Understanding the higher rates of smoking among lesbian and bisexual women

Smoking control measures and the resulting falling prevalence of smoking are one of the public health success stories in Australia. However while approximately 17 percent of adults still smoke, prevalence data indicate that this is not evenly spread across the community. Smoking rates are much higher in marginalised groups such as Indigenous Australians, low socioeconomic status populations and those with mental health issues. Smoking rates are also higher in lesbian and bisexual women. This research attempts to answer the question why.While the majority of lesbian and bisexual women lead happy lives with good healthy lifestyle choices there is overwhelming evidence that this is not the case for all of these women. Higher rates of substance use, overweight and obesity, mental health and other health issues are reported. Smoking rates are higher than the wider Australian female population and this has been found in other Western countries as well.Using qualitative research methodology of grounded theory, in-depth interviews were undertaken with a group of women who identified as lesbian or bisexual and were either current smokers or recent ex-smokers. A comprehensive literature review was also completed and further qualitative data was obtained from one on-line lesbian social networking site. A conceptual framework of symbolic interactionism was used for the research approach, which allowed for issues of identity formation and reflection, social influence, and behaviour to be analysed.Both smoking and minority sexual identity have undergone rapid social change with the former becoming increasingly socially undesirable and the latter slowly becoming more socially accepted. This provides a backdrop for the reporting of the results of the research. In trying to explain the higher levels of smoking in this group, three core categories of dissonance, resolution and redefinition factors emerged. Knowledge, expectations, denial, identity, stigma, loss and fitting in all contribute to reported dissonance for participants in both their smoking behaviour and their sexual orientation identity. Resolution was reached through justification, identity declaration, minimising of social loss, reported positives of behaviour and ways of managing stigma. Redefinition factors were articulated as relating to changing social acceptability and life-course. The core categories are encapsulated in the core theme of self-concept.In discussing the results and providing recommendations for future action it became clear that minority membership of two groups, that of smokers and of sexual minority identity, play an important part in self-concept and to understand and address higher rates of smoking prevalence required acknowledgement of this. More inclusive mainstream smoking control interventions are required that acknowledge the unique and complex interplay of factors for this group. In addition there is scope for targeted interventions at a lesbian/bisexual women or gay community level as a clear connection to some community attributes was reported.Stigma at many levels (internalised, structural, covert and overt) and discrimination based on sexual orientation still exists in Australia and many countries. Until fundamental changes occur in the real acceptance of sexual orientation diversity at a broad community level, poor health in this minority group will result. Social change on both of these areas has been encouraging but there is still much work to be done for true equity to be reached. Smoking control has accomplished a measure of success however until low smoking prevalence is achieved in all marginalised populations there is still much to realise. Smoking is still the largest cause of preventable morbidity and mortality and therefore the public health dollar must stretch to encompass and succeed in these challenging areas before we can say that we have won the battle. This needs to be done while being cognisant of the stigma that is attached to being a smoker today.This research project adds to the literature by exploring and understanding the complexities of smoking behaviour in lesbian and bisexual women. Recommendations are made for public health interventions to address this