Using structural equation modeling to assess pathways between structural stigma and tobacco use among sexual and gender minority young adults living in the United States

Using structural equation modeling to assess pathways between structural stigma and tobacco use among sexual and gender minority young adults living in the United States | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Using structural equation modeling to assess pathways between structural stigma and tobacco use among sexual and gender minority young adults living in the United States Wilson Figueroa, Srini Sridhar, Emma Jankowski, Alysha Ennis, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5417843/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 08 May, 2025 Read the published version in International Journal for Equity in Health → Version 1 posted 15 You are reading this latest preprint version Abstract Background: Sexual and gender minority young adult (SGM YA) populations use tobacco at higher rates than their non-SGM YA peers. Prior studies have identified significant correlations between interpersonal stigma and tobacco use, yet structural stigma may also influence tobacco use among SGM YA. This study aimed to assess the indirect effects of structural stigma on current tobacco use among SGM YA and non-SGM YA via depletion of economic resources, interpersonal discrimination, and perceived psychological stress. Methods : Structural Equation Modeling was used to conduct a secondary data analysis from a cross-sectional parent study. Eligible participants were 18-35 years old and currently residing in the U.S. (N = 2,857). Current use of combustible cigarettes and nicotine vapes was our dependent variable. Our independent variable of interest, structural stigma, was a latent variable comprised of three state-level indicator items: Attitudes toward SGM people, SGM protective policies (absence of), and SGM discriminatory policies (introduced or passed in 2022). We assessed three mediators of interest: Depletion of economic resources was a latent variable, which included two indicator items: food insecurity and financial strain. Interpersonal discrimination and perceptions of psychological stress were also assessed. Covariates included race/ethnicity, age, and educational attainment. Results: Structural stigma was indirectly associated with current tobacco use via depletion of economic resources for SGM YA, but not non-SGM YA. Interpersonal discrimination was also directly and indirectly associated with current tobacco use via depletion of economic resources for both groups. Conclusions: Future tobacco intervention research should consider the role of structural stigma when working with SGM YA; specifically, how interventions promoting economic stability may influence tobacco use and cessation in this population . Structural Stigma Tobacco use Economic Stability Sexual and Gender Minorities Structural Equation Modeling Figures Figure 1 Figure 2 BACKGROUND Sexual and gender minority young adult (SGM YA) populations use tobacco at significantly higher rates than their non-SGM YA peers, with disparities beginning in adolescence and continuing into young adulthood.[ 1 – 3 ] Minority stress theory purports that the unique multilevel stressors experienced by SGM YA lead them to engage in risky health behaviors (such as nicotine vape and cigarette use) at higher rates.[ 4 ] Prior studies have identified significant correlations between minority stressors and tobacco use; however, most of these studies have focused on individual and interpersonal stigma, including experiences of internalized queerphobia and perceived discrimination.[ 5 ] Yet, structural or societal-level stressors may also influence tobacco use among SGM YA. Structural stigma has been defined as “societal-level conditions, cultural norms, and institutional policies that constrain the opportunities, resources, and wellbeing” of minoritized populations.[ 6 ] In 2023, there were 510 anti-SGM bills introduced in state legislatures in the United States (US), a three-fold increase from the previous year. This trend is continuing in 2024, with 527 anti-SGM bills introduced into state legislatures to date. These bills span a variety of issues, from laws prohibiting free speech and expression to those limiting healthcare access for SGM people.[ 7 ] A recent narrative review of quantitative studies examining the effect of structural stigma on SGM health found that, to date, 14 studies have examined how structural stigma is associated with tobacco use among SGM.[ 8 ] These studies examined a diverse set of exposures and reported mixed results. Seven studies found that protective structural factors (e.g., community supportiveness, anti-discrimination laws) decreased rates of smoking among SGM youth and young adults.[ 9 – 15 ] An additional three studies found that greater levels of structural stigma (e.g., negative community attitudes, discriminatory policies) were associated with higher rates of tobacco use.[ 16 – 18 ] The remaining studies demonstrated mixed effects. For example, a study of US adults indicated that legalization of same sex relationships led to higher smoking among women in same sex households but not men.[ 19 ] None of these studies examined mediating mechanisms by which structural stigma may influence tobacco use among SGM YA. Ecological models of population health suggest that upstream factors, such as living in SGM discriminatory contexts (i.e., experiencing structural stigma), deplete the economic resources available to SGM people and increase interpersonal discrimination experiences, ultimately leading to increased psychological stress and maladaptive coping behaviors.[ 20 ] Previous work supports this hypothesis, though this work is sparse, with only 10% of studies examining structural stigma and its relation to health having examined mediating effects.[ 8 ] The extant literature has predominantly explored interpersonal and individual-level minority stress (e.g., discrimination experiences, internalized queerphobia) as candidate mechanisms between structural stigma and mental health outcomes.[ 8 ] Generally, these studies find that SGM youth and adults living in states with high structural stigma (vs low structural stigma) experience greater interpersonal and internalized minority stress, which is associated with poor mental health. No studies examined economic factors as candidate mechanisms between structural stigma and poor health outcomes. However, in one study of gay men, individuals living in states with greater structural stigma (defined as prejudicial attitudes) reported decreased wages, and prejudice coming from their workplace managers was found to mediate this association.[ 21 ] Together, this body of theoretical and empirical research suggests that structural stigma may be influencing health outcomes among SGM people through several mediating mechanisms. Purpose of the Study This study builds on the limited evidence testing the mechanisms through which structural stigma influences SGM health behaviors. We aimed to assess the indirect effects of structural stigma on current tobacco use among SGM YA and cisgender heterosexual YA (non-SGM YA). Consistent with ecological and minority stress models, we examined the potential pathways that may create and exacerbate disparities in tobacco use. Specifically, we were interested in how the depletion of economic resources, interpersonal discrimination, and perceived psychological stress might mediate the relationship between structural stigma and current tobacco use among SGM and non-SGM YA. METHODS Study Design This study is a secondary data analysis from a larger, cross-sectional parent study meant to evaluate the effectiveness of tobacco public health education messages among young adults. Prolific ( https://www.prolific.co/ ), an online subject recruitment platform, was used to recruit participants, due to its large access to US nationals (~ 38.000), its base of young adults (approximately one-third are < 35 years old), and its effectiveness for reaching minoritized populations, including SGM people. The parent study purposively oversampled SGM people, people who smoke cigarettes, and people who vape nicotine. We also sampled proportionally for each racial/ethnic group per US Census 2020 estimates. Potential participants were prescreened via Prolific. Those who met the eligibility criteria of being aged 18–35 years old and currently residing in the US were directed to an online consent form. After consenting, participants (N = 2,857) were directed to a Qualtrics survey. They received $ 4.50 for participating. The parent study was approved by The Ohio State University Institutional Review Board (2021C0020).). Measures Measures are described in detail in Table 1. Our sample included two subgroups of interest: SGM YA and non-SGM YA. We used two items to assess participants’ self-reported sexual identity group and self-reported gender identity group. Individuals identifying with sexual or gender minority identity groups (e.g., lesbian, gay, bisexual, queer, transgender, nonbinary) were defined as SGM; those identifying with cisgender and heterosexual groups were defined as non-SGM. Our dependent variable, current tobacco use, was a latent variable comprised of two indicator items: past 30-day use of combustible cigarettes or past 30-day use of nicotine vapes. Our independent variable of interest, structural stigma, was a latent variable comprised of three state-level indicator items: Attitudes toward SGM people, SGM protective policies (absence of), and SGM discriminatory policies (introduced or passed in 2022). We assessed three mediators of interest: Depletion of economic resources was a latent variable, which included two indicator items. The first assessed past 12-month experiences of food insecurity and the second assessed perceived financial strain. Interpersonal discrimination was assessed using the everyday discrimination scale, which assesses self-reported frequency of daily discrimination experiences in social situations.[ 22 ] We used a general measure of discrimination rather than assessing SGM-specific discrimination experiences so that we could assess the influence of this hypothesized mediator on tobacco use among non-SGM YA. Finally, the four-item Perceived Stress Scale was used to assess individual perceptions of psychological stress.[ 23 ] Covariates included race/ethnicity, age, and educational attainment. Table 1. Survey Measures Analysis A comprehensive investigation was conducted using Structural Equation Modeling (SEM) to examine the association between structural stigma and current tobacco use, including combustible cigarettes and nicotine vapes. This study employed SEM with Maximum Likelihood Estimation (MLE) to examine the relationship between multiple variables, considering their direct and indirect effects on current tobacco use. All SEM analyses were performed in R (V 4·2·2) using the Lavaan package (0·6–16). Modification indices were inspected for significant areas of model misfit; however, none were detected so model adjustment was not necessary. Model fit was evaluated using the following fit indices: Comparative Fit Index (CFI), Root Mean Square Error of Approximation (RMSEA), and Standardized Root Mean Squared Residual (SRMR). Indicators of acceptable model fit were considered as CFI > 0·9, RMSEA < 0·06, and SRMR < 008. An alpha of ·05 was used to indicate statistically significant pathways between constructs. RESULTS Sample Description As shown in Table 2, across both groups (n = 1,288 SGM and n = 1,368 heterosexual), most participants were White (64% SGM, 55% non-SGM) and had similar current use of nicotine vapes (35% SGM, 36% heterosexual). More non-SGM than SGM YA were Black, Indigenous, and People of Color (BIPOC; 45% vs 36%), aged 25–35 years (31% vs 26%), held a four-year degree or higher (53% vs 47%), and currently smoked combustible cigarettes (31% vs 26%). SGM YA reported greater financial strain (M = 5·35 vs. M = 4·62), food insecurity (M = 4·24 vs. M = 3·62), interpersonal discrimination (M = 11·98 vs. 10·47), and perceived stress (M = 8·61 vs. 7·26) compared to non-SGM YA. Preliminary analyses Bivariate correlations among all measured variables are presented in Table 3. Among non-SGM YA, our indicator variables of structural stigma (attitudes towards SGM individuals, SGM discriminatory bills, absence of SGM protective policies) were not significantly associated with our outcome variables (current combustible cigarette and nicotine vape use). Other than financial strain (r = 0·06, p < 0·05), our indicator variables of structural stigma were not related to mediators nor covariates. However, there was a significant positive intercorrelation between our measures of financial strain, food insecurity, interpersonal discrimination, and perceived stress. Finally, all covariates (age, race, and education) were significantly associated with our outcome variables. For race, being a race other than White was associated with increased current use of combustible cigarettes and nicotine vapes. For education, having less than a four-year degree was associated with increased current use of combustible cigarettes and nicotine vapes. For age, being between 25–35 years was associated with greater current use of combustible cigarettes, while being between 18–24 years was associated with greater current use of nicotine vapes. Latinx ethnicity was not significantly associated with our outcome variables among non-SGM YA. Among SGM YA, like non-SGM YA, none of our indicator variables of structural stigma were directly associated with current use of combustible cigarettes or nicotine vapes. However, discriminatory bills under consideration were positively associated with financial strain and enacted discriminatory bills were positively associated with food insecurity. There was a significant positive intercorrelation between our measures of financial strain, food insecurity, experiences of interpersonal discrimination, and perceived stress. Finally, like non-SGM YA, being between 25–35 years was associated with greater current use of combustible cigarettes, while being between 18–24 years was associated with greater current use of nicotine vapes for SGM YA. No other covariates were associated with outcome variables among the SGM group. Table 3. Correlation among measured variables, Heterosexual Table 3 (continued). Correlation among measured variables, SGM Minority Stress Model: SEM was used to test the hypothesized model (Figs. 1 and 2), examining the indirect effects of structural stigma (i.e., discriminatory attitudes, discriminatory policies, and absence of protective policies) on current tobacco use among subpopulations of SGM and non-SGM YA. Depletion of economic resources (i.e., food insecurity and financial strain) and perceived discrimination experiences were assessed as mediators between structural stigma and current tobacco use. The data fit for both SGM YA (χ 2 = 267·5, p < 0·05, CFI = 0·92, SRMR = 0·05, RMSEA = 0·06; Fig. 1) and non-SGM YA (χ 2 = 234·6, p < 0·05, CFI = 0·95, SRMR = 0·05, RMSEA = 0·05; Fig. 2). Figure 1. Structural Equation Model assessing theoretically informed pathways between structural stigma and current tobacco use among sexual and gender minority (SGM) young adults Figure 2. Structural Equation Model assessing theoretically informed pathways between structural stigma and current tobacco use among cisgender heterosexual (non-SGM) young adults Table 4. Indirect effects of structural stigma, economic depletion, and interpersonal discrimination on current use of combustible cigarettes or nicotine vapes. Pathways between structural stigma and current tobacco use among SGM YA The final model accounted for 5.5% of the variance in current tobacco use among SGM YA. Structural stigma was indirectly associated with greater current tobacco use through depletion of economic resources for the SGM YA group (β = 0·01, z = 2·16, p < 0·05, Table 4). This indicates that greater structural stigma is associated with greater depletion of economic resources which, in turn, is associated with increased current tobacco use among our sample of SGM YA. Pathways between interpersonal discrimination and current tobacco use among SGM YA Experiencing interpersonal discrimination was both directly and indirectly, via depletion of economic resources, associated with greater current tobacco use among SGM YA. As seen in Table 4, the indirect effect of interpersonal discrimination on current tobacco use was statistically significant (β = 0·06, z = 3.01, p < 0·01). Pathways between perceived stress and current tobacco use among SGM YA Depletion of economic resources and experiencing interpersonal discrimination were also both directly associated with perceived stress, yet there was no association between perceived stress and current tobacco use for SGM YA. Pathways between structural stigma and current tobacco use among non-SGM YA The final model accounted for 11·7% of the variance in current tobacco use for the non-SGM YA group. While structural stigma was significantly associated with depletion of economic resources among non-SGM YA, there was not a significant indirect pathway linking structural stigma and current tobacco use via depletion of economic resources for non-SGM YA. Pathways between interpersonal discrimination and current tobacco use among non-SGM YA Experiencing interpersonal discrimination was both directly and indirectly, via depletion of economic resources, associated with greater current tobacco use among non-SGM YA. As seen in Table 4, the indirect effect of interpersonal discrimination on current tobacco use was statistically significant (β = 0·04, z = 2·12, p < 0·05). Pathways between perceived stress and current tobacco use among non-SGM YA Depletion of economic resources and experiencing interpersonal discrimination were also both directly associated with perceived stress, yet there was no association between perceived stress and current tobacco use for non-SGM YA. Covariate associations with current tobacco use In terms of covariates, age was significantly associated with current tobacco use for non-SGM YA, indicating that individuals ages 25–35 years were more likely to use tobacco compared to those aged 18–24 years. Additionally, race was associated with current tobacco use only for non-SGM YA, indicating that more BIPOC YA in this group reported current tobacco use more than White YA. Discussion Our study is one of the first to assess how structural stigma may influence current tobacco use among SGM and non-SGM YA via theoretically informed pathways. Results indicated that structural stigma was indirectly associated with current tobacco use through the depletion of economic resources (increased financial strain and food insecurity) for SGM YA, but not for non-SGM YA. Additionally, interpersonal discrimination was both directly and indirectly, via depletion of economic resources, associated with current tobacco use for both SGM and non-SGM YA. Previous research examining food insecurity among SGM individuals has found that states with Religious Freedom Restoration Acts or “religious freedom” laws allow institutions, including food pantries, to deny services to select community members, such as SGM YA, based on religious beliefs.[24] Such laws may contribute to the higher rates of food insecurity seen in SGM compared to non-SGM individuals.[25] Food insecurity has been linked to tobacco use in a variety of vulnerable populations.[26] Although previous research has indicated that the direction of the association is unclear (i.e., causality cannot be established given that the majority of studies, including the present one, have been cross-sectional in nature), both financial strain and stress have been suggested as possible mechanisms that link food insecurity to tobacco use.[26] Longitudinal studies are needed to further examine the directionality of the association between food insecurity and tobacco use. Nevertheless, our results indicate depletion of economic resources may be one mechanism by which structural stigma and interpersonal discrimination influence current tobacco use among SGM YA. Given the well documented disparities in tobacco use among SGM YA, future tobacco intervention studies should consider food insecurity and financial strain as points of intervention for this population. In a recent narrative review examining the role of structural stigma on health outcomes (including behavioral health), a conceptual model was proposed indicating that interpersonal discrimination may mediate the association between structural stigma and behavioral health (i.e., current tobacco use) outcomes.[8] However, our study is one of the first to examine the pathway proposed by this conceptual model (i.e., structural stigma →interpersonal discrimination→behavioral health outcomes). In our study, structural stigma was not indirectly associated with current tobacco use via interpersonal discrimination. This null finding for an indirect pathway between structural stigma and current tobacco use via interpersonal discrimination may be due to construct operationalization. While our structural stigma measure was SGM-specific, our interpersonal discrimination measure assessed perceptions of interpersonal discrimination for any reason (e.g., due to SGM identity, race/ethnicity, religion body size, physical ability, etc.) so that we could assess this construct among non-SGM YA. However, similar to prior studies[5], we identified a direct association between interpersonal discrimination and current tobacco use. As mentioned previously, longitudinal studies are needed to examine how structural stigma may influence interpersonal discrimination over time and how this, in turn, may influence current tobacco use among SGM YA. This work should include measures assessing SGM-specific interpersonal discrimination, which may be more closely associated with structural stigma. Our study has limitations, including the use of cross-sectional data and the lack of a sufficient sample size to examine the SGM YA subgroup (e.g., bisexual vs gay, or by gender identity) as a moderator. Nevertheless, our study addressed several gaps identified previously in the literature and is one of the few to conduct mediational analyses examining the indirect effects of structural stigma on health outcomes among SGM YA. Previous research[17,18] indicates a need to examine how structural stigma may indirectly influence tobacco use among SGM individuals, specifically, and our study is one of the first to examine this association as it relates to current tobacco use in SGM YA. Our study also addresses a gap identified in the literature[8] by including a non-SGM YA comparison group. In doing so, we demonstrated that structural stigma is associated with current tobacco use, via depletion of economic resources, for SGM YA only. Given unprecedented increases in legislation targeting SGM rights, identifying intervention points to attenuate the negative effects of structural stigma on tobacco use is critical for promoting SGM health across the life course. Conclusions In conclusion, although the association between structural stigma and health in general has been well established among SGM, our study is one the first to examine the indirect effects of structural stigma on current tobacco use specifically among a highly vulnerable population, SGM YA. Future tobacco cessation and harm reduction intervention research should consider the role of structural stigma when working with SGM YA; specifically, how interventions promoting economic stability may influence tobacco use and cessation in this population. It will also be important to examine how changes in general attitudes towards SGM individuals and lack of protective policy and discriminatory policy toward SGM individuals influences tobacco use in SGM YA over time, as previous research has indicated that improvements in structural stigma may be associated with improvement in life satisfaction in this population.[27] Abbreviations BIPOC: Black, Indigenous, and People of Color CFI: Comparative Fit index MLE: Maximum Likelihood Estimation RMSEA: Root Mean Square Error of Approximation SEM: Structural Equation Modeling SGMYA: Sexual and gender minority young adult SGM: Sexual and gender minority SRMR: Standardized Root Mean Squared Residual YA: young adults Declarations Ethics approval and consent to participate The parent study was approved by The Ohio State University Institutional Review Board, which adheres to the ethical principles for the protection of research participants summarized in the Belmont Report and complies with federal regulations, guidance, and state laws related to human subjects protection, (2021C0020). All participants consented prior to completing the survey. Data availability statement Data and relevant code is available upon reasonable request from the PI (JGP). Funding Research reported in this publication was supported by the National Cancer Institute of the National Institutes of Health and the FDA Center for Tobacco Products under Award Numbers K99CA260718 and R00CA260718 (PI: JGP). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health or Food and Drug Administration. This study was supported by The Ohio State University (OSU) James-Comprehensive Cancer Center's Center for Tobacco Research and The OSU College of Public Health . Conflict of interests We have no conflicts of interest to disclose. Acknowledgements section: Thank you to all members of the Practice and Science for LGBTQ+ Health Equity Lab for their contributions to the parent study. AUTHOR CONTRIBUTIONS W.F.: Conceptualization, Methodology, Formal analysis, Writing ­– original draft, review and editing S.S.: Lead Formal Analysis, Writing-original draft E.J.: Data curation, Project administration, Writing- original draft, review and editing A.C.E.: Data curation, Project administration, Writing-review and editing A.T..: Writing-review and editing E.S.: Writing-review and editing J.G.P.: Funding Acquisition, Conceptualization, Methodology, Data curation, Project administration, Writing – original draft, review and editing References Drope J, Liber AC, Cahn Z, Stoklosa M, Kennedy R, Douglas CE, et al. Who’s still smoking? Disparities in adult cigarette smoking prevalence in the United States. CA Cancer J Clin [Internet]. 2018 [cited 2024 May 6];68:106–15. Available from: https://acsjournals.onlinelibrary.wiley.com/doi/10.3322/caac.21444 Hinds JT, Loukas A, Perry CL. Sexual and Gender Minority College Students and Tobacco Use in Texas. Nicotine Tob Res [Internet]. 2018 [cited 2024 May 6];20:383–7. Available from: https://academic.oup.com/ntr/article/20/3/383/3791455 Krueger EA, Braymiller JL, Barrington-Trimis JL, Cho J, McConnell RS, Leventhal AM. Sexual minority tobacco use disparities across adolescence and the transition to young adulthood. Drug Alcohol Depend. 2020;217:108298. Meyer IH, Frost DM. Minority Stress and the Health of Sexual Minorities. In: Patterson CJ, D’Augelli AR, editors. Handb Psychol Sex Orientat [Internet]. Oxford University Press; 2012 [cited 2023 Sep 29]. p. 252–66. Available from: https://academic.oup.com/book/6050/chapter/149494151 Li M, Chau K, Calabresi K, Wang Y, Wang J, Fritz J, et al. The Effect of Minority Stress Processes on Smoking for Lesbian, Gay, Bisexual, Transgender, and Queer Individuals: A Systematic Review. LGBT Health [Internet]. 2024 [cited 2024 May 2];lgbt.2022.0323. Available from: https://www.liebertpub.com/doi/10.1089/lgbt.2022.0323 Hatzenbuehler ML, Link BG. Introduction to the special issue on structural stigma and health. Soc Sci Med [Internet]. 2014 [cited 2024 May 2];103:1–6. Available from: https://linkinghub.elsevier.com/retrieve/pii/S0277953613007090 American Civil Liberties Union. Mapping Attacks on LGBTQ Rights in U.S. State Legislatures in 2023 [Internet]. American Civil Liberties Union; 2023 Dec. Available from: https://www.aclu.org/legislative-attacks-on-lgbtq-rights-2023 Hatzenbuehler ML, Lattanner MR, McKetta S, Pachankis JE. Structural stigma and LGBTQ+ health: a narrative review of quantitative studies. Lancet Public Health [Internet]. 2024 [cited 2024 May 2];9:e109–27. Available from: https://linkinghub.elsevier.com/retrieve/pii/S2468266723003122 Drabble LA, Munroe C, Mericle AA, Zollweg S, Trocki KF, Karriker-Jaffe KJ. Impact of the policy environment on substance use among sexual minority women. Drug Alcohol Depend Rep. 2022;3:100058. Hatzenbuehler ML, Wieringa NF, Keyes KM. Community-Level Determinants of Tobacco Use Disparities in Lesbian, Gay, and Bisexual Youth: Results From a Population-Based Study. Arch Pediatr Adolesc Med [Internet]. 2011 [cited 2024 May 2];165:527–32. Available from: http://archpedi.jamanetwork.com/article.aspx?doi=10.1001/archpediatrics.2011.64 Hatzenbuehler ML, Jun H-J, Corliss HL, Austin SB. Structural stigma and cigarette smoking in a prospective cohort study of sexual minority and heterosexual youth. Ann Behav Med Publ Soc Behav Med. 2014;47:48–56. Hatzenbuehler ML, Flores AR, Gates GJ. Social Attitudes Regarding Same‐Sex Marriage and LGBT Health Disparities: Results from a National Probability Sample. J Soc Issues [Internet]. 2017 [cited 2024 May 2];73:508–28. Available from: https://spssi.onlinelibrary.wiley.com/doi/10.1111/josi.12229 Poteat VP, Sinclair KO, DiGiovanni CD, Koenig BW, Russell ST. Gay–Straight Alliances Are Associated With Student Health: A Multischool Comparison of LGBTQ and Heterosexual Youth. J Res Adolesc [Internet]. 2013 [cited 2024 May 2];23:319–30. Available from: https://onlinelibrary.wiley.com/doi/10.1111/j.1532-7795.2012.00832.x Watson RJ, Park M, Taylor AB, Fish JN, Corliss HL, Eisenberg ME, et al. Associations Between Community-Level LGBTQ-Supportive Factors and Substance Use Among Sexual Minority Adolescents. LGBT Health. 2020;7:82–9. Watson RJ, Fish JN, Denary W, Caba A, Cunningham C, Eaton LA. LGBTQ state policies: A lever for reducing SGM youth substance use and bullying. Drug Alcohol Depend. 2021;221:108659. Pachankis JE, Hatzenbuehler ML, Bränström R, Schmidt AJ, Berg RC, Jonas K, et al. Structural stigma and sexual minority men’s depression and suicidality: A multilevel examination of mechanisms and mobility across 48 countries. J Abnorm Psychol [Internet]. 2021 [cited 2024 May 2];130:713–26. Available from: https://doi.apa.org/doi/10.1037/abn0000693 Titus AR, Gamarel KE, Thrasher JF, Meza R, Fleischer NL. State-Level Structural Stigma and Smoking Among Sexual Minority Adults in the USA, 2012-2014. Ann Behav Med Publ Soc Behav Med. 2020;55:557–70. White BP, Abuelezam NN, Fontenot HB, Jurgens CY. Exploring Relationships Between State-Level LGBTQ Inclusivity and BRFSS Indicators of Mental Health and Risk Behaviors: A Secondary Analysis. J Am Psychiatr Nurses Assoc [Internet]. 2023 [cited 2024 May 2];29:224–31. Available from: http://journals.sagepub.com/doi/10.1177/10783903211007900 Carpenter CS, Eppink ST, Gonzales G, McKay T. Effects of Access to Legal Same‐Sex Marriage on Marriage and Health. J Policy Anal Manage [Internet]. 2021 [cited 2024 May 2];40:376–411. Available from: https://onlinelibrary.wiley.com/doi/10.1002/pam.22286 Warnecke RB, Oh A, Breen N, Gehlert S, Paskett E, Tucker KL, et al. Approaching Health Disparities From a Population Perspective: The National Institutes of Health Centers for Population Health and Health Disparities. Am J Public Health. 2008;98:1608–15. The Relationship between Prejudice and Wage Penalties for Gay Men in the United States - Ian Burn, 2020 [Internet]. [cited 2024 Jul 19]. Available from: https://journals.sagepub.com/doi/full/10.1177/0019793919864891?casa_token=DHkTfZz5v4UAAAAA%3A1M4ZwaeVLzbzp_hHxOIAU0qJXeCIArAA-GNx6f0p9IiCH1puPoAqkMK5WnNtOPG5TeMRbktX1IPg Williams DR, Yan Yu null, Jackson JS, Anderson NB. Racial Differences in Physical and Mental Health: Socio-economic Status, Stress and Discrimination. J Health Psychol. 1997;2:335–51. Cohen S. Perceived stress in a probability sample of the United States. Soc Psychol Health. Thousand Oaks, CA, US: Sage Publications, Inc; 1988. p. 31–67. National Conference of State Legislatures. 2017 Religious Freedom Restoration Act Legislation [Internet]. National Conference of State Legislatures; 2017. Available from: https://www.ncsl.org/research/civil-and-criminal-justice/2017-religious-freedom-restoration-act-legislation Hasenbush A, Flores AR, Kastanis A, Sears B, Gates GJ. The LGBT divide: A data portrait of LGBT people in the midwestern, mountain & southern states [Internet]. The Williams Institute; 2014. Available from: https://escholarship.org/content/qt17m036q5/qt17m036q5_noSplash_76bbb27af26d1e610afb63d07a9c903f.pdf Kim-Mozeleski JE, Pandey R. The Intersection of Food Insecurity and Tobacco Use: A Scoping Review. Health Promot Pract. 2020;21:124S-138S. Bränström R, Pachankis JE. Structural Stigma and 7-Year Improvement in Life Satisfaction among Diverse Groups of Sexual Minority Individuals: A Repeated Cross-Sectional Study across 28 Countries. Soc Probl. 2023;spad029. Tables Tables 1 to 4 are available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files Table1.MeasuresIJHE.docx Table2descriptivesIJEH.docx Table3.CorrelationTableIJHE.docx Table4.IndirectpathwaysIJHE.docx Cite Share Download PDF Status: Published Journal Publication published 08 May, 2025 Read the published version in International Journal for Equity in Health → Version 1 posted Editorial decision: Revision requested 10 Feb, 2025 Reviews received at journal 10 Feb, 2025 Reviews received at journal 02 Feb, 2025 Reviews received at journal 29 Jan, 2025 Reviewers agreed at journal 13 Jan, 2025 Reviewers agreed at journal 11 Jan, 2025 Reviewers agreed at journal 08 Jan, 2025 Reviews received at journal 07 Jan, 2025 Reviewers agreed at journal 07 Jan, 2025 Reviewers agreed at journal 06 Jan, 2025 Reviewers agreed at journal 06 Jan, 2025 Reviewers invited by journal 02 Dec, 2024 Editor assigned by journal 17 Nov, 2024 Submission checks completed at journal 13 Nov, 2024 First submitted to journal 08 Nov, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5417843","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":386356730,"identity":"b0a336f9-7584-49c3-8116-a9b46ce19d7e","order_by":0,"name":"Wilson Figueroa","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA7ElEQVRIiWNgGAWjYBAC9mYYi5n58IMPEKYBXi08h+Ga2dIMZxCl5QCMxc9jIM1DlBZ29msSH/fYyDMwMxgY21TUJTawN2+TwKuFmadMcsazNMMGZoaExzlnDic28Bwrw6vFnpknTZrnwGFGoJYDxrltBxIbJHLMCNmSJv3nwGH7BmbGBmnLNqDD5N8Q0sJ+TJrhANA9zMwM0oxtzEBbeAjawmzZcyAtuY2Zjc2w58xh4zaetGILvFr4jz+88eOAjW0///nPD35U1Mn2sx/eeAOfFqAmSCywwfhsOFXCAfsDwmpGwSgYBaNgZAMAPBVAbgLO6C8AAAAASUVORK5CYII=","orcid":"","institution":"The Ohio State University","correspondingAuthor":true,"prefix":"","firstName":"Wilson","middleName":"","lastName":"Figueroa","suffix":""},{"id":386356731,"identity":"9d03c8d3-0b08-463e-a65a-5fbfa0a89b7c","order_by":1,"name":"Srini Sridhar","email":"","orcid":"","institution":"The Ohio State University","correspondingAuthor":false,"prefix":"","firstName":"Srini","middleName":"","lastName":"Sridhar","suffix":""},{"id":386356732,"identity":"7852c046-8cd8-4d8b-97a3-09e4b7405a61","order_by":2,"name":"Emma Jankowski","email":"","orcid":"","institution":"The Ohio State University","correspondingAuthor":false,"prefix":"","firstName":"Emma","middleName":"","lastName":"Jankowski","suffix":""},{"id":386356733,"identity":"8fffa492-05df-49c4-9712-468a11ccfe15","order_by":3,"name":"Alysha Ennis","email":"","orcid":"","institution":"The Ohio State University","correspondingAuthor":false,"prefix":"","firstName":"Alysha","middleName":"","lastName":"Ennis","suffix":""},{"id":386356734,"identity":"0b320e10-601f-4210-a56e-11e4d0edfcb1","order_by":4,"name":"Anne Trinh","email":"","orcid":"","institution":"The Ohio State University","correspondingAuthor":false,"prefix":"","firstName":"Anne","middleName":"","lastName":"Trinh","suffix":""},{"id":386356735,"identity":"535d4711-6ba9-4b7b-9f0d-6985fcc96f6b","order_by":5,"name":"Eric Seiber","email":"","orcid":"","institution":"The Ohio State University","correspondingAuthor":false,"prefix":"","firstName":"Eric","middleName":"","lastName":"Seiber","suffix":""},{"id":386356736,"identity":"3237c962-d470-4684-9b1a-3121194b5969","order_by":6,"name":"Joanne Patterson","email":"","orcid":"","institution":"The Ohio State University","correspondingAuthor":false,"prefix":"","firstName":"Joanne","middleName":"","lastName":"Patterson","suffix":""}],"badges":[],"createdAt":"2024-11-08 16:23:18","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5417843/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5417843/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12939-025-02487-2","type":"published","date":"2025-05-08T15:57:50+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":71634910,"identity":"8fb3f636-0f0d-4bd4-b49e-d4df78c68dfc","added_by":"auto","created_at":"2024-12-17 10:01:05","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":240827,"visible":true,"origin":"","legend":"\u003cp\u003eStructural Equation Model assessing theoretically informed pathways between structural stigma and current tobacco use among sexual and gender minority (SGM) young adults\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-5417843/v1/e35642da176b5d50320bb648.png"},{"id":71633502,"identity":"ea3abb9e-330c-46c0-8805-b21466a3cf08","added_by":"auto","created_at":"2024-12-17 09:53:05","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":144541,"visible":true,"origin":"","legend":"\u003cp\u003eStructural Equation Model assessing theoretically informed pathways between structural stigma and current tobacco use among cisgender heterosexual (non-SGM) young adults\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-5417843/v1/e2f707f6a40638ac8a68d01e.png"},{"id":82537628,"identity":"9d9c4cec-e923-4d33-9346-dbfceaf5e3d9","added_by":"auto","created_at":"2025-05-12 16:09:28","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1351073,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5417843/v1/ea7faa94-ef14-46f4-b025-e8bf155a7017.pdf"},{"id":71633499,"identity":"05c40761-65f3-40bc-bd56-91acd75c0c80","added_by":"auto","created_at":"2024-12-17 09:53:05","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":40999,"visible":true,"origin":"","legend":"","description":"","filename":"Table1.MeasuresIJHE.docx","url":"https://assets-eu.researchsquare.com/files/rs-5417843/v1/450283ee51adfd54e4ecb25c.docx"},{"id":71633498,"identity":"35cbfb56-b651-4939-abd8-1a7607ed75a1","added_by":"auto","created_at":"2024-12-17 09:53:05","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":26494,"visible":true,"origin":"","legend":"","description":"","filename":"Table2descriptivesIJEH.docx","url":"https://assets-eu.researchsquare.com/files/rs-5417843/v1/bc98bd6b657ccff30881420d.docx"},{"id":71633507,"identity":"757c8e51-723e-4b76-a33d-52f3a1fcfb32","added_by":"auto","created_at":"2024-12-17 09:53:05","extension":"docx","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":34260,"visible":true,"origin":"","legend":"","description":"","filename":"Table3.CorrelationTableIJHE.docx","url":"https://assets-eu.researchsquare.com/files/rs-5417843/v1/bf1ed77968c3a1be86db9903.docx"},{"id":71634911,"identity":"f45f6903-09a7-415e-9531-b567b5585252","added_by":"auto","created_at":"2024-12-17 10:01:05","extension":"docx","order_by":4,"title":"","display":"","copyAsset":false,"role":"supplement","size":25502,"visible":true,"origin":"","legend":"","description":"","filename":"Table4.IndirectpathwaysIJHE.docx","url":"https://assets-eu.researchsquare.com/files/rs-5417843/v1/d7ec3f32340c3c4adc07a9fb.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Using structural equation modeling to assess pathways between structural stigma and tobacco use among sexual and gender minority young adults living in the United States","fulltext":[{"header":"BACKGROUND","content":"\u003cp\u003eSexual and gender minority young adult (SGM YA) populations use tobacco at significantly higher rates than their non-SGM YA peers, with disparities beginning in adolescence and continuing into young adulthood.[\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e–\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] Minority stress theory purports that the unique multilevel stressors experienced by SGM YA lead them to engage in risky health behaviors (such as nicotine vape and cigarette use) at higher rates.[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e] Prior studies have identified significant correlations between minority stressors and tobacco use; however, most of these studies have focused on individual and interpersonal stigma, including experiences of internalized queerphobia and perceived discrimination.[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] Yet, structural or societal-level stressors may also influence tobacco use among SGM YA.\u003c/p\u003e \u003cp\u003eStructural stigma has been defined as “societal-level conditions, cultural norms, and institutional policies that constrain the opportunities, resources, and wellbeing” of minoritized populations.[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] In 2023, there were 510 anti-SGM bills introduced in state legislatures in the United States (US), a three-fold increase from the previous year. This trend is continuing in 2024, with 527 anti-SGM bills introduced into state legislatures to date. These bills span a variety of issues, from laws prohibiting free speech and expression to those limiting healthcare access for SGM people.[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] A recent narrative review of quantitative studies examining the effect of structural stigma on SGM health found that, to date, 14 studies have examined how structural stigma is associated with tobacco use among SGM.[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] These studies examined a diverse set of exposures and reported mixed results. Seven studies found that protective structural factors (e.g., community supportiveness, anti-discrimination laws) decreased rates of smoking among SGM youth and young adults.[\u003cspan additionalcitationids=\"CR10 CR11 CR12 CR13 CR14\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e–\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] An additional three studies found that greater levels of structural stigma (e.g., negative community attitudes, discriminatory policies) were associated with higher rates of tobacco use.[\u003cspan additionalcitationids=\"CR17\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e–\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] The remaining studies demonstrated mixed effects. For example, a study of US adults indicated that legalization of same sex relationships led to higher smoking among women in same sex households but not men.[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] None of these studies examined mediating mechanisms by which structural stigma may influence tobacco use among SGM YA.\u003c/p\u003e \u003cp\u003eEcological models of population health suggest that upstream factors, such as living in SGM discriminatory contexts (i.e., experiencing structural stigma), deplete the economic resources available to SGM people and increase interpersonal discrimination experiences, ultimately leading to increased psychological stress and maladaptive coping behaviors.[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] Previous work supports this hypothesis, though this work is sparse, with only 10% of studies examining structural stigma and its relation to health having examined mediating effects.[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] The extant literature has predominantly explored interpersonal and individual-level minority stress (e.g., discrimination experiences, internalized queerphobia) as candidate mechanisms between structural stigma and mental health outcomes.[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] Generally, these studies find that SGM youth and adults living in states with high structural stigma (vs low structural stigma) experience greater interpersonal and internalized minority stress, which is associated with poor mental health. No studies examined economic factors as candidate mechanisms between structural stigma and poor health outcomes. However, in one study of gay men, individuals living in states with greater structural stigma (defined as prejudicial attitudes) reported decreased wages, and prejudice coming from their workplace managers was found to mediate this association.[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e] Together, this body of theoretical and empirical research suggests that structural stigma may be influencing health outcomes among SGM people through several mediating mechanisms.\u003c/p\u003e\n\u003ch3\u003ePurpose of the Study\u003c/h3\u003e\n\u003cp\u003eThis study builds on the limited evidence testing the mechanisms through which structural stigma influences SGM health behaviors. We aimed to assess the indirect effects of structural stigma on current tobacco use among SGM YA and cisgender heterosexual YA (non-SGM YA). Consistent with ecological and minority stress models, we examined the potential pathways that may create and exacerbate disparities in tobacco use. Specifically, we were interested in how the depletion of economic resources, interpersonal discrimination, and perceived psychological stress might mediate the relationship between structural stigma and current tobacco use among SGM and non-SGM YA.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003cdiv id=\"Sec4\" class=\"Section3\"\u003e \u003c/div\u003e \u003c/div\u003e\n\n \n\n"},{"header":"METHODS","content":"\u003ch2\u003eStudy Design\u003c/h2\u003e\u003cp\u003eThis study is a secondary data analysis from a larger, cross-sectional parent study meant to evaluate the effectiveness of tobacco public health education messages among young adults. Prolific (\u003cspan class=\"ExternalRef\"\u003e \u003cspan class=\"RefSource\"\u003ehttps://www.prolific.co/\u003c/span\u003e \u003cspan address=\"https://www.prolific.co/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e \u003c/span\u003e), an online subject recruitment platform, was used to recruit participants, due to its large access to US nationals (~ 38.000), its base of young adults (approximately one-third are \u0026lt; 35 years old), and its effectiveness for reaching minoritized populations, including SGM people. The parent study purposively oversampled SGM people, people who smoke cigarettes, and people who vape nicotine. We also sampled proportionally for each racial/ethnic group per US Census 2020 estimates. Potential participants were prescreened via Prolific. Those who met the eligibility criteria of being aged 18–35 years old and currently residing in the US were directed to an online consent form. After consenting, participants (N = 2,857) were directed to a Qualtrics survey. They received \u003cspan\u003e$\u003c/span\u003e4.50 for participating. The parent study was approved by The Ohio State University Institutional Review Board (2021C0020).).\u003c/p\u003e\u003ch3\u003eMeasures\u003c/h3\u003e\u003cp\u003eMeasures are described in detail in Table\u0026nbsp;1. Our sample included two subgroups of interest: SGM YA and non-SGM YA. We used two items to assess participants’ self-reported sexual identity group and self-reported gender identity group. Individuals identifying with sexual or gender minority identity groups (e.g., lesbian, gay, bisexual, queer, transgender, nonbinary) were defined as SGM; those identifying with cisgender and heterosexual groups were defined as non-SGM. Our dependent variable, current tobacco use, was a latent variable comprised of two indicator items: past 30-day use of combustible cigarettes or past 30-day use of nicotine vapes. Our independent variable of interest, structural stigma, was a latent variable comprised of three state-level indicator items: Attitudes toward SGM people, SGM protective policies (absence of), and SGM discriminatory policies (introduced or passed in 2022). We assessed three mediators of interest: Depletion of economic resources was a latent variable, which included two indicator items. The first assessed past 12-month experiences of food insecurity and the second assessed perceived financial strain. Interpersonal discrimination was assessed using the everyday discrimination scale, which assesses self-reported frequency of daily discrimination experiences in social situations.[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] We used a general measure of discrimination rather than assessing SGM-specific discrimination experiences so that we could assess the influence of this hypothesized mediator on tobacco use among non-SGM YA. Finally, the four-item Perceived Stress Scale was used to assess individual perceptions of psychological stress.[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e] Covariates included race/ethnicity, age, and educational attainment.\u003c/p\u003e\u003cp\u003e \u003cb\u003eTable\u0026nbsp;1. Survey Measures\u003c/b\u003e \u003c/p\u003e\u003ch3\u003eAnalysis\u003c/h3\u003e\u003cp\u003eA comprehensive investigation was conducted using Structural Equation Modeling (SEM) to examine the association between structural stigma and current tobacco use, including combustible cigarettes and nicotine vapes. This study employed SEM with Maximum Likelihood Estimation (MLE) to examine the relationship between multiple variables, considering their direct and indirect effects on current tobacco use. All SEM analyses were performed in R (V 4·2·2) using the Lavaan package (0·6–16). Modification indices were inspected for significant areas of model misfit; however, none were detected so model adjustment was not necessary. Model fit was evaluated using the following fit indices: Comparative Fit Index (CFI), Root Mean Square Error of Approximation (RMSEA), and Standardized Root Mean Squared Residual (SRMR). Indicators of acceptable model fit were considered as CFI \u0026gt; 0·9, RMSEA \u0026lt; 0·06, and SRMR \u0026lt; 008. An alpha of ·05 was used to indicate statistically significant pathways between constructs.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cdiv id=\"Sec8\"\u003e\n \u003ch2\u003eSample Description\u003c/h2\u003e\n \u003cp\u003eAs shown in Table 2, across both groups (n\u0026thinsp;=\u0026thinsp;1,288 SGM and n\u0026thinsp;=\u0026thinsp;1,368 heterosexual), most participants were White (64% SGM, 55% non-SGM) and had similar current use of nicotine vapes (35% SGM, 36% heterosexual). More non-SGM than SGM YA were Black, Indigenous, and People of Color (BIPOC; 45% vs 36%), aged 25\u0026ndash;35 years (31% vs 26%), held a four-year degree or higher (53% vs 47%), and currently smoked combustible cigarettes (31% vs 26%). SGM YA reported greater financial strain (M\u0026thinsp;=\u0026thinsp;5\u0026middot;35 vs. M\u0026thinsp;=\u0026thinsp;4\u0026middot;62), food insecurity (M\u0026thinsp;=\u0026thinsp;4\u0026middot;24 vs. M\u0026thinsp;=\u0026thinsp;3\u0026middot;62), interpersonal discrimination (M\u0026thinsp;=\u0026thinsp;11\u0026middot;98 vs. 10\u0026middot;47), and perceived stress (M\u0026thinsp;=\u0026thinsp;8\u0026middot;61 vs. 7\u0026middot;26) compared to non-SGM YA.\u003c/p\u003e\n\u003c/div\u003e\n\u003ch3\u003ePreliminary analyses\u003c/h3\u003e\n\u003cp\u003eBivariate correlations among all measured variables are presented in Table\u0026nbsp;3. Among non-SGM YA, our indicator variables of structural stigma (attitudes towards SGM individuals, SGM discriminatory bills, absence of SGM protective policies) were not significantly associated with our outcome variables (current combustible cigarette and nicotine vape use). Other than financial strain (r\u0026thinsp;=\u0026thinsp;0\u0026middot;06, p\u0026thinsp;\u0026lt;\u0026thinsp;0\u0026middot;05), our indicator variables of structural stigma were not related to mediators nor covariates. However, there was a significant positive intercorrelation between our measures of financial strain, food insecurity, interpersonal discrimination, and perceived stress. Finally, all covariates (age, race, and education) were significantly associated with our outcome variables. For race, being a race other than White was associated with increased current use of combustible cigarettes and nicotine vapes. For education, having less than a four-year degree was associated with increased current use of combustible cigarettes and nicotine vapes. For age, being between 25\u0026ndash;35 years was associated with greater current use of combustible cigarettes, while being between 18\u0026ndash;24 years was associated with greater current use of nicotine vapes. Latinx ethnicity was not significantly associated with our outcome variables among non-SGM YA.\u003c/p\u003e\n\u003cp\u003eAmong SGM YA, like non-SGM YA, none of our indicator variables of structural stigma were directly associated with current use of combustible cigarettes or nicotine vapes. However, discriminatory bills under consideration were positively associated with financial strain and enacted discriminatory bills were positively associated with food insecurity. There was a significant positive intercorrelation between our measures of financial strain, food insecurity, experiences of interpersonal discrimination, and perceived stress. Finally, like non-SGM YA, being between 25\u0026ndash;35 years was associated with greater current use of combustible cigarettes, while being between 18\u0026ndash;24 years was associated with greater current use of nicotine vapes for SGM YA. No other covariates were associated with outcome variables among the SGM group.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable\u0026nbsp;3. Correlation among measured variables, Heterosexual\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable\u0026nbsp;3 (continued). Correlation among measured variables, SGM\u003c/strong\u003e\u003c/p\u003e\n\u003ch3\u003eMinority Stress Model:\u003c/h3\u003e\n\u003cp\u003eSEM was used to test the hypothesized model (Figs. 1 and 2), examining the indirect effects of structural stigma (i.e., discriminatory attitudes, discriminatory policies, and absence of protective policies) on current tobacco use among subpopulations of SGM and non-SGM YA. Depletion of economic resources (i.e., food insecurity and financial strain) and perceived discrimination experiences were assessed as mediators between structural stigma and current tobacco use. The data fit for both SGM YA (\u0026chi;\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;267\u0026middot;5, p\u0026thinsp;\u0026lt;\u0026thinsp;0\u0026middot;05, CFI\u0026thinsp;=\u0026thinsp;0\u0026middot;92, SRMR\u0026thinsp;=\u0026thinsp;0\u0026middot;05, RMSEA\u0026thinsp;=\u0026thinsp;0\u0026middot;06; Fig. 1) and non-SGM YA (\u0026chi;\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;234\u0026middot;6, p\u0026thinsp;\u0026lt;\u0026thinsp;0\u0026middot;05, CFI\u0026thinsp;=\u0026thinsp;0\u0026middot;95, SRMR\u0026thinsp;=\u0026thinsp;0\u0026middot;05, RMSEA\u0026thinsp;=\u0026thinsp;0\u0026middot;05; Fig. 2).\u003c/p\u003e\n\u003cp\u003eFigure 1. \u003cstrong\u003eStructural Equation Model assessing theoretically informed pathways between structural stigma and current tobacco use among sexual and gender minority (SGM) young adults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFigure 2. \u003cstrong\u003eStructural Equation Model assessing theoretically informed pathways between structural stigma and current tobacco use among cisgender heterosexual (non-SGM) young adults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable\u0026nbsp;4. Indirect effects of structural stigma, economic depletion, and interpersonal discrimination on current use of combustible cigarettes or nicotine vapes.\u003c/strong\u003e\u003c/p\u003e\n\u003cdiv id=\"Sec11\"\u003e\n \u003ch2\u003ePathways between structural stigma and current tobacco use among SGM YA\u003c/h2\u003e\n \u003cp\u003eThe final model accounted for 5.5% of the variance in current tobacco use among SGM YA. Structural stigma was indirectly associated with greater current tobacco use through depletion of economic resources for the SGM YA group (\u0026beta;\u0026thinsp;=\u0026thinsp;0\u0026middot;01, z\u0026thinsp;=\u0026thinsp;2\u0026middot;16, p\u0026thinsp;\u0026lt;\u0026thinsp;0\u0026middot;05, Table\u0026nbsp;4). This indicates that greater structural stigma is associated with greater depletion of economic resources which, in turn, is associated with increased current tobacco use among our sample of SGM YA.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec12\"\u003e\n \u003ch2\u003ePathways between interpersonal discrimination and current tobacco use among SGM YA\u003c/h2\u003e\n \u003cp\u003eExperiencing interpersonal discrimination was both directly and indirectly, via depletion of economic resources, associated with greater current tobacco use among SGM YA. As seen in Table\u0026nbsp;4, the indirect effect of interpersonal discrimination on current tobacco use was statistically significant (\u0026beta;\u0026thinsp;=\u0026thinsp;0\u0026middot;06, z\u0026thinsp;=\u0026thinsp;3.01, p\u0026thinsp;\u0026lt;\u0026thinsp;0\u0026middot;01).\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec13\"\u003e\n \u003ch2\u003ePathways between perceived stress and current tobacco use among SGM YA\u003c/h2\u003e\n \u003cp\u003eDepletion of economic resources and experiencing interpersonal discrimination were also both directly associated with perceived stress, yet there was no association between perceived stress and current tobacco use for SGM YA.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec14\"\u003e\n \u003ch2\u003ePathways between structural stigma and current tobacco use among non-SGM YA\u003c/h2\u003e\n \u003cp\u003eThe final model accounted for 11\u0026middot;7% of the variance in current tobacco use for the non-SGM YA group. While structural stigma was significantly associated with depletion of economic resources among non-SGM YA, there was not a significant indirect pathway linking structural stigma and current tobacco use via depletion of economic resources for non-SGM YA.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec15\"\u003e\n \u003ch2\u003ePathways between interpersonal discrimination and current tobacco use among non-SGM YA\u003c/h2\u003e\n \u003cp\u003eExperiencing interpersonal discrimination was both directly and indirectly, via depletion of economic resources, associated with greater current tobacco use among non-SGM YA. As seen in Table\u0026nbsp;4, the indirect effect of interpersonal discrimination on current tobacco use was statistically significant (\u0026beta;\u0026thinsp;=\u0026thinsp;0\u0026middot;04, z\u0026thinsp;=\u0026thinsp;2\u0026middot;12, p\u0026thinsp;\u0026lt;\u0026thinsp;0\u0026middot;05).\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec16\"\u003e\n \u003ch2\u003ePathways between perceived stress and current tobacco use among non-SGM YA\u003c/h2\u003e\n \u003cp\u003eDepletion of economic resources and experiencing interpersonal discrimination were also both directly associated with perceived stress, yet there was no association between perceived stress and current tobacco use for non-SGM YA.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec17\"\u003e\n \u003ch2\u003eCovariate associations with current tobacco use\u003c/h2\u003e\n \u003cp\u003eIn terms of covariates, age was significantly associated with current tobacco use for non-SGM YA, indicating that individuals ages 25\u0026ndash;35 years were more likely to use tobacco compared to those aged 18\u0026ndash;24 years. Additionally, race was associated with current tobacco use only for non-SGM YA, indicating that more BIPOC YA in this group reported current tobacco use more than White YA.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eOur study is one of the first to assess how structural stigma may influence current tobacco use among SGM and non-SGM YA via theoretically informed pathways. Results indicated that structural stigma was indirectly associated with current tobacco use through the depletion of economic resources (increased financial strain and food insecurity) for SGM YA, but not for non-SGM YA. Additionally, interpersonal discrimination was both directly and indirectly, via depletion of economic resources, associated with current tobacco use for both SGM and non-SGM YA. Previous research examining food insecurity among SGM individuals has found that states with Religious Freedom Restoration Acts or \u0026ldquo;religious freedom\u0026rdquo; laws allow institutions, including food pantries, to deny services to select community members, such as SGM YA, based on religious beliefs.[24] Such laws may contribute to the higher rates of food insecurity seen in SGM compared to non-SGM individuals.[25] Food insecurity has been linked to tobacco use \u0026nbsp;in a variety of vulnerable populations.[26] Although previous research has indicated that the direction of the association is unclear (i.e., causality cannot be established given that the majority of studies, including the present one, have been cross-sectional in nature), both financial strain and stress have been suggested as possible mechanisms that link food insecurity to tobacco use.[26] Longitudinal studies are needed to further examine the directionality of the association between food insecurity and tobacco use. Nevertheless, our results indicate depletion of economic resources may be one mechanism by which structural stigma and interpersonal discrimination influence current tobacco use among SGM YA. Given the well documented disparities in tobacco use among SGM YA, future tobacco intervention studies should consider food insecurity and financial strain as points of intervention for this population.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn a recent narrative review examining the role of structural stigma on health outcomes (including behavioral health), a conceptual model was proposed indicating that interpersonal discrimination may mediate the association between structural stigma and behavioral health (i.e., current tobacco use) outcomes.[8] However, our study is one of the first to examine the pathway proposed by this conceptual model (i.e., structural stigma \u0026rarr;interpersonal discrimination\u0026rarr;behavioral health outcomes). In our study, structural stigma was not indirectly associated with current tobacco use via interpersonal discrimination. This null finding for an indirect pathway between structural stigma and current tobacco use via interpersonal discrimination may be due to construct operationalization. While our structural stigma measure was SGM-specific, our interpersonal discrimination measure assessed perceptions of interpersonal discrimination for any reason (e.g., due to SGM identity, race/ethnicity, religion body size, physical ability, etc.) so that we could assess this construct among non-SGM YA. However, similar to prior studies[5], we identified a direct association between interpersonal discrimination and current tobacco use. As mentioned previously, longitudinal studies are needed to examine how structural stigma may influence interpersonal discrimination over time and how this, in turn, may influence current tobacco use among SGM YA. This work should include measures assessing SGM-specific interpersonal discrimination, which may be more closely associated with structural stigma.\u003c/p\u003e\n\u003cp\u003eOur study has limitations, including the use of cross-sectional data and the lack of a sufficient sample size to examine the SGM YA subgroup (e.g., bisexual vs gay, or by gender identity) as a moderator. Nevertheless, our study addressed several gaps identified previously in the literature and is one of the few to conduct mediational analyses examining the indirect effects of structural stigma on health outcomes among SGM YA. Previous research[17,18] indicates a need to examine how structural stigma may indirectly influence tobacco use among SGM individuals, specifically, and our study is one of the first to examine this association as it relates to current tobacco use in SGM YA. Our study also addresses a gap identified in the literature[8] by including a non-SGM YA comparison group. In doing so, we demonstrated that structural stigma is associated with current tobacco use, via depletion of economic resources, for SGM YA only. Given unprecedented increases in legislation targeting SGM rights, identifying intervention points to attenuate the negative effects of structural stigma on tobacco use is critical for promoting SGM health across the life course.\u0026nbsp;\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eIn conclusion, although the association between structural stigma and health in general has been well established among SGM, our study is one the first to examine the indirect effects of structural stigma on current tobacco use specifically among a highly vulnerable population, SGM YA. Future tobacco cessation and harm reduction intervention research should consider the role of structural stigma when working with SGM YA; specifically, how interventions promoting economic stability may influence tobacco use and cessation in this population. It will also be important to examine how changes in general attitudes towards SGM individuals and lack of protective policy and discriminatory policy toward SGM individuals influences tobacco use in SGM YA over time, as previous research has indicated that improvements in structural stigma may be associated with improvement in life satisfaction in this population.[27]\u0026nbsp;\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eBIPOC: \u0026nbsp;Black, Indigenous, and People of Color\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCFI: Comparative Fit index\u003c/p\u003e\n\u003cp\u003eMLE: Maximum Likelihood Estimation\u003c/p\u003e\n\u003cp\u003eRMSEA: Root Mean Square Error of Approximation\u003c/p\u003e\n\u003cp\u003eSEM: Structural Equation Modeling\u003c/p\u003e\n\u003cp\u003eSGMYA: Sexual and gender minority young adult\u003c/p\u003e\n\u003cp\u003eSGM: Sexual and gender minority\u003c/p\u003e\n\u003cp\u003eSRMR: Standardized Root Mean Squared Residual\u003c/p\u003e\n\u003cp\u003eYA: young adults\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe parent study was approved by The Ohio State University Institutional Review Board, which adheres to the ethical principles for the protection of research participants summarized in the Belmont Report and complies with federal regulations, guidance, and state laws related to human subjects protection, (2021C0020). All participants consented prior to completing the survey.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability statement\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eData and relevant code is available upon reasonable request from the PI (JGP).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eResearch reported in this publication was supported by the National Cancer Institute of the National Institutes of Health and the FDA Center for Tobacco Products under Award Numbers K99CA260718 and R00CA260718 (PI: JGP). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health or Food and Drug Administration. This study was supported by The Ohio State University (OSU) James-Comprehensive Cancer Center\u0026apos;s Center for Tobacco Research and The OSU College of Public Health\u003cstrong\u003e.\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of interests\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWe have no conflicts of interest to disclose.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements section:\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThank you to all members of the Practice and Science for LGBTQ+ Health Equity Lab for their contributions to the parent study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAUTHOR CONTRIBUTIONS\u003c/strong\u003e\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eW.F.: Conceptualization, Methodology, Formal analysis, Writing \u0026shy;\u0026ndash; original draft, review and editing\u003c/li\u003e\n \u003cli\u003eS.S.: Lead Formal Analysis, Writing-original draft\u003c/li\u003e\n \u003cli\u003eE.J.: Data curation, Project administration, Writing- original draft, review and editing\u003c/li\u003e\n \u003cli\u003eA.C.E.: Data curation, Project administration, Writing-review and editing\u003c/li\u003e\n \u003cli\u003eA.T..: Writing-review and editing\u003c/li\u003e\n \u003cli\u003eE.S.: Writing-review and editing\u003c/li\u003e\n \u003cli\u003eJ.G.P.: Funding Acquisition, Conceptualization, Methodology, Data curation, Project administration, Writing \u0026ndash; original draft, review and editing\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eDrope J, Liber AC, Cahn Z, Stoklosa M, Kennedy R, Douglas CE, et al. Who\u0026rsquo;s still smoking? Disparities in adult cigarette smoking prevalence in the United States. CA Cancer J Clin [Internet]. 2018 [cited 2024 May 6];68:106\u0026ndash;15. Available from: https://acsjournals.onlinelibrary.wiley.com/doi/10.3322/caac.21444\u003c/li\u003e\n\u003cli\u003eHinds JT, Loukas A, Perry CL. Sexual and Gender Minority College Students and Tobacco Use in Texas. Nicotine Tob Res [Internet]. 2018 [cited 2024 May 6];20:383\u0026ndash;7. Available from: https://academic.oup.com/ntr/article/20/3/383/3791455\u003c/li\u003e\n\u003cli\u003eKrueger EA, Braymiller JL, Barrington-Trimis JL, Cho J, McConnell RS, Leventhal AM. Sexual minority tobacco use disparities across adolescence and the transition to young adulthood. Drug Alcohol Depend. 2020;217:108298. \u003c/li\u003e\n\u003cli\u003eMeyer IH, Frost DM. Minority Stress and the Health of Sexual Minorities. In: Patterson CJ, D\u0026rsquo;Augelli AR, editors. Handb Psychol Sex Orientat [Internet]. Oxford University Press; 2012 [cited 2023 Sep 29]. p. 252\u0026ndash;66. Available from: https://academic.oup.com/book/6050/chapter/149494151\u003c/li\u003e\n\u003cli\u003eLi M, Chau K, Calabresi K, Wang Y, Wang J, Fritz J, et al. The Effect of Minority Stress Processes on Smoking for Lesbian, Gay, Bisexual, Transgender, and Queer Individuals: A Systematic Review. LGBT Health [Internet]. 2024 [cited 2024 May 2];lgbt.2022.0323. Available from: https://www.liebertpub.com/doi/10.1089/lgbt.2022.0323\u003c/li\u003e\n\u003cli\u003eHatzenbuehler ML, Link BG. Introduction to the special issue on structural stigma and health. Soc Sci Med [Internet]. 2014 [cited 2024 May 2];103:1\u0026ndash;6. Available from: https://linkinghub.elsevier.com/retrieve/pii/S0277953613007090\u003c/li\u003e\n\u003cli\u003eAmerican Civil Liberties Union. Mapping Attacks on LGBTQ Rights in U.S. State Legislatures in 2023 [Internet]. American Civil Liberties Union; 2023 Dec. Available from: https://www.aclu.org/legislative-attacks-on-lgbtq-rights-2023\u003c/li\u003e\n\u003cli\u003eHatzenbuehler ML, Lattanner MR, McKetta S, Pachankis JE. Structural stigma and LGBTQ+ health: a narrative review of quantitative studies. Lancet Public Health [Internet]. 2024 [cited 2024 May 2];9:e109\u0026ndash;27. Available from: https://linkinghub.elsevier.com/retrieve/pii/S2468266723003122\u003c/li\u003e\n\u003cli\u003eDrabble LA, Munroe C, Mericle AA, Zollweg S, Trocki KF, Karriker-Jaffe KJ. Impact of the policy environment on substance use among sexual minority women. Drug Alcohol Depend Rep. 2022;3:100058. \u003c/li\u003e\n\u003cli\u003eHatzenbuehler ML, Wieringa NF, Keyes KM. Community-Level Determinants of Tobacco Use Disparities in Lesbian, Gay, and Bisexual Youth: Results From a Population-Based Study. Arch Pediatr Adolesc Med [Internet]. 2011 [cited 2024 May 2];165:527\u0026ndash;32. Available from: http://archpedi.jamanetwork.com/article.aspx?doi=10.1001/archpediatrics.2011.64\u003c/li\u003e\n\u003cli\u003eHatzenbuehler ML, Jun H-J, Corliss HL, Austin SB. Structural stigma and cigarette smoking in a prospective cohort study of sexual minority and heterosexual youth. Ann Behav Med Publ Soc Behav Med. 2014;47:48\u0026ndash;56. \u003c/li\u003e\n\u003cli\u003eHatzenbuehler ML, Flores AR, Gates GJ. Social Attitudes Regarding Same‐Sex Marriage and LGBT Health Disparities: Results from a National Probability Sample. J Soc Issues [Internet]. 2017 [cited 2024 May 2];73:508\u0026ndash;28. Available from: https://spssi.onlinelibrary.wiley.com/doi/10.1111/josi.12229\u003c/li\u003e\n\u003cli\u003ePoteat VP, Sinclair KO, DiGiovanni CD, Koenig BW, Russell ST. Gay\u0026ndash;Straight Alliances Are Associated With Student Health: A Multischool Comparison of LGBTQ and Heterosexual Youth. J Res Adolesc [Internet]. 2013 [cited 2024 May 2];23:319\u0026ndash;30. Available from: https://onlinelibrary.wiley.com/doi/10.1111/j.1532-7795.2012.00832.x\u003c/li\u003e\n\u003cli\u003eWatson RJ, Park M, Taylor AB, Fish JN, Corliss HL, Eisenberg ME, et al. Associations Between Community-Level LGBTQ-Supportive Factors and Substance Use Among Sexual Minority Adolescents. LGBT Health. 2020;7:82\u0026ndash;9. \u003c/li\u003e\n\u003cli\u003eWatson RJ, Fish JN, Denary W, Caba A, Cunningham C, Eaton LA. LGBTQ state policies: A lever for reducing SGM youth substance use and bullying. Drug Alcohol Depend. 2021;221:108659. \u003c/li\u003e\n\u003cli\u003ePachankis JE, Hatzenbuehler ML, Br\u0026auml;nstr\u0026ouml;m R, Schmidt AJ, Berg RC, Jonas K, et al. Structural stigma and sexual minority men\u0026rsquo;s depression and suicidality: A multilevel examination of mechanisms and mobility across 48 countries. J Abnorm Psychol [Internet]. 2021 [cited 2024 May 2];130:713\u0026ndash;26. Available from: https://doi.apa.org/doi/10.1037/abn0000693\u003c/li\u003e\n\u003cli\u003eTitus AR, Gamarel KE, Thrasher JF, Meza R, Fleischer NL. State-Level Structural Stigma and Smoking Among Sexual Minority Adults in the USA, 2012-2014. Ann Behav Med Publ Soc Behav Med. 2020;55:557\u0026ndash;70. \u003c/li\u003e\n\u003cli\u003eWhite BP, Abuelezam NN, Fontenot HB, Jurgens CY. Exploring Relationships Between State-Level LGBTQ Inclusivity and BRFSS Indicators of Mental Health and Risk Behaviors: A Secondary Analysis. J Am Psychiatr Nurses Assoc [Internet]. 2023 [cited 2024 May 2];29:224\u0026ndash;31. Available from: http://journals.sagepub.com/doi/10.1177/10783903211007900\u003c/li\u003e\n\u003cli\u003eCarpenter CS, Eppink ST, Gonzales G, McKay T. Effects of Access to Legal Same‐Sex Marriage on Marriage and Health. J Policy Anal Manage [Internet]. 2021 [cited 2024 May 2];40:376\u0026ndash;411. Available from: https://onlinelibrary.wiley.com/doi/10.1002/pam.22286\u003c/li\u003e\n\u003cli\u003eWarnecke RB, Oh A, Breen N, Gehlert S, Paskett E, Tucker KL, et al. Approaching Health Disparities From a Population Perspective: The National Institutes of Health Centers for Population Health and Health Disparities. Am J Public Health. 2008;98:1608\u0026ndash;15. \u003c/li\u003e\n\u003cli\u003eThe Relationship between Prejudice and Wage Penalties for Gay Men in the United States - Ian Burn, 2020 [Internet]. [cited 2024 Jul 19]. Available from: https://journals.sagepub.com/doi/full/10.1177/0019793919864891?casa_token=DHkTfZz5v4UAAAAA%3A1M4ZwaeVLzbzp_hHxOIAU0qJXeCIArAA-GNx6f0p9IiCH1puPoAqkMK5WnNtOPG5TeMRbktX1IPg\u003c/li\u003e\n\u003cli\u003eWilliams DR, Yan Yu null, Jackson JS, Anderson NB. Racial Differences in Physical and Mental Health: Socio-economic Status, Stress and Discrimination. J Health Psychol. 1997;2:335\u0026ndash;51. \u003c/li\u003e\n\u003cli\u003eCohen S. Perceived stress in a probability sample of the United States. Soc Psychol Health. Thousand Oaks, CA, US: Sage Publications, Inc; 1988. p. 31\u0026ndash;67. \u003c/li\u003e\n\u003cli\u003eNational Conference of State Legislatures. 2017 Religious Freedom Restoration Act Legislation [Internet]. National Conference of State Legislatures; 2017. Available from: https://www.ncsl.org/research/civil-and-criminal-justice/2017-religious-freedom-restoration-act-legislation\u003c/li\u003e\n\u003cli\u003eHasenbush A, Flores AR, Kastanis A, Sears B, Gates GJ. The LGBT divide: A data portrait of LGBT people in the midwestern, mountain \u0026amp; southern states [Internet]. The Williams Institute; 2014. Available from: https://escholarship.org/content/qt17m036q5/qt17m036q5_noSplash_76bbb27af26d1e610afb63d07a9c903f.pdf\u003c/li\u003e\n\u003cli\u003eKim-Mozeleski JE, Pandey R. The Intersection of Food Insecurity and Tobacco Use: A Scoping Review. Health Promot Pract. 2020;21:124S-138S. \u003c/li\u003e\n\u003cli\u003eBr\u0026auml;nstr\u0026ouml;m R, Pachankis JE. Structural Stigma and 7-Year Improvement in Life Satisfaction among Diverse Groups of Sexual Minority Individuals: A Repeated Cross-Sectional Study across 28 Countries. Soc Probl. 2023;spad029. \u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1 to 4 are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"international-journal-for-equity-in-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ijeh","sideBox":"Learn more about [International Journal for Equity in Health](http://equityhealthj.biomedcentral.com)","snPcode":"12939","submissionUrl":"https://submission.nature.com/new-submission/12939/3","title":"International Journal for Equity in Health","twitterHandle":"@equityhealthj","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Structural Stigma, Tobacco use, Economic Stability, Sexual and Gender Minorities, Structural Equation Modeling","lastPublishedDoi":"10.21203/rs.3.rs-5417843/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5417843/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e Sexual and gender minority young adult (SGM YA) populations use tobacco at higher rates than their non-SGM YA peers. Prior studies have identified significant correlations between interpersonal stigma and tobacco use, yet structural stigma may also influence tobacco use among SGM YA. This study aimed to assess the indirect effects of structural stigma on current tobacco use among SGM YA and non-SGM YA via depletion of economic resources, interpersonal discrimination, and perceived psychological stress.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e: Structural Equation Modeling was used to conduct a secondary data analysis from a cross-sectional parent study. Eligible participants were 18-35 years old and currently residing in the U.S. (N = 2,857). Current use of combustible cigarettes and nicotine vapes was our dependent variable. Our independent variable of interest, structural stigma, was a latent variable comprised of three state-level indicator items: Attitudes toward SGM people, SGM protective policies (absence of), and SGM discriminatory policies (introduced or passed in 2022). We assessed three mediators of interest: Depletion of economic resources was a latent variable, which included two indicator items: food insecurity and financial strain. Interpersonal discrimination and perceptions of psychological stress were also assessed. Covariates included race/ethnicity, age, and educational attainment.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e Structural stigma was indirectly associated with current tobacco use via depletion of economic resources for SGM YA, but not non-SGM YA. Interpersonal discrimination was also directly and indirectly associated with current tobacco use via depletion of economic resources for both groups.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions: \u003c/strong\u003eFuture tobacco intervention research should consider the role of structural stigma when working with SGM YA; specifically, how interventions promoting economic stability may influence tobacco use and cessation in this population\u003cstrong\u003e.\u003c/strong\u003e\u003c/p\u003e","manuscriptTitle":"Using structural equation modeling to assess pathways between structural stigma and tobacco use among sexual and gender minority young adults living in the United States","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-12-17 09:53:00","doi":"10.21203/rs.3.rs-5417843/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-02-10T11:27:46+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-02-10T09:28:57+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-02-02T16:28:14+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-01-30T04:12:33+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"328479224091153813939314973210624979947","date":"2025-01-13T06:49:37+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"136111396358049805782568695869774685454","date":"2025-01-11T21:13:49+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"111537054490015045244633920746324999461","date":"2025-01-08T15:21:03+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-01-07T21:20:50+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"165141331363445433514216197703943049722","date":"2025-01-07T14:56:22+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"107567855485092766494248441254385571514","date":"2025-01-06T15:19:39+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"143165967403151195808478748885386898648","date":"2025-01-06T14:43:11+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-12-02T05:48:49+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-11-17T23:21:42+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-11-13T06:52:42+00:00","index":"","fulltext":""},{"type":"submitted","content":"International Journal for Equity in Health","date":"2024-11-08T16:17:17+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"international-journal-for-equity-in-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ijeh","sideBox":"Learn more about [International Journal for Equity in Health](http://equityhealthj.biomedcentral.com)","snPcode":"12939","submissionUrl":"https://submission.nature.com/new-submission/12939/3","title":"International Journal for Equity in Health","twitterHandle":"@equityhealthj","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"54dce66d-7966-44ac-be97-31edf380168e","owner":[],"postedDate":"December 17th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-05-12T16:06:20+00:00","versionOfRecord":{"articleIdentity":"rs-5417843","link":"https://doi.org/10.1186/s12939-025-02487-2","journal":{"identity":"international-journal-for-equity-in-health","isVorOnly":false,"title":"International Journal for Equity in Health"},"publishedOn":"2025-05-08 15:57:50","publishedOnDateReadable":"May 8th, 2025"},"versionCreatedAt":"2024-12-17 09:53:00","video":"","vorDoi":"10.1186/s12939-025-02487-2","vorDoiUrl":"https://doi.org/10.1186/s12939-025-02487-2","workflowStages":[]},"version":"v1","identity":"rs-5417843","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5417843","identity":"rs-5417843","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}