COCHRAN, GRELLA, AND MAYS 675
Do Substance Use Norms and Perceived Drug Availability
Mediate Sexual Orientation Differences in Patterns
of Substance Use? Results from the California Quality of
Life Survey II
SUSAN D. COCHRAN, PH.D., M.S.,a,* CHRISTINE E. GRELLA, PH.D.,b AND VICKIE M. MAYS, PH.D., M.S.P.H.c
aDepartment of Epidemiology, Fielding School of Public Health, University of California, Los Angeles, Los Angeles, California
bDepartment of Psychiatry, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
cDepartment of Psychology, University of California, Los Angeles, Los Angeles, California
ABSTRACT. Objective: Illicit drug and heavy alcohol use is more
common among sexual minorities compared with heterosexuals. This
difference has sometimes been attributed to more tolerant substance use
norms within the gay community, although evidence is sparse. The cur-
rent study investigated the role of perceived drug availability and tolerant
injunctive norms in mediating the linkage between minority sexual ori-
entation status and higher rates of prior-year substance use. Method: We
used data from the second California Quality of Life Survey (Cal-QOL
II), a followback telephone survey in 2008–2009 of individuals fi rst in-
terviewed in the population-based 2007 California Health Interview Sur-
vey. The sample comprised 2,671 individuals, oversampled for minority
sexual orientation. Respondents were administered a structured interview
assessing past-year alcohol and illicit drug use, perceptions of perceived
illicit drug availability, and injunctive norms concerning illicit drug and
heavier alcohol use. We used structural equation modeling methods to
test a mediational model linking sexual orientation and substance use
behaviors via perceptions of drug availability and social norms pertain-
ing to substance use. Results: Compared with heterosexual individuals,
sexual minorities reported higher levels of substance use, perceived drug
availability, and tolerant social norms. A successfully fi tting model sug-
gests that much of the association between minority sexual orientation
and substance use is mediated by these sexual orientation–related differ-
ences in drug availability perceptions and tolerant norms for substance
use. Conclusions: Social environmental context, including subcultural
norms and perceived drug availability, is an important factor infl uenc-
ing substance use among sexual minorities and should be addressed in
community interventions. (J. Stud. Alcohol Drugs, 73, 675–685, 2012)
DA 20826 and National Center for Minority Health and Health Disparities
Grant P60-MD 000508.
*Correspondence may be sent to Susan D. Cochran at the Department
of Epidemiology, Fielding School of Public Health, Center for Health Sci-
ences, University of California, Los Angeles, Box 951772, Los Angeles, CA
90095-1772, or via email at: email@example.com.
Received: January 2, 2012. Revision: February 28, 2012.
This study was supported by National Institute on Drug Abuse Grant R01-
of their gender, tend to have higher rates of illicit drug and
heavy alcohol use than do their same-gender heterosexual
counterparts (Burgard et al., 2005; Cochran et al., 2000,
2004; Drabble et al., 2005; Gruskin et al., 2001; Hughes
et al., 2010; McCabe et al., 2009; McLaughlin et al., 2010;
Talley et al., 2011). Several population-based studies have
reported higher rates of illicit drug and alcohol use and
problem drinking among homosexually active women
compared with exclusively heterosexual women, even after
controlling for differences in sociodemographic charac-
teristics (Burgard et al., 2005; Cochran et al., 2000, 2004;
Drabble et al., 2005; Gruskin et al., 2001; Hughes et al.,
2010; McCabe et al., 2009; McLaughlin et al., 2010; Talley
et al., 2011). Further, a population-based survey of women
CCUMULATING EVIDENCE SHOWS THAT indi-
viduals with minority sexual orientation, regardless
ages 18–29 in low-income neighborhoods in northern Cali-
fornia found that women who reported having both male
and female sexual partners had signifi cantly higher rates
of injection drug use compared with others (Scheer et al.,
2002). Similarly, studies conducted with men who have sex
with men have observed elevated rates of substance use
disorders (Cochran et al., 2004; McCabe et al., 2009; Tal-
ley et al., 2011). For example, Stall and colleagues (2001)
found that men who have sex with men, including gay and
bisexual identifi ed men, recruited from four urban areas
nationally, had elevated levels of alcohol-related problems
and recreational drug use when compared with national
rates found among men in general.
Several explanations have been posited for these sexual
orientation–related differences (Cochran, 2001). Most often
these disparities are attributed to a greater probability for
exposure to antigay stigma and discrimination, both in child-
hood and as adults (Hamilton and Mahalik, 2009; Hughes
et al., 2010; Mays and Cochran, 2001; Stall et al., 2003;
Wilsnack and Wilsnack, 1995). Known as the “minority
stress hypothesis” (Meyer, 2003; Stall et al., 2003), this per-
spective asserts that the higher rates of dysfunctional alcohol
and illicit drug use found among lesbian, gay, and bisexual
individuals are a direct or indirect consequence of social
676 JOURNAL OF STUDIES ON ALCOHOL AND DRUGS / JULY 2012
ferences. Elsewhere, studies have demonstrated consistent
evidence of neighborhood and community infl uence on
substance use behaviors and attitudes. For example, there is
a positive relationship between neighborhood alcohol outlet
density and social norms regarding alcohol use, as well as
rates of alcohol consumption (Scribner et al., 2000). In this
regard, the social organization of a visible gay and lesbian
community, traditionally centered on “gay bars” and social
outlets, may encourage the use of alcohol and illicit drugs
(Green and Feinstein, 2011; Simon Rosser et al., 2008). The
effect may be to create a climate of tolerant injunctive social
norms surrounding substance use in which illicit drugs are,
in turn, more readily available. Injunctive norms refer to
people’s perceptions that the behaviors in question are either
socially approved or disapproved (Schultz et al., 2007).
Indeed, Stall and colleagues (2003) have underscored that
illicit substance use is woven into a pattern of socializing and
sexual practices among young gay and bisexual men living
in an urban gay male culture, implying a milieu in which
substance use is seen as normative.
Consistent with this view, some types of drug use have
become essentially institutionalized within “gay culture,”
including use of inhalants (“poppers”), “club drugs,” and
methamphetamines, all of which are also associated with
high-risk sexual behavior among men who have sex with
men (Ober et al, 2009; Ostrow et al., 2009). Trocki and col-
leagues (2005) observed that women who reported histories
of same-gender sexual partners spent more time in bars and
party settings than exclusively heterosexual women and that
sexual minority women also consumed more alcohol in these
settings. However, the same study also found contradictory
evidence with regard to men. Specifi cally, rates of heavy
drinking among men did not vary by sexual orientation
across settings, even though gay men spent more time in bars
than bisexual and heterosexual men did.
Some researchers (Cochran, 2001; Green and Feinstein,
2011; McKirnan and Peterson, 1989) have speculated that
tolerant norms regarding drug use are endemic among sexual
orientation minorities, particularly among those living in ar-
eas of higher gay density. In one study of more than 700 gay
men living in New York City, men with more “gay-centric”
networks had higher rates of substance use (Carpiano et al.,
2011). Another study of gay men who had moved to a gay
resort area in South Florida found that those who had lived
in the area for 1 year or longer had higher levels of risky
behaviors and more drug-using friends compared with newer
arrivals (Egan et al., 2011). Thus, adoption of gay identity
and acculturation within a gay-identifi ed community may
increase one’s exposure to more tolerant social norms regard-
ing drug use. Further, these tolerant norms may be especially
infl uential for individuals who are more vulnerable to the ef-
fects of stress, such as from genetic disposition, high rates of
cumulative exposure to stressors, or lack of adaptive coping
However, there may be additional reasons for these dif- skills (Cicchetti et al., 2007; Heffernan, 1998; Kendler et al.,
2011; McKirnan and Peterson, 1988, 1989).
In the current study, we investigated the nature of the rela-
tionships among sexual orientation, perceived availability of
illicit drugs, and tolerant injunctive social norms regarding
substance use. To do so, we used data available from the sec-
ond California Quality of Life Survey (Cal-QOL II). We hy-
pothesized that the frequently observed association between
minority sexual orientation and higher rates of substance use
is, at least in part, mediated by both higher rates of perceived
drug availability and more tolerant injunctive social norms
regarding substance use among sexual minorities compared
with their heterosexual counterparts.
persons systematically selected from nearly 49,000 adult
respondents in the population-based 2007 California Health
Interview Survey (CHIS; CHIS, 2009). Both surveys were
structured telephone interviews. The parent random-digit-
dial CHIS survey received approval from three entities: the
University of California, Los Angeles (UCLA), Institutional
Review Board; the California Health and Human Services
Agency; and the Westat Institutional Review Board. All
participants provided anonymous responses. Cal-QOL II
eligibility comprised the following: 18–70 years of age at
the time of the CHIS interview (the group eligible for CHIS
sexual orientation assessment), interviewed in English or
Spanish (98% of CHIS interviewees), and agreement to be re-
contacted for future health surveys (91% of language-eligible
respondents). From this list, we divided the sampling frame
into two strata. One stratum, selected with certainty, included
all who reported in CHIS a lesbian, gay, or bisexual identity
and/or a same-gender sexual partner in the year before the
interview (n = 1,387). From the second stratum, we selected
3,613 individuals proportional to their representation in
the California population, except for oversampling African
Americans. Permission to interview these individuals received
approval from the CHIS Data Disclosure Review Committee
and the UCLA and Westat Institutional Review Boards.
The 2007 CHIS response rate was 21.1%, consistent with
other recent random-digit-dial telephone interviews (Burgard
et al., 2005; National Center for Chronic Disease Prevention
and Health Promotion, 2005; Simon et al., 2001) including
the 2007 California Behavior Risk Factor Surveillance Sys-
tem survey (18.7%) (CHIS, 2009). Of the 5,000 potential
respondents, 65 were deemed ineligible (e.g., moved out
of California, deceased). However, 2,815 were successfully
interviewed between August 2008 and January 2009 in either
English or Spanish for a Cal-QOL II–specifi c response rate
Participants in Cal-QOL II were drawn from 5,000 eligible
COCHRAN, GRELLA, AND MAYS 677
who were administered a shortened interview as part of an
embedded refusal conversion experiment; this shortened
instrument omitted norm-related questions. Thus, our fi nal
sample size was 2,671. The mean age of the unweighted
sample was 46.5 years (SD = 13.6 years). Approximately
51% of participants were female. Respondents reported
diverse ethnic/racial backgrounds including 545 Hispan-
ics and, among non-Hispanics, 1,539 Whites, 398 African
Americans, 157 Asian Americans, and 32 American Indian/
We excluded 144 of the 2,815 Cal-QOL II respondents
computer-assisted telephone interview by extensively trained
lay interviewers. Assessments included the following:
Sexual orientation. Individuals were asked the genders
of their sexual partners since age 18 and in the year before
the interview. Next, they were asked whether they con-
sidered themselves heterosexual or straight, lesbian (for
women) or gay, or bisexual. We used this information to
categorize respondents into one of two groups: exclusively
heterosexual (heterosexual identity and only different-
gender sexual partners, if any, since age 18 reported; n =
1,877) and sexual orientation minority (lesbian, gay, or bi-
sexual identity [n = 719] or a history of same-gender sexu-
al partners since age 18 [n = 75]). Finally, to assess sexual
orientation–related discrimination, respondents were asked,
“Sometimes people are treated badly or unfairly because
of their sexual orientation. How often has that happened to
you?” Answer options included 1 = never, 2 = rarely, 3 =
sometimes, and 4 = often.
Substance use. Respondents answered questions about
their alcohol and drug use in the 12 months before the inter-
view. Those who reported consuming fi ve or more alcoholic
drinks in a single drinking occasion on a weekly basis were
coded as heavier drinkers. Individuals were also queried
about past-year use of marijuana or hashish and 10 other
classes of drugs. Six of these were illicit drugs: cocaine or
crack, methamphetamine, heroin, hallucinogens, synthetic
or club drugs, and inhalants. Four included drugs available
by prescription (analgesics, tranquilizers, stimulants, and
sedatives) but specifi ed in the interview as being used either
without prescription or in greater amounts than prescribed.
From this, we coded two variables: past-year use of mari-
juana specifi cally (yes/no) and past-year illicit use of any
other drug (yes/no).
Perceived drug availability. The survey included three
questions drawn from the 2007 National Survey on Drug
Use and Health (Substance Abuse and Mental Health Ser-
vices Administration Offi ce of Applied Studies, 2008) as-
Respondents were administered a fully structured,
sessing perceived drug availability. Specifi cally, respondents
were asked, “How diffi cult or easy would it be for you to
get some (specifi ed drug), if you wanted some?” The three
specifi ed drugs were marijuana; cocaine; and lysergic acid
diethylamide (LSD), crystal methamphetamine (“crystal
meth”), or other hallucinogens. Answers were given on a
5-point scale: 1 = probably impossible, 2 = very diffi cult, 3
= fairly diffi cult, 4 = fairly easy, and 5 = very easy.
Injunctive norms. Four questions assessed injunctive
norms pertaining to heavy drinking and illicit drug use.
These questions were adapted from the 2007 National Sur-
vey on Drug Use and Health (Substance Abuse and Mental
Health Services Administration Offi ce of Applied Studies,
2008). Specifi cally, respondents were asked, (a) “How do you
feel about someone your age having four or fi ve drinks of
an alcoholic beverage nearly every day?” (b) “How do you
feel about adults trying marijuana or hashish once or twice?”
(c) “How do you feel about adults trying cocaine?” and (d)
“How do you feel about adults trying LSD, crystal meth, or
other hallucinogenic drugs?” Responses were recorded on a
3-point scale: 1 = strongly disapprove, 2 = somewhat disap-
prove, or 3 = neither approve nor disapprove.
Personal demographics. The interview also assessed
respondents’ age, gender, educational attainment, race/
ethnicity, relationship status, and urban residency. We coded
age into fi ve categories (18–29 years, 30–39 years, 40–49
years, 50–59 years, and 60–72 years), educational attainment
into fi ve categories (less than high school, high school degree,
some college, college degree, and graduate education), race/
ethnicity into two categories (non-Hispanic White, racial/
ethnic minority), relationship status into two groups (married
or cohabiting, other), and urban residency into two classifi -
cations (lives in urban metropolitan statistical area, other).
stitute Inc., Cary, NC) and MPlus (Muthén and Muthén,
2007) using weights to adjust for selection probability
and survey nonresponse. In the fi rst group of analyses, we
used Wald chi-square tests to evaluate anticipated sexual
orientation–related differences in demographic character-
istics and frequency of sexual orientation–related maltreat-
ment. Both demographic characteristics (gender, age, race/
ethnicity, educational attainment, relationship status, and
residency location) and perceived maltreatment were then
treated as possible study confounders because of previous
research suggesting their association both with alcohol and
drug use (Brady and Randall, 1999; Johnson and Gerstein,
1998; Mays and Cochran, 2001) and sexual orientation in
population-based surveys (Cochran, 2001; Cochran et al.,
2000; Gilman et al., 2001) similar to the Cal-QOL II. We
also evaluated sexual orientation–related differences in
the individual indicators of perceived availability of illicit
Data were analyzed using SAS Version 9.2 (SAS In-
678 JOURNAL OF STUDIES ON ALCOHOL AND DRUGS / JULY 2012
drugs, tolerant injunctive norms, and substance use using
either Wald F tests or Wald chi-square tests, as appropriate.
Next, we used structural equation modeling (SEM) meth-
ods with weighted least squares (WLS) estimators to build
and test both fi t and parameters of three possible mediational
models linking sexual orientation to substance use patterns
(Figure 1). In the general model, the predictive association
between sexual orientation and substance use was hypoth-
esized to result from both direct and indirect pathways via
perceived drug availability and tolerant injunctive norms. As
an initial step, we fi rst investigated, independently, the fi t of
three measurement models indexing the hypothesized latent
constructs of drug availability, tolerant substance use norms,
and substance use behaviors. After obtaining assurance that
these models had satisfactory properties, we then investigat-
ed bivariate associations (polychoric correlations) between
the three latent variables and both sexual orientation and
possible confounders. Statistical testing was accomplished
by use of the critical ratio (CR) test (estimate / SE), which
has an approximate Gaussian distribution. Those variables
evidencing an association consistent with p < .20 with a
particular latent variable were retained for the subsequent
Finally, we estimated the fi t of three variants of structural
relationships between sexual orientation status and the latent
construct of substance use. In the fi rst model, we evaluated a
mediational model where drug availability alone is the link
between sexual orientation and substance use. In the second
model, we hypothesized that injunctive norms alone mediate
the link between sexual orientation and substance use. More-
over, in the third model, we hypothesized that both factors
function as conjoint mediators. In all model testing steps,
models were evaluated for fi t, or their ability to capture the
covariance structure of the data, using three fi t indices: the
comparative fi t index (CFI; Bentler, 1990), the Tucker–Lewis
index (TLI; Brown, 2006), and the root mean square error of
approximation (RMSEA; Steiger, 1990). CFI and TLI values
above .95 and RMSEA values below .05 are consistent with
a good fi tting model (Hu and Bentler, 1999). We also report
the model chi-square statistic. Although a nonsignifi cant
chi-square is also consistent with model fi t, this statistic is
particularly sensitive to small departures from expected val-
ues in large sample sizes, such as the one used in the current
study (Kline, 2011). Tests of structural parameters, including
a comparison of mediation effects between perceived drug
availability and tolerant injunctive norms, were conducted
using CR tests. We also estimate meditation ratios (Ditlevsen
et al., 2005) for structural relationships testing mediational
FIGURE 1. Mediational model of sexual orientation, perceived drug availability, tolerant norms, and past-year substance use
COCHRAN, GRELLA, AND MAYS 679
hypotheses. The mediation ratio (MR) is the ratio of estimat-
ed indirect effects to the sum of estimated direct and indirect
effects, or the total effect. This ratio represents the percent-
age change in regression coeffi cients when a hypothesized
mediating variable is included in the model. Signifi cance of
all tests, other than adequacy of model fi t, was evaluated at
p < .05. All reported confi dence intervals (CIs) are at 95%.
Background differences by sexual orientation
respondents reported any markers of minority sexual ori-
entation, including identifying as lesbian, gay, or bisexual
(2.4%, CI [2.2, 2.8%]) or indicating a positive adult history
of same-gender sexual partners (2.1%, CI [1.5, 2.8%]). As
shown in Table 1, sexual minorities were generally older,
χ2(4) = 5.52, p < .001, and more educated, χ2(4) = 6.41, p
< .001; were less likely to be married or cohabitating, χ2(1)
= 14.06, p < .001; and were more likely to be non-Hispanic
White, χ2(1) = 42.10, p < .001. As expected, compared with
heterosexuals, sexual minorities also reported more frequent
experiences with being treated badly or unfairly because of
their sexual orientation, χ2(3) = 54.56, p < .001.
Rates of substance use differed by sexual orientation in
the expected directions (Table 2). Overall, sexual minorities
Approximately 4.5% (CI [3.9, 5.3]) of the weighted
were signifi cantly more likely than exclusively heterosexual
persons to report having used marijuana, χ2(1) = 18.67, p
< .001, or other illicit drugs, χ2(1) = 10.47, p = .001, and
showed a trend to report greater prevalence of weekly heavi-
er drinking, χ2(1) = 2.83, p = .09. Perceived illicit drug avail-
ability was also greater among sexual minorities, including
reporting signifi cantly greater ease of obtaining marijuana,
Wald F(1) = 27.30, p < .001, or hallucinogenic drugs, Wald
F(1) = 7.06, p < .01, but not cocaine, Wald F(1) = 1.02, p =
.31. Compared with exclusively heterosexual persons, sexual
minorities also evidenced signifi cantly more tolerant injunc-
tive norms concerning adults trying marijuana, Wald F(1) =
87.09, p < .001; trying cocaine, Wald F(1) = 41.32, p < .001;
trying hallucinogenic drugs, Wald F(1) = 29.05, p < .001; or
engaging in daily heavy consumption of alcohol, Wald F(1)
= 13.40, p < .001.
Development of latent variables
models depicted in Figure 1 by evaluating associations
among the indicators of hypothesized latent variables. The
polychoric correlation matrix is given in Table 2. Overall,
there were strong and signifi cant correlations among the
perceptions of drug availability and among norms related to
heavy alcohol and drug use, with the strongest associations
between cocaine and hallucinogens. Past-year marijuana use
We next investigated the fi t of the three measurement
TABLE 1. Characteristics of respondents in the second California Quality of Life Survey
by sexual orientation: Weighted percentages and standard errors shown
characteristics % (SE) % (SE)
Age, in years***
<High school degree
High school degree
51.5 (1.3) 57.1 (3.7)
Notes: Where relevant, percentages sum to 100% except for rounding error. Statistical
signifi cance evaluated by Wald chi square tests.
***p < .001.
(unweighted n = 1,877)
Sexual orientation minority
(unweighted n = 794)
680 JOURNAL OF STUDIES ON ALCOHOL AND DRUGS / JULY 2012
was positively associated with perceptions of greater avail-
ability of marijuana, cocaine, and hallucinogens; past-year
other illicit drug use was associated with past-year marijuana
use. Past-year weekly heavy episodic drinking was associ-
ated with perceived tolerant norms regarding heavy drinking
as well as past-year use of marijuana and other illicit drugs.
In the initial modeling step, we evaluated the adequacy of
our three measurement models embedded in Figure 1. First,
we hypothesized a single latent factor (drug availability)
indexing the three measured indicators of perceived ease of
obtaining marijuana, cocaine, or hallucinogenic drugs. This
model had adequate fi t to the data, χ2(1) = 15.197, p < .001
(CFI = 1.00; TLI = 1.00; RMSEA = .073). All estimated
factor loadings were strongly positive (availability of cocaine
loading fi xed at 1.0; marijuana: 0.79, SE = 0.01; hallucino-
gens: 0.86, SE = 0.01). Next, we investigated the fi t of the
model indexing a latent factor of tolerant injunctive norms
for substance use. Four measured indicators were used to
defi ne the factor; all were strong predictors of the construct
(approval or disapproval of cocaine fi xed at 1.0; hallucino-
gens: 0.91, SE = 0.01; marijuana: 0.78, SE = 0.02; alcohol:
0.53, SE = 0.02). This model demonstrated an excellent fi t
to the covariance structure, χ2(2) = 18.98, p < .001 (CFI =
1.00; TLI = 1.00; RMSEA = .045). Finally, three indicators
of substance use (past-year use of marijuana, past-year illicit
use of other drugs, and heavier drinking with at least weekly
frequency on average) successfully defi ned the third latent
factor refl ecting past-year substance use, χ2(1) = 1.24, p =
.266 (CFI = 1.00; TLI = .99; RMSEA = .009). All indicators
again were strongly related to the latent construct (marijuana
TABLE 2. Weighted means and percentages by sexual orientation and polychoric correlations of key indicator variables in the model
minority Polychoric correlations
SE 1. 2. 3. 4. 5. 6. 7. 8. 9.
4. Marijuana use***
5. Cocaine use***
6. Hallucinogen use***
7. Frequent heavy
Past-year substance use
8. Marijuana use***
9. Other illicit
10. Weekly heavy
.61*** .79*** .–
1.71 0.02 1.95 0.06 .12 .07 .10 .48*** .49*** .44*** .–
8.6 0.8 22.9 3.1 .42 .17 .14 .58*** .33*** .33*** .23 .–
9.4 0.8 19.6 3.0 .22 .14 .12 .27 .22 .16 .04 .50*** .–
5.8 0.6 9.5 2.1 .24 .10 .13 .14 .09 .15 .39*** .31*** .25***
Notes: Weighted means and percentages are shown. Results of signifi cance testing evaluating differences between exclusive heterosexuals and
sexual minorities are indicated next to the variable name. Results of tests of polychoric correlations are indicated next to estimate of the correlation.
aMeasured on 5-point scale, where 2 = very diffi cult, 3 = fairly diffi cult, 4 = fairly easy; bmeasured on 3-point scale, where 1 = strongly disapprove,
2 = somewhat disapprove, 3 = neither approve nor disapprove.
*p < .05; ***p < .001.
TABLE 3. Bivariate associations between latent factors and sexual orientation and potential control variables
Drug availability Tolerant norms Substance use
Variable Estimate (SE) Estimate (SE) Estimate (SE)
Sexual orientation minority
Higher educational attainment
sexual orientation maltreatment
0.12*** (0.04) 0.34*** (0.04) 0.27*** (0.05)
-0.02N.S. (0.02) -0.05† (0.02) -0.02† (0.01)
Notes: Polychoric correlations estimated independently for each latent variable; reported estimates are rounded to
two decimal points; statistical signifi cance was evaluated by critical ratio (CR) tests, where CR = estimate / SE. N.S.
= not statistically signifi cant. aReferent is non-Hispanic White.
†p < .20; *p < .05; ***p < .001.
COCHRAN, GRELLA, AND MAYS 681
fi xed at 1.0; illicit drugs: 0.54, SE = 0.05; heavier drinking:
0.44, SE = 0.07).
Having established the validity of the latent variables,
we then evaluated their bivariate associations with sexual
orientation and the seven potentially confounding demo-
graphic and maltreatment characteristics. As shown in
Table 3, sexual orientation was signifi cantly associated
with all three latent constructs. Perceived drug availabil-
ity was signifi cantly associated with most demographic
characteristics with the exception of ethnic/racial minority
status and urban residence. Specifi cally, younger individu-
als, men, persons with less education, and single persons
were signifi cantly more likely to report greater availability
of illicit drugs. Tolerant norms for substance use were posi-
tively and signifi cantly associated with being male, being
non-Hispanic White, and possessing higher levels of edu-
cation. Finally, the latent construct of substance use was
signifi cantly associated with being younger, male, and non-
Hispanic White; possessing lower levels of education; be-
ing single; and living in an urban environment. Frequency
of sexual orientation–related maltreatment was not strongly
related to any of the three latent constructs.
Evaluation of mediational models
depicted in Figure 1 while adjusting for possible confounding
because of retained demographic and sexual orientation–
related maltreatment measures (not shown in Figure 1). The
fi rst variant hypothesized that sexual orientation is linked to
substance use through direct structural linkage and via an
indirect pathway mediated by perceived drug availability.
This model was a good fi t to the covariance structure of
sample data (Table 4). Parameter estimates are consistent
We then explicitly evaluated three variants of the model
with a model in which perceived drug availability partially,
but not fully, mediates associations between sexual orienta-
tion and substance use. Indeed, results suggest that the ratio
of mediated effects via perceptions of drug availability to
total sexual orientation–related effects (MR = 0.12, CI [0.02,
0.22]) is relatively modest.
In the second variant of Figure 1, we hypothesized a struc-
tural model where the link between sexual orientation and
substance use is mediated solely by differences in tolerant
injunctive norms. This model, too, proved to be a good fi t
to the covariance structure of the data as shown in Table 4.
Both sexual orientation and tolerant injunctive norms were
signifi cant predictors of substance use. The ratio of estimated
indirect effects mediated by injunctive norms to the sexual
orientation–related total effects (MR = 0.39, CI [0.18, 0.61])
was considerably larger than that observed in the previous
Finally, we fi t a third structural model in which both
perceived drug availability and tolerant norms were hy-
pothesized as correlated mediators of sexual orientation–
related differences in substance use. This fi nal model also
proved to be an excellent fi t to the covariance structure of
the data as reported in Table 4. Estimates of indirect effects
linking sexual orientation and substance use via mediation
by perceptions of drug availability (b = 0.06, SE = 0.02)
were signifi cantly weaker than similar indirect effects es-
timated via the effects of injunctive norms (b = 0.24, SE
= 0.05; CR = -3.57, p < .001). Refl ecting this, the media-
tion ratio associated with drug availability (MR = 0.12, CI
[0.01, 0.24]) was smaller than that estimated for injunctive
norms (MR = 0.38, CI [0.18, 0.58]). Overall, the combined
effect of the two latent factors—drug availability and toler-
ant norms—was associated with a mediation ratio of 0.43
(CI [0.22, 0.64]).
TABLE 4. Direct and indirect effects and fi t indices for three mediational models linking sexual orientation and substance use in the California
Quality of Life Survey II: Partial results shown
(Figure 1) Model 1 Model 2 Est.
Direct effects (b)
Sexual orientation ? substance use
Sexual orientation ? drug availability
Drug availability ? substance use
Sexual orientation ? tolerant norms
Tolerant norms ? substance use
Sexual orientation via availability ? substance use
Sexual orientation via norms ? substance use
Total indirect effects
Comparative fi t index
Root mean square error of approximation
Note: Est. = estimate.
**p < .01; ***p < .001.
682 JOURNAL OF STUDIES ON ALCOHOL AND DRUGS / JULY 2012
sexual minority individuals in many convenience-based stud-
ies of the visible gay community (Cochran, 2001; McKirnan
and Peterson, 1988, 1989) and confi rmed more recently by
comparative population-based surveys (Burgard et al., 2005;
Cochran et al., 2000, 2004; Cochran and Mays, 2000; Drab-
ble et al., 2005; Gilman et al., 2001; Gruskin et al., 2001;
McCabe et al., 2009; Stall et al., 2001) has generally been
explained by reasons rooted in the collateral effects of psy-
chopathology (Cochran, 2001; Hatzenbuehler et al., 2011;
McLaughlin et al., 2010; Meyer, 2003; Talley et al., 2011).
According to this view, greater exposure to discrimination
results in higher rates of stress-related mental distress, and
this, in turn, encourages substance use as a coping behavior.
In support of this explanation, multiple studies have dem-
onstrated that exposure to stress and trauma is associated
with mental disorders, substance use, and treatment seek-
ing among individuals in general as well as among sexual
minorities (Frisell et al., 2010; Hatzenbuehler et al., 2011;
Hughes et al., 2010; Keyes et al., 2011; Marshal et al., 2012;
Mays and Cochran, 2001; McLaughlin et al., 2010; Talley et
As did others (Green and Feinstein, 2011), we observed a
greater risk for illicit drug use and heavier drinking among
sexual minorities when compared with exclusively hetero-
sexuals. However, our results suggest that additional social
factors, as well as minority stress, may warrant closer in-
spection. In particular, we demonstrated that individuals with
minority sexual orientation report both more tolerant norms
about substance use and greater availability of illicit drugs.
Further, these two factors appear to mediate a substantial
portion of the relationship between minority sexual orienta-
tion and substance use patterns. Our fi ndings underscore
the possible role of the socioenvironmental context in both
facilitating and maintaining greater risk for substance use
morbidity in this population. Importantly, the mediational
effects of tolerant norms and drug availability were largely
independent of each other, as seen in the stability of the ef-
fects attributable to these factors when entered independently
(Models 1 and 2) and simultaneously (Model 3), although
drug norms accounted for a larger share of the mediation
effect. Further, sexual orientation–related differences were
robust even after adjusting for reported frequency of sexual
The source of these differences may lie in the socializa-
tion of sexual minority persons. Some have hypothesized
that the clustering of individuals with minority sexual ori-
entation (i.e., “gay ghettos”) is comparable to ethnic com-
munities, with shared norms, values, and resources (LeVay
and Nonas, 1995). This hypothesis has been dubbed the “gay
neighborhood drug subculture hypothesis” (Carpiano et al.,
2011). Sexual minorities may seek out neighborhoods that
The higher levels of substance use disorders seen among
are perceived to be more tolerant of behaviors traditionally
deemed as deviant, including homosexuality, drug use, and
commercialized sex work. Urban geographers have examined
the emergence of lesbian and gay urban areas, which histori-
cally have served as a destination for young people seeking
to come out. Such areas afford a sense of community, identi-
ty, and shared values, in contrast to the marginalization many
may have experienced in their home communities (Valentine
and Skelton, 2003). Within this context, substance use may
be integral to promoting social connectedness as part of a
younger “lesbian and gay scene” that is often centered in
clubs and bars (Valentine and Skelton, 2003) and “sexualized
social contexts” such as sex clubs (Garofalo et al., 2007).
In that regard, a recent study found that alcohol use among
lesbian/bisexual college students, compared with hetero-
sexual women, was more strongly infl uenced by desires to
get in with a preferred group, although this same effect was
not present among men (Talley et al., 2012). It is also pos-
sible that tolerant substance use norms are simply part of a
cluster of more liberal attitudes about a broad range of social
issues that are characteristic of this subpopulation (Herek et
al., 2010). Either way, our results hint that the relationships
among minority sexual orientation, tolerant drug norms, and
greater drug availability may be mutually reinforcing, lead-
ing to higher levels of substance misuse across the life span.
Several study limitations warrant consideration. First,
the latent construct of “substance use” combined indicators
of illicit drug use and alcohol consumption. Therefore, we
could not discern relationships of specifi c types of substance
use with the precursor variables. However, we note that cor-
relations among illicit drug, marijuana, and heavier alcohol
use were strong. Second, our limited measurement of sexual
orientation–related discrimination may have underestimated
the effects of discrimination. Thus, our fi ndings should not
be interpreted as a test of the comparative strength of the
minority stress hypothesis versus a socioenvironmental one.
Third, it is likely that there are differences among those
classifi ed as sexual minorities. Sample size limitations pre-
cluded considering this issue within the SEM approach used.
Research elsewhere has documented that bisexual women
and homosexually experienced men who do not self-identify
as gay/bisexual are especially likely to be at increased risk
for substance use morbidity (Cochran and Mays, 2009;
McCabe et al., 2009). It may also be true that behaviors in
these two groups are under less normative control by the
gay community. Thus, determinants of use may vary across
sexual minority subpopulations. In a similar vein, sample
size precluded investigation of possible race/ ethnicity dif-
ferences in the fi t and functioning of the SEM models
raising similar concerns. Finally, like other cross-sectional
telephone surveys, the Cal-QOL II survey shares common
limitations typical of such designs, including the inability to
test truly causal hypotheses and the possible introduction of
bias through loss to followback.
COCHRAN, GRELLA, AND MAYS 683
suggest strongly that two factors—perceived drug availabil-
ity and tolerant substance use norms—contribute to sexual
orientation–related disparities in substance use. This has
direct and translatable implications for community-level
interventions targeting reductions in substance use. Previ-
ous work has found that although changing social norms
at a community level is diffi cult, once accomplished these
changes are particularly sustainable (Latkin et al., 2003).
For example, anti-smoking campaigns and legislation in
the United States have greatly reduced smoking rates on a
broad level (Middlestadt et al., 2011; Tang et al., 2010; Zhu
et al., 2007). In addition, interventions to reduce drinking
and/or alter patterns of substance use have directly targeted
changing social norms with some success (LaBrie et al.,
2009; Latkin et al., 2009; Moreira et al., 2009; Neighbors
et al., 2010). Further, norm-related interventions are known
to be effective within the visible gay community (Kelly,
2000, 2004; NIMH Collaborative HIV/STD Prevention Trial
Going forward, campaigns to change levels of social
approval of illicit drug use and heavy alcohol consumption
may serve to reduce the burden of substance use in this
population. In crafting these efforts, it is essential to address
the ways in which individual characteristics may shape nor-
mative infl uences. Like other populations, characteristics
such as age, gender, ethnicity/race, and social disadvan-
tages linked to poverty and geographic location may have
relevance here, creating multiple, complex, and sometimes
confl icting social and behavioral norms (Latkin et al., 2003).
But, in addition, individuals with minority sexual orientation
are a particularly diverse group where only some are reach-
able through campaigns targeting the visible lesbian and gay
community. Advocates for sexual minority health have long
argued for the need for culturally competent interventions
incorporating the unique aspects of gay, lesbian, bisexual,
and transgender identity and community into the content of
intervention materials (Mayer et al., 2008; Shoptaw and Re-
back, 2007). Efforts that can successfully reach the diversity
of this vulnerable population in its entirety are needed.
Despite these concerns, the robust fi ndings reported here
Bentler, P. M. (1990). Comparative fi t indexes in structural models. Psycho-
logical Bulletin, 107, 238–246.
Brady, K. T., & Randall, C. L. (1999). Gender differences in substance use
disorders. Psychiatric Clinics of North America, 22, 241–252.
Brown, T. (2006). Confi rmatory factor analysis for applied research. New
York, NY: Guilford Press.
Burgard, S. A., Cochran, S. D., & Mays, V . M. (2005). Alcohol and tobacco
use patterns among heterosexually and homosexually experienced Cali-
fornia women. Drug and Alcohol Dependence, 77, 61–70.
California Health Interview Survey. (2009). CHIS 2007 Methodology report
series. Report 1: Sample design. Retrieved from http://www.chis.ucla.
Carpiano, R. M., Kelly, B. C., Easterbrook, A., & Parsons, J. T. (2011).
Community and drug use among gay men: The role of neighborhoods
and networks. Journal of Health and Social Behavior, 52, 74–90.
Cicchetti, D., Rogosch, F. A., & Sturge-Apple, M. L. (2007). Interactions of
child maltreatment and serotonin transporter and monoamine oxidase A
polymorphisms: Depressive symptomatology among adolescents from
low socioeconomic status backgrounds. Development and Psychopathol-
ogy, 19, 1161–1180.
Cochran, S. D. (2001). Emerging issues in research on lesbians’ and gay
men’s mental health: Does sexual orientation really matter? The Ameri-
can Psychologist, 56, 931–947.
Cochran, S. D., Ackerman, D., Mays, V. M., & Ross, M. W. (2004). Preva-
lence of non-medical drug use and dependence among homosexually
active men and women in the US population. Addiction, 99, 989–998.
Cochran, S. D., Keenan, C., Schober, C., & Mays, V. M. (2000). Estimates
of alcohol use and clinical treatment needs among homosexually active
men and women in the U.S. population. Journal of Consulting and
Clinical Psychology, 68, 1062–1071.
Cochran, S. D., & Mays, V. M. (2000). Relation between psychiatric syn-
dromes and behaviorally defi ned sexual orientation in a sample of the
US population. American Journal of Epidemiology, 151, 516–523.
Cochran, S. D., & Mays, V. M. (2009). Burden of psychiatric morbidity
among lesbian, gay, and bisexual individuals in the California Quality
of Life Survey. Journal of Abnormal Psychology, 118, 647–658.
Ditlevsen, S., Christensen, U., Lynch, J., Damsgaard, M. T., & Keiding, N.
(2005). The mediation proportion: A structural equation approach for
estimating the proportion of exposure effect on outcome explained by
an intermediate variable. Epidemiology, 16, 114–120.
Drabble, L., Midanik, L. T., & Trocki, K. (2005). Reports of alcohol con-
sumption and alcohol-related problems among homosexual, bisexual
and heterosexual respondents: Results from the 2000 National Alcohol
Survey. Journal of Studies on Alcohol, 66, 111–120.
Egan, J. E., Frye, V ., Kurtz, S. P., Latkin, C., Chen, M., Tobin, K., . . . Kob-
lin, B. A. (2011). Migration, neighborhoods, and networks: Approaches
to understanding how urban environmental conditions affect syndemic
adverse health outcomes among gay, bisexual and other men who have
sex with men. AIDS and Behavior, 15, Supplement 1, 35–50.
Frisell, T., Lichtenstein, P., Rahman, Q., & Långström, N. (2010). Psychi-
atric morbidity associated with same-sex sexual behaviour: Infl uence
of minority stress and familial factors. Psychological Medicine, 40,
Garofalo, R., Mustanski, B. S., McKirnan, D. J., Herrick, A., & Donenberg,
G. R. (2007). Methamphetamine and young men who have sex with
men: Understanding patterns and correlates of use and the associa-
tion with HIV-related sexual risk. Archives of Pediatrics & Adolescent
Medicine, 161, 591–596.
Gilman, S. E., Cochran, S. D., Mays, V. M., Hughes, M., Ostrow, D., &
Kessler, R. C. (2001). Risk of psychiatric disorders among individuals
reporting same-sex sexual partners in the National Comorbidity Survey.
American Journal of Public Health, 91, 933–939.
Green, K. E., & Feinstein, B. A. (2011). Substance use in lesbian, gay, and
bisexual populations: An update on empirical research and implications
for treatment. Psychology of Addictive Behaviors. Advance online pub-
Gruskin, E. P., Hart, S., Gordon, N., & Ackerson, L. (2001). Patterns of
cigarette smoking and alcohol use among lesbians and bisexual women
enrolled in a large health maintenance organization. American Journal
of Public Health, 91, 976–979.
Hamilton, C. J., & Mahalik, J. R. (2009). Minority stress, masculinity, and
social norms predicting gay men’s health risk behaviors. Journal of
Counseling Psychology, 56, 132–141.
Hatzenbuehler, M. L., Corbin, W. R., & Fromme, K. (2011). Discrimination
and alcohol-related problems among college students: A prospective
684 JOURNAL OF STUDIES ON ALCOHOL AND DRUGS / JULY 2012
examination of mediating effects. Drug and Alcohol Dependence, 115,
Heffernan, K. (1998). The nature and predictors of substance use among
lesbians. Addictive Behaviors, 23, 517–528.
Herek, G. M., Norton, A. T., Allen, T. J., & Sims, C. L. (2010). Demograph-
ic, psychological, and social characteristics of self-identifi ed lesbian,
gay, and bisexual adults in a US probability sample. Sexuality Research
and Social Policy, 7, 176–200.
Hu, L.-T., & Bentler, P. M. (1999). Cutoff criteria for fi t indexes in covari-
ance structure analysis: Conventional criteria versus new alternatives.
Structural Equation Modeling: A Multidisciplinary Journal, 6, 1–55.
Hughes, T., Szalacha, L. A., & McNair, R. (2010). Substance abuse and
mental health disparities: Comparisons across sexual identity groups
in a national sample of young Australian women. Social Science &
Medicine, 71, 824–831.
Johnson, R. A., & Gerstein, D. R. (1998). Initiation of use of alcohol,
cigarettes, marijuana, cocaine, and other substances in US birth cohorts
since 1919. American Journal of Public Health, 88, 27–33.
Kelly, J. A. (2000). HIV prevention interventions with gay or bisexual men
and youth. AIDS, 14, Supplement 2, S34–S39.
Kelly, J. A. (2004). Popular opinion leaders and HIV prevention peer educa-
tion: Resolving discrepant fi ndings, and implications for the develop-
ment of effective community programmes. AIDS Care, 16, 139–150.
Kendler, K. S., Gardner, C. O., & Prescott, C. A. (2011). Toward a compre-
hensive developmental model for alcohol use disorders in men. Twin
Research and Human Genetics, 14, 1–15.
Keyes, K. M., Hatzenbuehler, M. L., & Hasin, D. S. (2011). Stressful life
experiences, alcohol consumption, and alcohol use disorders: The
epidemiologic evidence for four main types of stressors. Psychophar-
macology, 218, 1–17.
Kline, R. B. (2011). Principles and practice of structural equation modeling
(3rd ed.). New York, NY: Guilford Press.
LaBrie, J. W., Hummer, J. F., Huchting, K. K., & Neighbors, C. (2009).
A brief live interactive normative group intervention using wireless
keypads to reduce drinking and alcohol consequences in college student
athletes. Drug and Alcohol Review, 28, 40–47.
Latkin, C. A., Donnell, D., Metzger, D., Sherman, S., Aramrattna, A.,
Davis-Vogel, A., . . . Celentano, D. D. (2009). The effi cacy of a network
intervention to reduce HIV risk behaviors among drug users and risk
partners in Chiang Mai, Thailand and Philadelphia, USA. Social Science
& Medicine, 68, 740–748.
Latkin, C. A., Forman, V., Knowlton, A., & Sherman, S. (2003). Norms,
social networks, and HIV-related risk behaviors among urban disadvan-
taged drug users. Social Science & Medicine, 56, 465–476.
LeVay, S., & Nonas, E. (1995). City of friends: A portrait of the gay and
lesbian community in America. Cambridge, MA: MIT Press.
Marshal, M. P., Sucato, G., Stepp, S. D., Hipwell, A., Smith, H. A., Fried-
man, M. S., . . . Markovic, N. (2012). Substance use and mental health
disparities among sexual minority girls: Results from the Pittsburgh
girls study. Journal of Pediatric and Adolescent Gynecology, 25, 15–18.
Mayer, K. H., Bradford, J. B., Makadon, H. J., Stall, R., Goldhammer, H.,
& Landers, S. (2008). Sexual and gender minority health: What we
know and what needs to be done. American Journal of Public Health,
Mays, V . M., & Cochran, S. D. (2001). Mental health correlates of perceived
discrimination among lesbian, gay, and bisexual adults in the United
States. American Journal of Public Health, 91, 1869–1876.
McCabe, S. E., Hughes, T. L., Bostwick, W. B., West, B. T., & Boyd, C.
J. (2009). Sexual orientation, substance use behaviors and substance
dependence in the United States. Addiction, 104, 1333–1345.
McKirnan, D. J., & Peterson, P. L. (1988). Stress, expectancies, and vulner-
ability to substance abuse: A test of a model among homosexual men.
Journal of Abnormal Psychology, 97, 461–466.
McKirnan, D. J., & Peterson, P. L. (1989). Psychosocial and cultural factors
in alcohol and drug abuse: An analysis of a homosexual community.
Addictive Behaviors, 14, 555–563.
McLaughlin, K. A., Hatzenbuehler, M. L., & Keyes, K. M. (2010). Respons-
es to discrimination and psychiatric disorders among Black, Hispanic,
female, and lesbian, gay, and bisexual individuals. American Journal of
Public Health, 100, 1477–1484.
Meyer, I. H. (2003). Prejudice, social stress, and mental health in lesbian,
gay, and bisexual populations: Conceptual issues and research evidence.
Psychological Bulletin, 129, 674–697.
Middlestadt, S. E., Macy, J. T., Seo, D.-C., Jay, S. J., & Kolbe, L. J. (2011).
The combined effect of behavioral intention and exposure to a smoke-
free air law on taking measures to quit smoking. Health Promotion
Practice. Advance online publication. doi:10.1177/1524839910386221
Moreira, M. T., Smith, L. A., & Foxcroft, D. (2009). Social norms inter-
ventions to reduce alcohol misuse in university or college students.
Cochrane Database of Systematic Reviews, 3, CD006748.
Muthén, L. K., & Muthén, B. O. (2007). Mplus user’s guide (5th ed.). Los
Angeles, CA: Authors.
National Center for Chronic Disease Prevention and Health Promotion.
(2005). 2004 Behavioral risk factor surveillance system summary data
quality report. Retrieved from ftp://ftp.cdc.gov/pub/Data/Brfss/2004Su
Neighbors, C., Lewis, M. A., Atkins, D. C., Jensen, M. M., Walter, T., Fos-
sos, N. . . . Larimer, M. E. (2010). Effi cacy of web-based personalized
normative feedback: a two-year randomized controlled trial. Journal of
Consulting and Clinical Psychology, 78, 898–911.
NIMH Collaborative HIV/STD Prevention Trial Group. (2010). Results of
the NIMH collaborative HIV/sexually transmitted disease prevention
trial of a community popular opinion leader intervention. Journal of
Acquired Immune Defi ciency Syndromes, 54, 204–214.
Ober, A., Shoptaw, S., Wang, P. C., Gorbach, P., & Weiss, R. E. (2009). Fac-
tors associated with event-level stimulant use during sex in a sample of
older, low-income men who have sex with men in Los Angeles. Drug
and Alcohol Dependence, 102, 123–129.
Ostrow, D. G., Plankey, M. W., Cox, C., Li, X., Shoptaw, S., Jacobson, L.
P., & Stall, R. C. (2009). Specifi c sex drug combinations contribute to
the majority of recent HIV seroconversions among MSM in the MACS.
Journal of Acquired Immune Defi ciency Syndromes, 51, 349–355.
Scheer, S., Peterson, I., Page-Shafer, K., Delgado, V., Gleghorn, A., Ruiz,
J., . . . Klausner, J., & the Young Women’s Survey Team. (2002). Sexual
and drug use behavior among women who have sex with both women
and men: Results of a population-based survey. American Journal of
Public Health, 92, 1110–1112.
Schultz, P. W., Nolan, J. M., Cialdini, R. B., Goldstein, N. J., & Griskevicius,
V. (2007). The constructive, destructive, and reconstructive power of
social norms. Psychological Science, 18, 429–434.
Scribner, R. A., Cohen, D. A., & Fisher, W. (2000). Evidence of a structural
effect for alcohol outlet density: a multilevel analysis. Alcoholism Clini-
cal and Experimental Research, 24, 188–195.
Shoptaw, S., & Reback, C. J. (2007). Methamphetamine use and infectious
disease-related behaviors in men who have sex with men: Implications
for interventions. Addiction, 102, Supplement 1, 130–135.
Simon, P. A., Wold, C. M., Cousineau, M. R., & Fielding, J. E. (2001).
Meeting the data needs of a local health department: The Los Ange-
les County Health Survey. American Journal of Public Health, 91,
Simon Rosser, B. R., West, W., & Weinmeyer, R. (2008). Are gay com-
munities dying or just in transition? Results from an international
consultation examining possible structural change in gay communities.
AIDS Care: Psychological and Socio-medical Aspects of AIDS/HIV , 20,
Stall, R., Mills, T. C., Williamson, J., Hart, T., Greenwood, G., Paul, J.,
. . . Catania, J. A. (2003). Association of co-occurring psychosocial
COCHRAN, GRELLA, AND MAYS 685 Download full-text
health problems and increased vulnerability to HIV/AIDS among urban
men who have sex with men. American Journal of Public Health, 93,
Stall, R., Paul, J. P., Greenwood, G., Pollack, L. M., Bein, E., Crosby, G.
M., . . . Catania, J. A. (2001). Alcohol use, drug use and alcohol-related
problems among men who have sex with men: The Urban Men’s Health
Study. Addiction, 96, 1589–1601.
Steiger, J. H. (1990). Structural model evaluation and modifi cation: An
interval estimation approach. Multivariate Behavioral Research, 25,
Substance Abuse and Mental Health Services Administration Offi ce of Ap-
plied Studies. (2008). Results from the 2007 National Survey on Drug
Use and Health: National Findings (DHHS Publication No. SMA 08-
4343). Rockville, MD: Author.
Talley, A. E., Sher, K. J., Steinley, D., Wood, P. K., & Littlefi eld, A. K.
(2012). Patterns of alcohol use and consequences among empirically
derived sexual minority subgroups. Journal of Studies on Alcohol and
Drugs, 73, 290–302.
Talley, A. E., Tomko, R. L., Littlefi eld, A. K., Trull, T. J., & Sher, K. J.
(2011). The infl uence of general identity disturbance on reports of
lifetime substance use disorders and related outcomes among sexual
minority adults with a history of substance use. Psychology of Addictive
Behaviors, 25, 530–541.
Tang, H., Abramsohn, E., Park, H.-Y., Cowling, D. W., & Al-Delaimy, W. K.
(2010). Using a cessation-related outcome index to assess California’s
cessation progress at the population level. Tobacco Control, 19, i56–i61.
Trocki, K. F., Drabble, L., & Midanik, L. (2005). Use of heavier drinking
contexts among heterosexuals, homosexuals and bisexuals: Results
from a National Household Probability Survey. Journal of Studies on
Alcohol, 66, 105–110.
Valentine, G., & Skelton, S. (2003). Finding oneself, losing oneself: The
lesbian and gay ‘scene’ as a paradoxical space. International Journal of
Urban and Regional Research, 27, 849–866.
Wilsnack, S. C., & Wilsnack, R. W. (1995). Drinking and problem drink-
ing in US women. Patterns and recent trends. Recent Developments in
Alcoholism, 12, 29–60.
Zhu, S.-H., Wong, S., Tang, H., Shi, C.-W., & Chen, M. S. (2007). High quit
ratio among Asian immigrants in California: Implications for popula-
tion tobacco cessation. Nicotine & Tobacco Research, 9, Supplement