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Journal of LGBT Health Research

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Smoking It All Away: Influences of Stress, Negative Emotions, and Stigma on

Lesbian Tobacco Use
Elisabeth P. Gruskin a; Kimberly M. Byrne; Andrea Altschuler a; Suzanne L. Dibble b
a
Kaiser Permanente Division of Research, b Institute for Health & Aging, School of Nursing, University of
California San Francisco,

Online Publication Date: 01 January 2008

To cite this Article Gruskin, Elisabeth P., Byrne, Kimberly M., Altschuler, Andrea and Dibble, Suzanne L.(2008)'Smoking It All Away:
Influences of Stress, Negative Emotions, and Stigma on Lesbian Tobacco Use',Journal of LGBT Health Research,4:4,167 — 179
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 Smoking It All Away:
Influences of Stress, Negative Emotions, and Stigma
on Lesbian Tobacco Use
Elisabeth P. Gruskin
Kimberly M. Byrne
Andrea Altschuler
Suzanne L. Dibble

ABSTRACT. This study explored the reported processes, conditions, and consequences of lesbian
Downloaded By: [Canadian Research Knowledge Network] At: 18:01 7 October 2009

and heterosexual female smoking and relapse to understand the reasons for elevated lesbian smoking
rates. Using grounded theory techniques, we conducted semistructured, face-to-face interviews with an
ethnically diverse sample of 35 lesbian and 35 heterosexual female participants in Northern California.
We found minority stress/sexual stigma to be an additional, unique cause of negative emotions and
stress reported by 75% of lesbian participants, leading to smoking and relapse. Implications for smoking
cessation programs tailored to lesbians are discussed.

KEYWORDS. Tobacco use, lesbians, sexual orientation, stigma, stress

Health problems caused by using tobacco are
some of the most preventable in the United
States. Although tobacco use is declining, it
is responsible for nearly 443,000 deaths per
year (US Department of Health and Human Ser-
vices, 2008). There is great incentive for smok-
ers to quit, as smoking cessation has both long-
and short-term health benefits. According to the
American Cancer Society, smoking cessation re-
duces the incidence of cancers affecting the lung,
mouth, nasal cavities, larynx, pharynx, esopha-
gus, stomach, liver, pancreas, kidney, bladder,
and uterine cervix, as well as myeloid leukemia
(American Cancer Society, 2003). In addition,
research has consistently indicated that people
who quit smoking live longer than people who
continue to smoke. Smokers who quit before the
age of 50 cut their risk of dying in the next 15
years in half, compared to those who continue to
smoke. Although the incentive to quit is there,
the vast majority of people who try to quit start
again. In 2007, 39.8% of current adult smok-
ers tried to quit smoking (Thorne, Malarcher, &
Caraballo, 2008). Approximately 76% of those
who attempt to quit relapse within weeks of their
cessation (Gulliver, Hughes, Solomon, & Dey,

Elisabeth P. Gruskin, DrPH, is affiliated with the Kaiser Permanente Division of Research; Kimberly
M. Byrne, EdD, works as an Individual Consultant; Andrea Altschuler, PhD, is affiliated with the Kaiser
Permanente Division of Research; Suzanne L. Dibble, DNSc, RN, is Professor Emerita in the Institute for
Health & Aging, School of Nursing, University of California San Francisco.
Address correspondence to: Elisabeth P. Gruskin, DrPH, Kaiser Permanente Division of Research, 2000
Broadway, 3rd Floor, Oakland, CA 94612 (E-mail: egruskin@gmail.com).
The authors thank Emerald O’Leary for her help with recruitment. The authors also thank the American
Cancer Society for its support of this project.

Journal of LGBT Health Research, Vol. 4(4) 2008

Copyright
C Taylor & Francis Group, LLC
doi: 10.1080/15574090903141104 167
 168 JOURNAL OF LGBT HEALTH RESEARCH
1995). This makes it particularly important to
understand smoking relapse to best strategize
smoking cessation programs.
There are disparities in smoking and smok-
ing relapse, including disparities due to sex-
ual orientation. Research indicates that lesbians
have higher rates of smoking than heterosexual
women (Cochran et al., 2001; Diamant, Wold,
Spritzer, & Gelberg, 2000; Gruskin & Gordon,
2006; Gruskin, Greenwood, Matevia, Pollack,
& Bye, 2007; Gruskin, Hart, Gordon, & Ack-
erson, 2001; Stall, Greenwood, Acree, Paul, &
Coates, 1999; Tang et al., 2004; Valanis et al.,
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2000). However, there has yet to be a study pub-
lished that explores potential reasons for these
disparities.
One possible explanation for these dispari-
ties is the stress and negative affect that les-
bians experience due to their minority status.
Researchers have demonstrated that there is re-
lationship between stress, negative affect and
smoking relapse in the general population. Shiff-
man et al. (2007) identified the components of
negative affect as anger, depression and anxiety.
Although the commonality among these mood
states is a generalized sense of distress or lack
of pleasure, it is unclear to what extent each of
these mood states influences smoking and re-
lapse. In one of the most well-developed models
on smoking relapse, the negative affect model,
Kenford et al. (2002) hypothesized the following
constructs to be important in smoking relapse:
history of severe negative affect such as depres-
sion, postcessation negative affect, high levels of
stress, lack of coping skill, and the expectations
of positive effects of substance use.
Smoking relapse because of stress and nega-
tive affect may be particularly relevant for les-
bians, although it has yet to be explored in
this population. Meyer (2003) further devel-
oped Brooks’ (1981) minority stress model to
explore mental health and alcohol-related out-
comes caused by a stigmatizing social context,
but he did not expand this to include other ad-
dictive behaviors. The minority stress model de-
scribes minority stress as chronic, because prej-
udice and discrimination tend to be woven into
the fabric of a culture or society; structural,
and therefore socially-based; and distinct from,
and experienced in addition to, stressors expe-
rienced by heterosexuals. Meyer’s model high-
lights three stress processes: objectively stress-
ful events and conditions; the minority individ-
ual’s expectation of and vigilance for objectively
stressful events; and internalization of negative
societal attitudes. In the minority stress model,
Meyer noted that both general stressors (e.g., job
loss, death of a loved one) and minority stress
processes impact mental health outcomes such
as depression and alcohol use.
Expanding upon Meyer’s (2003) minority
stress model, Herek (2007) proposed a concep-
tual framework for understanding the four differ-
ent ways in which minority stress is experienced
by individuals: (a) enacted stigma, manifesting
as ostracism, interpersonal rejection, discrimina-
tion, and hate crimes committed against the gay
or lesbian individual; (b) vicarious stigma, man-
ifesting as witnessing others’ enacted stigma; (c)
felt stigma, manifesting as the subjective expe-
rience of and adaptation to the threats posed by
stigma; and (d) self-stigmatization, manifesting
as internalized homophobia or negative feelings
about one’s own sexual orientation.
In interpreting the results of this study, we
build upon the work of Meyer (2003) and Herek
(2007) by expanding their framework and ap-
plying it to smoking. Specifically, we explored
how negative emotions, stress, and social con-
text affect the smoking and cessation behav-
iors of lesbians in comparison to heterosexual
females. Our goal in this study was to under-
stand whether the reasons for lesbian smok-
ing and relapse differ from those of heterosex-
ual females by examining how negative emo-
tions, stress, and social context manifest in the
smoking/quitting/relapse process for these two
groups. As we investigated the core differences
of smoking behavior between the two groups, we
developed the concept of stigma vulnerability to
describe lesbians’ heightened susceptibility to
smoke as a result of the experience of different
types of stigma. We explore the components of
stigma vulnerability throughout the article and
discuss its implications in the conclusion of the
article.
METHODS
We conducted one-on-one, in-depth,
semistructured interviews with 70 lesbian and
 Gruskin et al.
heterosexual women in Northern California.
We used grounded theory techniques in the data
collection and analysis. This approach can be
used to expand an already existing theory by
applying it to a different content area, as in the
case of this study. Grounded theory techniques
are inductive, logically consistent procedures
for data analysis and collection (Charmaz,
2006). At the same time, the identification of
sensitizing concepts provides a starting point to
guide inquiry. The sensitizing concepts for this
study—enhancement of social relationships,
negative emotions, and stress—were derived
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from current tobacco research.
Sampling Plan
Our recruitment goals were to achieve eth-
nic/racial diversity and to have an equal number
of lesbian participants and heterosexual partici-
pants. Recruitment strategies included advertis-
ing in newspapers catering to lesbians, as well
as in general audience newspapers; posting on
lesbian-specific Web sites and list servers; and
mailing or posting flyers at smoking cessation
groups, community-based organizations, health
care organizations, and businesses frequented by
lesbians and/or heterosexual women. We also re-
cruited a small proportion of our participants via
snowball sampling, whereby women who had al-
ready participated informed friends and acquain-
tances about the study.
Eligibility criteria for the study included hav-
ing quit smoking and relapsed within the past
3 months and being between the ages of 18 and
70. We focused on women who were trying to
quit smoking for the reason that this is an im-
portant target audience for smoking cessation
programs. However, in their interviews the par-
ticipants talked about other topics than smoking
cessation, such as smoking initiation, smoking in
general, and smoking relapses. The participants
were fluent in both written and spoken English,
self-identified as either a lesbian or a heterosex-
ual woman, and resided in the San Francisco
Bay Area. Participants received a $50 gift card
to thank them for their participation.
The study and all protocols were approved
by the Kaiser Permanente Northern California
Institutional Review Board.
169
Data Collection and Analysis
We developed a semistructured, open-ended
interview guide to explore participants’ ex-
periences with smoking, quitting smoking,
and smoking relapse. This format left room
for participants to express their feelings about
smoking, stress, social context, and negative
emotions, and sometimes led us in unanticipated
directions such as the role of stigma in smoking.
We followed up the general responses with
more specific probes.
The interviews were tape recorded and lasted
approximately 60 to 90 min. They were then
transcribed verbatim. All interviews were con-
ducted face-to-face at the Kaiser Permanente Di-
vision of Research in Oakland, California. Drs.
Gruskin and Altschuler conducted 35 interviews
each.
Consistent with grounded theory techniques,
data collection and analysis were conducted
simultaneously. Memos were developed
throughout the entire study, especially during
data collection. Our process is best captured by
the observations of Giles (2002), who has noted
that in grounded theory data analysis “the gen-
eral principle is that data are studied initially at
a descriptive level, and as the analysis continues
and the data organized into smaller and smaller
units, the organizing concepts become increas-
ingly abstract and explanatory, until they can
be interpreted by one overarching framework
or process” (p. 167). In this way, we performed
three levels of coding: initial, focused, and
theoretical (Charmaz, 2006). Our coding pro-
cedure was to divide the data into meaningful
chunks (e.g., events, descriptions of emotions,
experiences) and then assign that chunk a
word or phrase that summarized its meaning or
described its relationship to the overall research
question. In the first phase of data collection,
Drs. Gruskin, Altschuler, and Dibble coded
three or four transcripts individually. Then, they
met to discuss the codes, check for consistency
in code choices, and discuss the thematic flow
of the transcripts. Some examples of initial
codes were anger, sadness, anxiety, sexuality,
family, everyday hassles, social interactions, and
race/ethnicity. At a later date, Dr. Byrne inde-
pendently conducted initial coding. Comparison
of both instances of initial coding yielded very
 170 JOURNAL OF LGBT HEALTH RESEARCH
TABLE 1. Final Iteration of Interview Guide
Domain
Sexual orientation
Smoking behavior
Negative affect
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Support
Lesbian community
Interrelationship of gender,
race/ethnicity, and sexual orientation
Note. LGBT = Lesbian, gay, bisexual, and transgender.
similar results, enhancing the credibility of this
stage of data analysis through triangulation.
Based on this analysis, we revised the in-
terview guide to include questions about the
interrelationship of smoking, race/ethnicity, and
sexual orientation once it became clear that this
was becoming a salient theme. Table 1 includes
the final interview domains and examples of
questions posed. Because the goal of the in-
terviews was to allow the participants to de-
scribe their experiences, the questions asked and
follow-up probes were customized for each par-
ticipant.
Once we completed all the interviews, they
were professionally transcribed, and we entered
them into the software program Atlas.ti (Muhr,
2004). In Atlas.ti, we highlighted segments of
text from the transcribed interviews and either
created new codes to describe the highlighted
text or attached an already existing code.
Types of Questions
1. What is it like to be a lesbian woman for you? Can you tell me about the
positive aspects?
2. Can you give me an example when it was stressful (where, when, who
involved)
1. Smoking history
2. What was it like for you to quit smoking?
3. How did you manage to maintain your abstinence?
4. Under what circumstances did you relapse? When, where, with whom,
why?
5. Under what circumstances did you start smoking? When, where, with
whom, why?
1. How do you deal with anger?
2. How do you deal with sadness?
3. Do you ever feel down or blue for longer than 2 weeks at a time?
4. Have you ever been diagnosed with depression?
5. Do you experience anxiety?
6. Can you tell me about it? (Under what circumstances? How does it
affect your life?)
1. Who are your primary supports?
2. Do you have friends and family who play an important role in your life?
3. Do you smoke or drink with them?
4. Do you feel like you have enough support?
1. Do you feel a part of the lesbian community?
2. Do you participate in lesbian community events?
3. Do you spend time in LGBT bars and clubs? Do you feel that
contributes to your smoking?
1. In terms of being a woman, in terms of being a lesbian, in terms of
being African-American/Asian/Hispanic, do you feel that you face any
kind of ongoing discrimination that creates stress for you?
2. How do you deal with this stress?
Next, Dr. Byrne performed focused coding.
With the assistance of Atlas.ti, she identified
significant or frequent initial codes. Then, she
sorted these codes and began to identify a hi-
erarchy of concepts. After Dr. Byrne had com-
pleted this stage of analysis, Dr. Gruskin pro-
vided critique and revisions. Four particular
codes gleaned from focused coding were neg-
ative emotions, stress, social influences, and
sexuality-specific experiences.
Last, Dr. Byrne performed theoretical cod-
ing. In this step, she specified the relation-
ships among the focused codes, “weav[ing] the
fractured story back together” (Charmaz, 2006,
p. 72). While coding in this way, she kept the-
oretical memos about the process that helped
her to identify the connections among the mi-
nority stress model, the empirical findings of
tobacco research, and the experiences described
by many of the participants. In the grounded
 Gruskin et al. 171

theory approach, the resulting theory is a set TABLE 2. Race/Ethnicity and Sexual Orientation
of well-developed concepts that are connected
through statements of relationship and consti- Female
tute a framework to explain phenomena. During Lesbians Heterosexuals
the process of theoretical coding, Dr. Gruskin
Race/Ethnicity N % N %
provided feedback, suggestions, and guidance
in developing the stigma vulnerability frame- Caucasian 17 49 9 26
work. After theoretical coding was completed, African American 12 34 17 49
Drs. Altschuler and Dibble evaluated the results Asian 3 9 1 3
Latina 3 9 8 22
of this final stage of data analysis and provided Total 35 100 35 100
feedback on the stigma vulnerability framework.
Triangulation of investigators bolstered the cred-
ibility of the theoretical coding process.
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In evaluating the trustworthiness of findings, RESULTS

Lincoln and Guba (1985) have noted that qual-
itative research should be assessed in terms Characteristics of Study Participants
of its credibility, transferability, dependability,
and confirmability. Devers (1999) has provided Our sample consisted of 35 lesbian and 35 het-
the following guidelines for understanding these erosexual female participants between the ages
constructs. Credibility, roughly comparable to of 18 and 70 who had quit smoking within the
internal validity in quantitative research, is the past three months. Approximately two-thirds of
truth of the findings as interpreted by the par- the participants were women of color, as shown
ticipants or the research context. Transferability, in Table 2. The age distribution was relatively
similar to external validity, is the extent to which diverse as seen in Table 3.
the findings are applicable to other contexts. De- We found much commonality in the smoking
pendability, parallel to reliability, is the extent to behavior of both lesbian and heterosexual fe-
which others would arrive at similar findings if male participants. Both lesbians and heterosex-
carried out as described. Finally, confirmability, ual females reported smoking for three main rea-
like objectivity in quantitative research, is the sons: emotional regulation, stress management,
extent to which findings are based on evidence and enhancement of social relationships. Eighty
rather than researcher bias (Lincoln & Guba, percent of participants reported smoking in re-
1985, as cited in Devers, 1999, p. 1165–1166). sponse to stress, making this reason the most
In this study, we took the following measures often reported by both groups. Although many
within the context of grounded theory techniques stressors were common to lesbians and hetero-
to ensure the trustworthiness of our conclusions. sexual females, we found some stressors that
Credibility of our conclusions was strengthened were unique to the experience of lesbians. The
through triangulation of investigators in data col- fact that 75% of lesbian participants had reported
lection and stages of analysis (Devers, 1999). In
keeping with grounded theory protocol (Char-
maz, 2006), we developed memos at all stages TABLE 3. Age and Sexual Orientation
of the study that detailed data collection, emerg-
ing themes, and development of theory; this
Female
full documentation enhanced the dependability Lesbians Heterosexuals
and confirmability of our findings (Giles, 2002).
Dependability and confirmability were further Age N % N %
strengthened through skeptical peer review (De-
20–29 years 12 34 5 14
vers, 1999) when our manuscript was critiqued 30–39 years 10 29 6 17
at various stages of development by experts in 40–49 years 9 26 13 37
sexual stigma, minority stress, and public health, 50+years 3 9 9 26
as well as by peers at the 2008 “NIH Summit: Unknown 1 3 2 6
Total 35 100 35 100
The Science of Eliminating Health Disparities.”
 172 JOURNAL OF LGBT HEALTH RESEARCH
smoking to manage their stress and/or emotional
reactions to experiencing sexual stigma led us
to develop the construct stigma vulnerability.
Stigma vulnerability describes a heightened sus-
ceptibility to the temptation to smoke as a result
of the experience of different types of stigma. In
the sections that follow, we highlight the com-
monalities of participants’ smoking, while em-
phasizing the influences of stigma vulnerability
on lesbian smoking.
Emotional Regulation
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Both lesbians and heterosexual females re-
ported smoking to manage their emotions.
Smoking functioned to calm down those who
were angry, frustrated, overwhelmed, or anx-
ious; comfort those who were sad; entertain
those who were bored; and keep company those
who were lonely. Some participants reported ex-
periencing these emotions as they coped with
stressful events, such as family crises, relation-
ship breakups, or financial problems. Partici-
pants also described experiencing two or more
negative emotions simultaneously. For exam-
ple, a 34-year old heterosexual described the
emotions that led to her smoking relapse: “For
the past 2 months, it’s been anger, frustration
and anxiety. I feel like I could drown eas-
ily.” The positive emotional effects of smok-
ing were highlighted by this 39-year-old lesbian
participant:
What do [cigarettes] do for me? They def-
initely reduced my anxiety level, and I
mean, I always liked to smoke. It gave me
back the same kind of little bit of pleasure,
little bit of . . . I don’t know . . . something
to do. Whether it really reduces stress or
not, I don’t know, but I felt like it did,
. . . And I don’t know, maybe during this
time it gave me something, or I felt like it
was giving me something.
A 34-year old lesbian observed: “[Smoking
is] a really effective way for me to not feel
my feelings. . . . I’ll want a cigarette whether
I feel really good or whether I feel really
bad.” A 57-year-old lesbian participant de-
scribed how smoking helped her to manage neg-
ative emotions:
I became angry about something. I don’t
remember what. And I just felt like I was
going to be overcome and couldn’t toler-
ate the feeling. Smoking provides an emo-
tional smokescreen. It’s not a metaphor; it
is a smokescreen. And anger has always
done it. Anger has always been the impe-
tus.
This participant also smoked when anxious:
“Smoking gave me whatever I needed to be suc-
cessful with managing my anxiety through a
means other than eating.” A 34-year-old hetero-
sexual explained: “Anxi[ety] and stuff like that.
[Smoking]’ll just mellow me out a minute; it
makes me reflect on what’s going on; it gives me
time.”
There were really no differences in the ways
that lesbian participants and heterosexual female
participants used smoking to cope with negative
emotions. Where the difference lay, however,
was in the experience of sexual stigma, which
was an additional, unique cause of negative emo-
tions for lesbian participants. During or after ex-
periencing sexual stigma, lesbians felt ashamed,
angry, sad, or alienated, and then smoked as a
result. A 23-year-old lesbian remembered:
I was outed. [Laughs] I was outed actually
by a friend. . . . But the next day, it was
all around. . . . None of my friends wanted
anything to do with me. So at that point, it
was all about smoking. I mean . . . I guess
that wasn’t even sadness. That was deeper
than that. It was like finding yourself not
having anybody to talk to. And that was
frustration too. I mean, the frustration of
reaching out and not having anything to
hold onto. And it’s, like, “OK, let me grab
a cigarette.” I think frustration is what it
is for me. I mean, I guess you could call
it stress or sadness, but being frustrated
inside of being stressed, or frustrated inside
of being sad. Does that make sense?
Expectation of such stigma kept a 44-year-old
lesbian closeted, leading to loneliness, sadness,
 Gruskin et al.
and isolation, which she dealt with by smoking:
“The thing that where I smoked, too, was that I
didn’t come out for a long time. . . . It was one of
those things where I just didn’t want to be differ-
ent; I did not want to rock the boat, per se, is what
it was.” In both of these cases, when the partic-
ipants became isolated, frustrated, stressed, and
sad as a result of either anticipating stigma or
experiencing stigma, they turned to smoking as
a comfort and way to regulate their emotions.
This kind of chain reaction is at the heart of
the concept of stigma vulnerability: The neg-
ative emotions related to experiencing stigma
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heightened the temptation to smoke, making the
lesbian smoker more vulnerable to smoking or
relapse.
Stress and negative emotions were interde-
pendent and complex constructs. When the first
participant quoted described her emotions as
“stress or sadness, but being frustrated inside
of being stressed, or frustrated inside of being
sad,” she described a common experience. Both
heterosexual female participants and lesbian par-
ticipants reported smoking to manage stress at
the same time that they were smoking to regu-
late negative emotions. The tangling together of
stress and negative emotions was typical in the
language of both groups of participants. Even
so, regulation of stress emerged as the dominant
reason that participants reported smoking.
Stress Management
Meyer (2003) has divided stress into two
categories: (a) general stressors and (b) minor-
ity stress processes. General stressors are those
common to all people regardless of sexual orien-
tation. Predictably, the general stressors reported
by lesbian participants and heterosexual female
participants as triggering their smoking differed
very little. Both lesbian participants and hetero-
sexual female participants identified finances,
poverty, unemployment, work environment, type
of job, school, significant others, children, sib-
lings, and parents as sources of stress. A 34-
year-old lesbian described the connection be-
tween her job and her smoking: “Yes. I tend to
have a full plate, and so the more that I take on
[at work] the more that I feel like I’m stressed,
and I completely know that I’m stressing my-
173
self out, and I always feel, ‘Oh, I’m so stressed,
I need to smoke.”’ A 43-year-old heterosex-
ual attributed her smoking to a combination
of stresses stemming from unemployment and
poverty: “Stresses were about my housing situ-
ation, looking for work because I am poor, that
stresses me out, so that’s why I smoke.” Family
stress also led to cigarette smoking. For example,
a 22-year-old lesbian smoked to deal with stress
from child care: “So, I had the boys for 2 days.
And that drove me bananas. I smoked. I was
crying.” Similarly, negative emotions caused by
family relationships led to smoking for a 50-
year-old heterosexual:
[exasperated noise] Why am I the only one
that does everything for everybody else and
nobody does anything for me? I don’t know
whether that’s anger or what, but it’s like,
that’s when I want to go out and have a
cigarette.
A main finding was that, unlike heterosexual
female participants, lesbian participants reported
additional and unique stressors resulting from
the experience of sexual stigma. Participants re-
ported experiencing sexual stigma within their
own families. The following quote is from a 23-
year-old participant struggling with her parents
over her sexual orientation:
I think that just . . . my parents aren’t quite
as supportive as I’d like them to be, and
they don’t even realize it. . . . And so that
definitely adds stress. . . . [J]ust recently, I
wanted to jump out of [my mother’s] car
and smoke because I asked her a little bit
about [her past homophobic comments],
and [my mother] was, like, “Oh, no, that
didn’t happen.” So, the denial that goes
along with my being gay, that has noth-
ing to do with my own personal denial, is
stressful.
This participant described experiencing both
overt and anticipated stigma as well as her “own
personal denial,” which we interpreted as a ref-
erence to internalized homophobia. These three
stressors made her more susceptible to the temp-
tation to smoke.
 174 JOURNAL OF LGBT HEALTH RESEARCH
In another example of stress caused by
sexual stigma, a 30-year-old lesbian participant
described how her ex-husband used her sexual
orientation against her to gain custody of their
child. She remembered: “My son’s father, he
had me stressing knowing that I’m gay and
wanting to take it to another level . . . and he [has
been] constantly harassing me and everything.
That started me back up [smoking] again.” In
this case, the participant linked her smoking
relapse directly to the stress caused by the
harassment of her ex-husband.
Just because lesbian participants experienced
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sexual stigma, it was not a guarantee of elevated
smoking. An example can be found in the follow-
ing quote from a 22-year-old lesbian participant:
Does [anything about being a lesbian]
make me smoke more? I think sometimes
yes, because I am . . . once people find out
[about my being a lesbian], some people
do treat me differently. But I’m finally at a
point where I’m okay with who I am and I
know who I am.
This participant is describing a change in her
reaction to stigmatizing experiences. In some
cases, when this participant is discriminated
against because of her sexual orientation, she is
more vulnerable to smoking and is more likely to
smoke. However, she also says that “I’m finally
at a point where I’m okay with who I am and
I know who I am,” an observation that suggests
that with self-acceptance, lesbian smokers like
her can become less vulnerable to smoking in
response to stigmatizing experiences.
Participants of color—both heterosexual and
lesbian—identified racial and ethnic discrimina-
tion as a source of stress, as well. Undoubtedly,
racial/ethnic discrimination was a fact of life for
all participants of color, but the participants who
reported that experiences of discrimination trig-
gered smoking were primarily the lesbians of
color. A 34-year-old Asian lesbian poignantly
described the role of smoking in managing her
negative affect and stress:
So, in terms of relating it to my smoking,
I think that the discrimination part, or the
racism, is related to the self-esteem issues.
Just my sense of, “Who am I? Why do I
experience myself in a way that is so dif-
ferent than the way most people perceive
me?” This constant sense of it doesn’t mat-
ter what I do; I will always be limited by the
way I look. And then, it’s a great place for
me to go to smoking. I don’t want to feel
bad. I don’t want to feel. . . . Sometimes
that sense just feels so insurmountable that
smoking was really a great way to just not
deal with it all. . . . Smoking is a really great
way for me to check out from that.
When asked about ongoing discrimination
that creates stress for her and makes her smoke
more, a 45-year-old African American lesbian
pointed to a recent experience that highlighted
the stress that resulted from institutional racism:
Child please. [Long Pause]. I had to have a
review [for final exams in divinity school]
before a committee of 17 people. No one
on that committee looks like me: nobody,
not one brown face. Sort of brown: there
was a Hawaiian brother, [a] Pacific Island
woman, [an] Asian woman, and the rest
were European men.
Heterosexual women of color also reported
stress from experiences of discrimination. For
example, a 47-year-old African American het-
erosexual described this stress reaction:
I went home, after the dinner, and I smoked
five cigarettes in a row. I was just so angry.
Don’t freaking assume that, because I’m a
Black person, or Black woman, that I’m not
as intelligent as you are, if you’re White,
or Asian, or whatever.
The experience of multiple marginalization
was a theme discussed by a 34-year-old Asian
lesbian. When asked if she smokes to cope with
discrimination, she explained:
Yeah, definitely. I’ve always experienced
more discrimination as an Asian woman
than I have for being queer, and, in fact,
one of my huge frustrations is that when
white people look at me . . . they see an
 Gruskin et al.
Asian woman before they see that I may be
possibly queer.
A 44-year old African American lesbian had
similar sentiments:
So, being a lesbian of color is not a stres-
sor; being a person of color is a stressor of
course, but being all of it together, you’re
really not sure which one you’re being op-
pressed about!
A 34-year old Asian lesbian also experienced
Downloaded By: [Canadian Research Knowledge Network] At: 18:01 7 October 2009
marginalization from within the lesbian commu-
nity:
When I came out, I thought that I would
have this really great community of women
and what I found out in the meantime is
that there is just a much stronger commu-
nity of White lesbian women that’s very,
very culturally White and that’s been dif-
ficult. . . . White lesbians . . . see me as an
Asian woman, but they don’t think “queer
woman.” That’s just been a huge point of
frustration for me.
In fact, perhaps as a way of coping with the
stress of this situation, some participants, such as
this 31-year-old Asian woman, chose to identify
as queer rather than lesbian:
“Lesbian” feels very White to me and it
feels older. . . . What I love about “queer”
is that it also implies a political and social
position that is at odds with the mainstream
. . . whatever the lesbian mainstream is. So
“queer” just signifies so much more about
my position in the world.
These findings suggest that participants who
were in both a sexual minority and a racial/ethnic
minority experience stressors and lifestyle fac-
tors associated with multiple minority statuses
that increase the cumulative risk for smoking.
Enhancement of Social Relationships
Enhancement of social relationships refers
to the social connection that smoking creates
175
among smokers. Smoking was a way to create,
develop, and enhance social relationships, with
one heterosexual participant describing smoking
as a “form of communication” among smok-
ers, and another observing that “I knew that
our best conversation would be out there with a
cigarette.” A 47-year-old heterosexual described
smoking is an ice-breaker among strangers:
“Smoking is this big bonding thing between peo-
ple. And it’s not just something else that people
have in common: It’s like instant friendship.”
Similar language was used by a 31-year-old les-
bian: “That was our bond, even if we had abso-
lutely nothing else in common, we all smoked.
So I had 11 immediate friends, which made the
transition to college a little easier.”
Smoking in social groups was described by
a 44-year-old lesbian participant: “Being a les-
bian, [smoking cigars] was kind of like a thing
that butch lesbians did. . . . I had friends and es-
pecially when we were in a group thing . . . we’d
go out on the patio and talk and smoke a cigar.”
Smoking in social spaces such as bars was re-
called by a 27-year-old lesbian participant:
When I started again it was because I was
going to a lot of bars . . . and with drinking
and smoking it always paired up for me, it
was really easy just to start again, because
. . . what do you when you’re drinking?
Well, I might as well pick up a cigarette.
By smoking to feel accepted socially, both les-
bian participants and heterosexual female par-
ticipants were managing emotions such as anxi-
ety and loneliness, as well as promoting positive
emotions such as belonging and happiness.
Stigma vulnerability, unique to lesbian partic-
ipants, also has a social component that became
clear in the data. One 44-year-old lesbian par-
ticipant recounted that smoking was a way to
conceal her sexual orientation in high school:
“When I started [smoking] in high school, it was
a way to hide being different because you have
a peer group that smokes.” Stigma vulnerability
was manifested when this participant smoked to
fit into her peer group. Once she had quit, the so-
cial payoff of fitting in, in addition to the stress
associated with remaining closeted, heightened
 176 JOURNAL OF LGBT HEALTH RESEARCH
the temptation to smoke, making this participant
more vulnerable to smoking relapse as a result.
The social component of stigma vulnerabil-
ity also could be seen in the experiences of
the “out” (sexual orientation generally known)
participants. Although our sample consisted of
adults, lesbian participants recollected the stress-
ful or emotional events from their youth that led
to smoking initiation. A 27-year-old lesbian re-
membered:
Pretty much everyone I hung out with in
high school and middle school with whom
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I was smoking [was] queer. . . . There’s a re-
ally specific community of kids . . . they’re
all gay, and they’re all coping, I think,
through cigarettes and drugs, and trying to
fit in that way.
A 48-year-old lesbian participant’s story
shows another side of the same problem. She
recalled:
It [was] harder to try to fit in [with the
heterosexuals in junior high school] than
it [was] to just take the crap [from them].
So that’s what [the other lesbian and I] did,
we took the crap, but we were smoking by
then.
Stigma vulnerability was illustrated in these
accounts when lesbian participants and their
peers used tobacco to cope with the stress
associated with experiencing both overt and
anticipated discrimination based on sexual
orientation.
DISCUSSION
These findings add context to the existing
smoking literature by painting a fuller picture
of the interrelated roles of stress management,
emotional regulation, and enhancement of so-
cial relationships in the smoking behavior of les-
bians. Our conclusions regarding stress manage-
ment and emotional regulation in both lesbian
and heterosexual female smokers are consistent
with the smoking literature: stress and negative
affect have been found to be higher in smok-
ers and to serve as cues for smoking (Kassel,
Stroud, & Paronis, 2003); similarly, postcessa-
tion negative affect has been found to be one of
the stronger predictors of relapse (Kenford et al.,
2002).
There were marked commonalities among
lesbian and heterosexual participants. For exam-
ple, we found that both groups reported smoking
as a result of the same stressors: family (prob-
lems caused by ex-partners, children, parents,
and/or siblings), finances, and employment were
the most common.
A challenge we faced in this study was cap-
turing the intersection of identities and positions
in society described by participants. The theory
of intersectionality argues that social identities
and social inequality are not additive, but “inter-
dependent and mutually constitutive” (Bowleg,
2008, p. 312). The participants in this study often
quite explicitly noted the conflicts and complex-
ity of their multiply marginalized statuses. Be-
cause all were women, the participants fell into at
least one socially marginalized group. A subset
of the sample was marginalized further: identi-
fying as female and person of color or as female
and lesbian. Another subset of the sample was
differently marginalized: identifying as female,
lesbian, and person of color. Stress from expe-
rienced marginalization often led to smoking.
For example, participants of color, regardless
of sexual orientation, reported that stress from
racism led to smoking. Lesbian participants of
color especially emphasized experiencing stress
related to discrimination from within the lesbian
community. Some identified as queer1 to claim
a political and social position at odds with the
mainstream, often a form of resistance against
white lesbian culture.
Participant reports of their struggles to regu-
late emotions such as anger, anxiety, and depres-
sion were critical in understanding their reasons
for smoking. The role of negative emotions in
smoking and relapse is also supported by the
scientific literature (Kenford et al., 2002). In
many participant accounts, stress and negative
emotions were intertwined and interrelated, in
some cases seeming to simultaneously trigger
smoking.
The drive to connect socially was a way for
participants to regulate negative emotions and
 Gruskin et al.
manage stress. Especially as teenagers, partic-
ipants reported smoking to “fit in” or to “look
cool,” concerns that are associated with anxiety
and stress about not belonging. The downside
of this source of social support is that, to fit in,
participants had to smoke. The lure of social
relationships with other smokers was especially
insidious for smoking for lesbian participants.
Adult lesbian participants reported smoking
when they were young to conceal their sexual
orientation, for example, as a consequence of
felt stigma (Herek & Garnets, 2007), or to
form alliances with others who also perceived
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themselves as sexual minority outcasts. It can be
argued that sexual minority youth are especially
vulnerable to smoking initiation because they
struggle to fit in socially. Because prejudice
and discrimination are a part of the modern
American culture, social support is crucial for
lesbians to survive rejection by loved ones and
other forms of social alienation. This makes
the social connection created by smoking very
seductive.
The main differences between lesbian and
heterosexual female reasons for smoking cen-
tered on additional and unique stressors caused
by sexual stigma. Thus, we propose the con-
cept of stigma vulnerability as a framework for
understanding how the experience of minority
stress works to elevate lesbian smoking rates.
Although stigma vulnerability draws from the
minority stress model in terms of minority stress
processes, it differs from minority stress/sexual
stigma (Herek, 2007; Meyer, 2003) in two key
ways: (a) The stigma vulnerability construct is
more broadly applicable than minority stress the-
ory or sexual stigma theory. With its focus on
smoking addiction, and potentially addictions
and substance abuse, generally, stigma vulnera-
bility bridges the fields of psychology and public
health; (b) in stigma vulnerability, we have inte-
grated different types of stigma (Herek, 2007),
rather than just internalized homophobia and en-
acted stigma, the focus of sexual minority the-
ory (Meyer, 2003), making stigma vulnerability
more appropriate for describing the diversity of
lesbian experiences.
It is our contention that the concept of stigma
vulnerability provides a rationale for elevated
lesbian smoking rates. Based on our analysis of
177
participant accounts, we developed the concept
of stigma vulnerability to describe the height-
ened susceptibility to the temptation to smoke
as a result of the experience of sexual stigma.
For example, we identified experienced sexual
stigma when lesbian participants reported be-
ing involuntarily outed (and thus being placed
at greater risk for enacted stigma), being re-
jected by unsupportive families, and experienc-
ing ostracism, interpersonal rejection, and dis-
crimination. Even when lesbian participants did
not directly attribute their increased smoking to
managing the stress caused by experiencing sex-
ual stigma, they described negative emotions—
such as anger, sadness, frustration, or anxiety—
resulting from the experience of being stigma-
tized, which they later reported managing by
smoking. Whether or not a participant reported
giving in to the temptation to smoke during a
stigmatizing experience depended on how much
she relied on smoking to help her enhance so-
cial relationships, regulate emotions, and man-
age stress.
Strengths and Limitations
By interviewing participants about their
smoking, we were able to present detailed
accounts using the language that participants
chose to describe their smoking. Our use of
a convenience sample limits the generalizabil-
ity of findings, however, and, as Herek and
Garnets (2007) have pointed out, bias may
have been introduced into our sample be-
cause of this method of recruitment. Another
limitation is that our data came from par-
ticipant reports of emotions and stress expe-
riences. Although we find value in partici-
pant reports to identify reasons for smoking,
a follow-up study that objectively disentangles
stress from negative emotions and uses consis-
tent descriptive language is recommended.
We have presented stigma vulnerability as a
concept that is specific to smoking and empha-
sizes vulnerability to smoking related to sexual
stigma over other forms of stigma. It could be ar-
gued that stigma vulnerability applies to popula-
tions other than lesbians and to other addictions.
These are questions to be answered in other stud-
ies and are suggestions for further research.
 178 JOURNAL OF LGBT HEALTH RESEARCH
Implications
LGBT-focused smoking cessation programs
have been developed around the country, par-
ticularly in San Francisco, Washington, DC,
Philadelphia, Seattle, Michigan, Los Angeles,
Chicago, New York, Iowa, and Santa Bar-
bara (National LGBT Tobacco Control Network,
2009). These programs, and manuals that have
been developed as a result of them (Queer-
TIP, 2002; Scout, Miele, Bradford, & Perry,
2006), have focused primarily on providing so-
cial support in queer-specific contexts and, for
gay men and transgender smokers, education
Downloaded By: [Canadian Research Knowledge Network] At: 18:01 7 October 2009
about the implications smoking and HIV/AIDS
or hormone replacement. Although identified as
a cause of depression (QueerTIP, 2002), discus-
sion of stigma in the context of smoking cessa-
tion programs has been limited.
We have illuminated some of the stresses and
pressures that are specific to the experience of
lesbian smokers. By doing so, we have iden-
tified a focus for cessation programs and pre-
vention campaigns that would tailor content to
lesbian smokers. For example, in the QueerTIP
curriculum (2002), we agree that a strong focus
on social support is an excellent foundation for a
lesbian-specific cessation program. In addition,
we suggest that a lesbian-specific cessation pro-
gram be team taught by both a facilitator from
within the lesbian community and a psychologist
or social worker with training in stigma ther-
apy. The psychologist or social worker would
be able to provide intervention to cessation par-
ticipants to enable them to understand the im-
pact of stigma vulnerability on their smoking
and develop healthy coping strategies. Cessa-
tion programs facilitated by therapists specializ-
ing in lesbian identity issues would successfully
bring to bear on the task of smoking cessation
techniques for increasing self-acceptance, inte-
grating lesbian identity, and developing a collec-
tive lesbian identity. Gaining an understanding
the factors that contribute to lesbian smoking is
the first step in designing interventions to help
lesbian smokers learn to cope with multiple and
simultaneous sources of stress and negative emo-
tions without cigarettes.
Finally, the stigma vulnerability framework
should be investigated further. We suggest quan-
titative study that would test the generalizability
of the framework. In addition, we recommend
quantitative and qualitative research that would
apply stigma vulnerability to other addictions or
to other types of discrimination.
NOTE
1. For ease of discussion, participants who identified
as queer were referred to as lesbian at certain points in
this manuscript.
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