Early Alcohol and Smoking Initiation

A Contributor to Sexual Minority Disparities in Adult Use

Published in: American Journal of Preventive Medicine, Volume 57, Issue 6, pages 808–817 (December 2019). doi: 10.1016/j.amepre.2019.07.020

Posted on RAND.org on December 11, 2019

by Megan S. Schuler, Rebecca L. Collins

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Lesbian, gay, and bisexual adults report higher rates of smoking and alcohol use than heterosexual peers. Prior studies have not examined whether potential disparities in early initiation among lesbian, gay, and bisexual youth may contribute to adult disparities.


Data on 126,463 adults (including 8,241 lesbian, gay, and bisexual adults) were from the 2015–2017 National Survey on Drug Use and Health. Rates of reported early alcohol and smoking initiation (before age 15 years) among both lesbian/gay and bisexual adults were examined relative to same-gender heterosexual adults. Mediation analyses were used to assess whether early initiation differences contribute to disparities in adult heavy episodic drinking, alcohol use disorder, current smoking, and nicotine dependence for each subgroup. Analyses were conducted in 2018–2019.


For both lesbian/gay and bisexual women, early alcohol initiation rates were elevated and explained 21%–38% of their observed disparities in adult heavy episodic drinking and alcohol use disorder. Similarly, early smoking initiation rates were elevated among both lesbian/gay and bisexual women and explained 22%–29% of their disparities in adult smoking and nicotine dependence. By contrast, no evidence was observed that early initiation mediated adult disparities for gay or bisexual men.


A significant proportion of alcohol and smoking disparities among lesbian/gay and bisexual women in adulthood appear attributable to early initiation, indicating the need for enhanced early prevention efforts for these groups. Making routine adolescent screening for substance use, brief intervention, and referral to treatment more culturally sensitive to lesbian, gay, and bisexual youth may also be an important step in reducing adult disparities for lesbian, gay, and bisexual women.

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