Journal of Urban Health: Bulletin of the New York Academy of Medicine, Vol. 83, No. 6
* 2006 The New York Academy of Medicine
High Prevalence of Smoking Among Urban-Dwelling
Canadian Men Who Have Sex with Men
Thomas M. Lampinen, Simon J. Bonner, Melanie Rusch,
and Robert S. Hogg
ABSTRACT A small but consistent literature from the United States suggests increased
risk for smoking among lesbians and men who have sex with men (MSM). Few studies
have investigated smoking among MSM in other countries where different social
norms and restrictions on smoking in public apply. We measured smoking behaviours
in a convenience sample of urban-dwelling young Canadian MSM (median age 28
years). We compared the prevalence of smoking among MSM with that among other
men in British Columbia (BC) using National Population Health Survey data to
compute an age-adjusted standardized prevalence ratio (SPR). Independent predictors
of smoking among MSM were identified using adjusted odds ratios (OR) with 95%
confidence intervals (CI). Smoking during the previous year was reported by twice as
many MSM (54.5% of 354) as other men in BC (25.9%) (SPR=1.94, 95% CI 1.48–
2.59), with largest differentials observed among men under 25 years of age. In
multivariable analyses, smoking among MSM was significantly associated with
younger age (OR 0.94, CI 0.88–1.00 per year), greater number of depressive
symptoms (OR 1.12, CI 1.06–1.19 per symptom) and Canadian Aboriginal ethnicity
(OR 2.64, CI 1.05–6.60). In summary, MSM in our study were twice as likely to
smoke as other men in BC; the greatest differences were observed among the youngest
men. The design of effective prevention and cessation programs for MSM will require
identification of the age-dependent determinants of smoking initiation, persistence,
and attempts to quit.
KEYWORDS Homosexuality, Male, Prevalence, Tobacco, Smoking, Substance abuse
Smoking continues to present a serious health care problem despite ongoing anti-
smoking campaigns and introduction of legislation to limit tobacco advertising,
prevent smoking in youth, and promote quitting among adults. A Canadian report
in 2001 cited tobacco use as Bthe most important preventable risk factor for
respiratory disease^ including asthma, chronic obstructive pulmonary disease, and
lung cancer.1In 1998 more than 26,000 Canadians were killed by these 3 illnesses
Lampinen, Bonner, Rusch, and Hogg are with the Division of Epidemiology and Population Health, BC
Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada; Lampinen, Rusch, and Hogg are
with the Department of Health Care and Epidemiology, University of British Columbia, Vancouver, BC,
Correspondence: Thomas M. Lampinen, PhD, Division of Epidemiology and Population Health, BC
Centre for Excellence in HIV/AIDS, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada. (E-mail:
alone, and the direct burden on the health care system through physician, drug, and
institutional costs was almost 3.5 billion dollars.1,2
Higher rates of smoking among urban-dwelling lesbians and men who have sex
with men (MSM) are suggested by a small number of studies, all from the United
States.3–13A recent review article identified only three reports pertaining to
smoking among MSM.7Including reports published subsequently,4,8,9,11–13only
two employed probability sampling to generate representative samples of MSM.3,5
Different social norms and policies may influence smoking differently outside
the United States. In Vancouver, for example, smoking has been prohibited in
restaurants, bars and clubs for many years.
Identifying modifiable correlates of smoking among MSM that are amenable to
interventions could reduce overall morbidity and mortality in the population.
Moreover, reductions in smoking among MSM would mitigate risks for health
problems that affect them disproportionately; for example, smoking appears to be a
potent yet modifiable cofactor in the development of anal cancer.14–18Targeting
smoking prevention and cessation initiatives among MSM is difficult since only
a handful of studies have investigated correlates of smoking among sexual mi-
norities.3,4,6,11,13We undertook the present study to determine the prevalence and
correlates of smoking in a community-recruited cohort of urban-dwelling Canadian
MSM. We further compared the age-adjusted prevalence of smoking among MSM
and other men in British Columbia.
We measured smoking in the Vanguard Project, an open prospective cohort study of
HIV-1 seroincidence and risk behaviours specific to young MSM. Briefly, eligible
men were between 18 and 35 years of age at enrollment, lived in the greater
Vancouver region, had not previously tested HIV-positive, and self-identified as gay
or bisexual or reported having had sex with other men. Participants were recruited
through outreach at gay community events, community health clinics and local
physicians, and through gay and mainstream media. At enrollment and annually
thereafter, the men completed a self-administered questionnaire covering basic
demographics and substance use during the previous year including frequency of
tobacco use and numbers of alcoholic drinks consumed during a typical day, week
or month, as appropriate. We converted the alcohol responses into a measure of
numbers of drinks consumed in a typical week. We also administered the Rosenberg
Scale of Self-Esteem19and an abbreviated Center for Epidemiological Studies-De-
pression (CES-D) Scale.20,21
In the present cross-sectional analysis, we included only those self-administered
surveys completed in 1999 by HIV-1 seronegative Vanguard participants (or, if
lacking such a survey, one completed in 1998 or 2000); we applied this restriction
so that the data would be comparable with the 1999 Canadian National Population
Health Survey (NPHS Cycle 3).
The NPHS is a longitudinal study established in the early 1990s to examine
the effects of demographic, behavioural, and economic factors on the health of
Canadians. Randomly selected subjects from all ages and geographical areas are
administered surveys every two years that assess personal behaviours and health
status. The survey includes an item that asks whether respondents smoke daily,
occasionally, or never. In 1999, surveys were received from 88.2% of 17,276
LAMPINEN ET AL.1144
eligible individuals.22Results were weighted using information provided in the
dataset to account for potential sampling bias. For the present analyses, we used
data obtained from the 292 NPHS respondents who were British Columbia (BC)
residents between the ages of 18 and 39 years. Subjects in both samples were
classified as either smokers (daily or occasional) or non-smokers. We compared
smoking among MSM and other men in British Columbia using an age-
standardized prevalence ratio and 95% confidence interval (CI).
To measure associations of smoking frequency with demographic and
behavioural variables, we classified MSM as non-smokers (i.e., no smoking in the
previous year), occasional smokers (less than once per day on average), or regular
smokers (daily or more on average). Potential correlates of smoking frequency
we evaluated included age, ethnicity (Canadian Aboriginal vs. other), education
(grouped as: less than high school, high school, college, graduate school), average
number of alcoholic drinks consumed per week during the previous year, number of
depressive symptoms, and self-esteem score.
Adjusted odds ratios (OR) computed using multivariable logistic regression were
used to select variables that best differentiated smokers from non-smokers among
MSM in the cohort; only variables significant in univariate analyses (p-valueG0.05)
were evaluated. The final multivariable model included only independent predictors
of smoking; results were confirmed in both forward and backwards stepwise
procedures and the model fit was assessed using a Hosmer–Lemeshow Goodness-
A total of 354 HIV-1 seronegative Vanguard Project participants completed a
questionnaire between 1998 and 2000 and provided information about their
smoking behaviour. The median age of these men was 28 (range 18 to 35) years;
most had completed high school, 74.0% were Caucasian, and fewer than ten
percent were Canadian Aboriginal (Table 1).
Overall, 193 (54.5%) of young MSM reported tobacco use in the previous
year; 58 (30.1%) of these men reported smoking less than daily on average, 126
(65.3%) reported at least daily smoking, and the remaining 9 (4.7%) indicated they
smoked but did not provide the frequency. Among the 345 men providing complete
information, all demographic and behavioural variables tested displayed statisti-
cally significant trend associations with smoking frequency (Table 1). In univariate
analyses, variables positively associated with smoking frequency included Aborig-
inal ethnicity, alcohol consumption, and a greater number of depressive symptoms.
Variables negatively associated with smoking frequency included age, level of
educational attainment, and higher self-esteem scores. In a sub-analysis restricted to
smokers, Aboriginal MSM were more likely than non-Aboriginal MSM to report
smoking daily (p=0.006) (Table 1).
In univariate analyses, each of these variables was similarly associated with the
binary smoking status variable (any smoking during the previous year) (Table 2). In
multivariable analyses, smoking during the previous year was positively and
independently associated with younger age, a greater number of depressive
symptoms, and Aboriginal ethnicity (Table 2).
Among 292 men between the ages of 18 and 39 years old who completed the
NPHS survey in 1999, 72 (24.7%) reported smoking during the previous year. After
applying sampling weights, the overall smoking prevalence among male British
SMOKING AMONG YOUNG MSM1145
Columbians under the age of 39 was estimated to be 25.9%, compared to an
observed prevalence of 54.5% among MSM. Overall, the age-adjusted prevalence
of smoking among MSM in the Vanguard cohort was approximately twice that
among other young men in British Columbia [age-adjusted standardized prevalence
ratio=1.94 (95% CI: 1.65, 2.28)]. Smoking among MSM was more common than
among other males in British Columbia in every age stratum examined; of
particular note, absolute differences were greatest among men who were youngest
TABLE 2. Crude and adjusted odds ratios for smoking* among Vanguard cohort participants
Variable Crude OR (95% CI) Adjusted** OR (95% CI)
Depressive Symptoms Score
Self Esteem Score
Canadian Aboriginal Ethnicity
OR, odds ratio; CI, confidence interval.
*During the previous year.
**Final model includes only variables independently associated with smoking.
participants, overall and by typical smoking frequency during the previous year
Selected demographic and behavioural characteristics of Vanguard cohort
Less than daily
Depressive Symptoms Score.
Canadian Aboriginal Ethnicity#
32 (9.2)7 (4.4)2 (3.6)23 (18.7)
*Some observations missing. All variables in the table were significantly associated with smoking frequency
with smoking frequency in trend tests (pG0.001).
**During previous year.
LAMPINEN ET AL. 1146
In the present study, we found a highly significant, two-fold higher overall
prevalence of smoking in a convenience sample of urban, young adult MSM in
Vancouver, compared to other men of similar age in British Columbia. Over half
(54.5%) of young MSM in our cohort reported smoking during the previous year,
compared to one-fourth of the NPHS survey respondents. In multivariable analyses,
smoking among young adult MSM was significantly associated with younger age, a
greater number of depressive symptoms, and Canadian Aboriginal status. Similarly,
smoking frequency among MSM was positively associated in univariate analyses
with each of these variables, and with lower levels of education, more frequent
alcohol consumption, and lower self-esteem.
A particularly noteworthy observation in the present study is that the greatest
differentials in smoking prevalence between MSM and their heterosexual counter-
parts were observed among the youngest men. These results are consistent with
observations by Tang et al.4and remarkably similar to those reported by McKirnan
et al.13but they stand in contrast to those from a school-based survey that found no
difference in smoking at least weekly among adolescent boys who self-identify as
heterosexual versus gay or bisexual.9The reasons underlying this inconsistency are
unclear but may reflect differences among studies in the definition and self-
identification of sexual minority status, or in the distribution of participants_ age,
race-ethnicity, or indicators of socio-economic status. One report suggests that
differences in smoking between adult MSM and male heterosexuals are due in part
to access to health care insurance and utilisation, depressive symptoms and alcohol
Longitudinal studies will be required to identify the factors that account for the
age dependence of differentials in the prevalence of smoking among MSM and their
All BC Males
in the Vanguard Project cohort and among male British Columbian respondents to the 1999
National Population Health Survey.
Age-specific prevalence of smoking among young men who have sex with men (MSM)
SMOKING AMONG YOUNG MSM1147
heterosexual counterparts. It is possible that gay and bisexual adolescents have a
higher propensity to start smoking, compared to other adolescents. Alternatively,
the differentials may reflect cohort effects (different secular trends in the age at
which MSM versus other youth initiate cigarette smoking). Finally, younger MSM
may be relatively successful in their attempts to quit but, having started with a
greater prevalence of smoking in early adolescence, end up with a prevalence in
young adulthood that is still elevated when compared to their heterosexual
counterparts. To address these issues, future studies will likely need to follow
cohorts of adolescents for some years because self-identification as gay or bisexual
often does not occur until young adulthood.
The dearth of information regarding contemporary determinants of cigarette
smoking among MSM is cause for concern. A limited number of correlates of
smoking have been examined in the few previous studies of adult MSM; all of these
studies were conducted in the United States. Among men solicited from mailing lists
provided by gay organizations, 40% reported smoking during the previous year,
which was associated with less education.6Among bar and telephone-recruited
MSM in Oregon and Arizona, 48% of the men reported smoking during the
previous month, compared with 29% of the general male population of the U.S.
Significant correlates of smoking among MSM included lesser education, depres-
sion and alcohol consumption.3A population-based survey of lesbian, gay and
bisexual adults in California found that smoking was inversely associated with age,
education level, income, and white (non-Hispanic) race-ethnicity.4Another study
from California reported similar associations with age and education level.11Most
recently, McKirnan et al. compared a convenience sample of MSM in Illinois
(37.5% smokers) to local National Health Interview Survey respondents (28.4%
smokers);13younger age and lesser education were significantly associated with
current smoking among MSM while, in contrast, age was not significantly
associated with men in the general population sample. Taken together, these studies
suggest that younger age and less education are significant correlates of smoking
among MSM. However, a much more comprehensive understanding is obviously
needed to design and target effective smoking interventions for MSM.
Strengths of the present study include the ability to compute finely age-adjusted
expected smoking rates for our cohort based on provincial rather than nation-
al survey standards. Further, the availability of cohort study data permitted our
identification of correlates of the prevalence and frequency of smoking among
young adult MSM. At the same time, limitations of our study require that our
results be interpreted with caution. First, population-based data regarding the
smoking habits of the general male population within Vancouver were not available
for a standard. Previous school-based Youth Risk Behavior Survey results did not
suggest important difference in cigarette use among urban, suburban, and rural
adolescents.23Nevertheless, neither the magnitude nor direction of possible bias in
our urban sample can be determined. Although most gay and bisexual men migrate
to urban centers,24the representativeness of our convenience sample to other MSM
in Vancouver is unknown. Finally, smoking behaviours in our study were self-
reported and subject to errors in recall and socially desirable responses.
In summary, young adult MSM in our convenience sample were twice as likely
to smoke as other men of similar age in British Columbia, with greatest differentials
among men who are youngest. Smoking prevention and cessation initiatives are
needed for a very broad segment of the MSM community;11our results suggest
that, within this community, MSM who are youngest and who are ethnic minorities
LAMPINEN ET AL.1148
warrant special attention. Tobacco firms specifically and aggressively promote
cigarette smoking among young lesbian, gay and bisexual persons.25,26We propose
a very specific priority for smoking prevention research: the identification of age-
dependent determinants of smoking initiation, persistence and cessation among
adolescent and young adult MSM. As this prevention research proceeds, evaluation
of innovative pilot projects to promote smoking cessation among MSM will have
We thank the Vanguard Project participants and study advisors and staff including
Jennifer Adachi, Keith Chan, Marcus Greatheart, Steve Martindale, Mary Lou
Miller, Dr. Martin Schechter, Arn Schilder, and Dr. Steffanie Strathdee. We thank
the anonymous reviewers for suggestions that improved the manuscript. Drs.
Lampinen and Hogg and Ms. Rusch are supported by the Michael Smith Foun-
dation for Health Research.
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