no = 0) and the Social Integration and Psychological Distress factors as the multiple dependent measures. The omnibus test was statistically significant, F(2, 132) = 7.20, p = .001. Univariate tests revealed that smokers (M = .40, SD = .95) had significantly higher levels of Psychological Distress than did nonsmokers (M = −.18, SD = .82), F(1, 133) = 12.90, p < .001. Although smokers (M = −.04, SD = .82) had a slightly lower mean on Social Integration than did nonsmokers
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(M = .02, SD = .69), the univariate test for this measure indicated that this difference was not statistically significant, F(1, 133) = .23, p = .63.
cigarettes, and lacked advisement by medical care providers to quit smoking. However, a majority of smokers expressed interest in quitting and had previously attempted to quit in the past 12 months. By identifying positive social influences and focusing on decreasing psychological distress in LGBT individuals, practitioners can increase successful smoking cessation in this community.
Discussion Although the Institute of Medicine (2011) identified social influences as a priority research area among LGBT populations, specific types that affect smoking and smoking cessation have yet to be established (Burns et al., 2014). Based on the literature, it was expected that facets of social support would be related to health behavior choices, such as smoking, in this marginalized group (Weinert & Brandt, 1987). Previous studies have shown a positive correlation of social integration and health behaviors and health outcomes (Kelly et al., 2012). However, in this study, there were no significant differences in the levels of perceived social support, community connectedness, or the extent of outness among smokers and nonsmokers. Many of the participants who reported being current smokers had the highest level of social integration scores just as various individuals who reported not smoking had particularly low social integration scores. It is noteworthy that similar results were found when smokers and nonsmokers were compared on the individual scales representing social integration (i.e., social support, community connectedness, and outness). Smokers and nonsmokers had similar levels of social support, involvement in the LGBT community, and openness about their sexual orientation. Consistent with expectations, the psychological distress variables (depression, generalized anxiety, and perceived stress) were significantly associated with smoking. Participants who reported higher scores on these subscales were more likely to smoke than those with lower scores. Overall, psychological distress was a greater predictor of smoking behaviors than social support, community connectedness, or outness in this LGBT population. There is a well-established link between psychological distress and smoking in the general population (Purnell et al., 2012), so this was not a new or surprising finding. Nevertheless, the present study confirms the strong relationship between psychological distress and smoking in a population that experiences increased levels of distress, especially in a state without protection laws for LGBT individuals (Hatzenbuehler, Keyes, & Hasin, 2009).
Implications for Practitioners This study provides health care workers a research-based foundation for developing patient education programs and clinical interventions targeting smoking cessation in the Oklahoma LGBT population. Participants who reported being current smokers in this sample were moderately dependent on nicotine, had a high use of mentholated
Limitations and Future Research This study was subject to two important limitations. First, recruitment was primarily in LGBT community venues. To be aware of the survey, participants had to be involved with the LGBT community in some manner, even if it was simply by being on a mailing list for OkEq. Since Oklahoma does not include sexual orientation on any state questionnaires, convenience sampling is the most common option for surveying this hard-to-reach population. Second, participants were not asked about smoking behaviors of their social networks. An individual’s relationship with only the nightclub or bar community, as opposed to the Equality Center or LGBT specific support programs, may play a role in the type of social support available. For instance, those individuals who are actively involved in programs at the Equality Center may receive more positive support to not smoke than someone whose social integration is primarily through the bars where alcohol intake and tobacco use are the norm. Further investigation to determine the characteristics of social networks of Oklahoma’s LGBT community can help us better understand the complex ways in which social integration and psychological distress are linked with smoking behaviors in this population.
Conclusion These results add to the developing literature encompassing social influences and tobacco use in the LGBT population. The findings show that psychological distress is associated with smoking in this stigmatized community and that social integration does not necessarily provide a protective factor against smoking among Oklahoma LGBT individuals. Implementing targeted tobacco use education, psychological counseling opportunities, and smoking cessation interventions can have a vast impact on the health and welfare of this community. Author Roles Dr. Sivadon conducted this study as part of her doctoral dissertation and prepared the article for publication. Dr. Matthews provided consultation on study design, measurement, and analysis of study results and guided the article preparation. Dr. David assisted in data analysis and provided guidance for the interpretation of study results.
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Sivadon et al. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research project was funded in part by a research award from the Lambda Phi Chapter of Sigma Theta Tau International.
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