A reverse pattern appeared for transgender adolescents of color, however, such that transgender Latinx, American Indian or Alaskan Native, Black, Native Hawaiian or Pacific Islander, and multiracial adolescents evidenced greater adjusted odds of more frequent vaping relative to transgender white adolescents. For adolescents unsure of their gender identity, patterns were less consistent. Whereas Latinx, Black, and Native Hawaiian or Pacific Islander adolescents unsure of their gender identity evidenced greater odds of more days vaping relative to white adolescents unsure of their gender identity, Asian adolescents unsure of their gender identity evidenced lower odds of more days vaping than white adolescents unsure of their gender identity. Consistent with our hypothesis, we found that gender identity and race/ethnicity significantly interacted in their association in vaping frequency such that transgender adolescents of color were generally more likely to report a higher frequency of vaping compared to cisgender white adolescents. Although less consistent, some groups of adolescents of color who were unsure of their gender identity were also disproportionately more likely to report a higher frequency of vaping compared to cisgender white adolescents. In stratified models, we observed disparities in vaping frequency between transgender and cisgender adolescents within each race/ethnicity stratum as well as in vaping frequency among transgender Latinx, American Indian and Alaskan Native, Black, Native Hawaiian or Pacific Islander, and multiracial relative to their transgender white peers. The largest differences in both stratified models were among transgender Black adolescents who evidenced 6 times the odds of more frequent vaping relative to their cisgender Black peers and nearly 3 times the odds of more frequent vaping relative to their transgender white peers. In the model stratified by gender identity, we observed reversed patterns among cisgender adolescents, grow rack with white adolescents evidencing greater odds of more frequent vaping than their cisgender peers of color.
Taken together, our findings extend past research documenting vaping and other tobacco use disparities among transgender relative to cisgender youth to highlight pronounced disparities in vaping frequency among transgender adolescents of color. Our finding of gender identity disparities in vaping frequency among Black adolescents in particular aligns with a recent analysis of data from the 2018-19 Behavioral Risk Factor Surveillance System finding that transgender Black adults were more likely to be current smokers relative to cisgender Black adults.Additionally, our finding that cisgender adolescents of color tended to vape less frequently than their cisgender white peers is in keeping with prior research documenting greater prevalence of vaping among white adolescents compared to their Black and Latinx peers.Our study does not explain the reasons for the observed disparities in vaping frequency; however, structural injustice has been identified as a fundamental cause of health disparities.Structural injustice is enforced via inequitable socio-political and economic systems and norms which differentially influence access to resources and opportunities for groups based on relative societal power, and in turn, health behaviors and outcomes.Interpreting our findings through this understanding of structural injustice, gender minority stress,and intersectionality suggests multilevel discrimination and stressors may drive the observed disparities in vaping frequency among transgender adolescents of color. Transgender youth of color face pronounced housing instability, employment precarity, lack of access to healthcare, and violence and victimization,which may lead to vaping as a coping strategy. Qualitative research with racially/ethnically diverse LGBTQ youth smokers have found that participants describe smoking as a way to deal with stress and take back control from or rebel against oppressive systems.Limited supportive resources in schools may also underlie disparities in vaping among transgender adolescents of color. For example, participation in LGBTQ empowerment groups, i.e..
Gender and Sexuality Alliances , is associated with lower levels of school-based victimization and greater receptivity to school-based substance use prevention efforts among LGBTQ adolescents.However, there are several limitations to effective engagement of transgender adolescents and adolescents of color within GSAs, including limited considerations of or discussions regarding diverse gender identities and intersections of LGBTQ identities with race, ethnicity, and socioeconomic position among members.If GSAs or other LGBTQ specific resources in schools are not inclusive of or welcoming to youth with diverse gender identities or race/ethnicities, the potential for these resources to buffer against stress and/or prevent vaping may be inequitably distributed. Additionally, the enduring history of predatory marketing of tobacco and vape products to you may influence vaping disparities among transgender adolescents of color. A recent study found LGBTQ adolescents and Black and Latinx adolescents reported higher engagement with online tobacco and e-cigarette marketing compared to their non-LGBTQ and white peers, respectively.One might conclude that gender identity , as opposed to race/ethnicity , contributes more to disparities in vaping among transgender/unsure adolescents of color because the magnitude of these disparities is larger within race/ethnic groups than across race/ethnic groups. We caution against such an interpretation, as this logic contradicts the notion that systems of power are intersecting and interlocking; thus, identities or social positions cannot be neatly disentangled.Instead, we call attention to the increased vulnerability for higher vaping frequency among transgender adolescents of color with the framework of intersectionality in mind, and the need for future research to examine and intervene on the interlocking systems shaping these disparities. Our study should be considered within the context of its limitations. Our sample consists of adolescents in secondary schools in one U.S. state ; the extent that findings generalize to adolescents in California and more broadly is uncertain. Additionally, there is variability in the terms used by transgender and gender diverse people to describe their gender identity.Thus, our categories may not reflect the diversity of participants’ gender identities orbe culturally sensitive to gender identities among adolescents within particular racial/ethnic groups, such as American Indian or Alaskan Native adolescents who may identify as two-spirit or other gender identities not assessed in the CHKS.A similar concern relates to our measurement of race and ethnicity which we combined as race/ethnicity, leading to categorization of more than half the sample as Latinx . Although this approach to measurement is common, our failure to disentangle ethnicity from race may have masked nuanced disparities among Latinx adolescents who also identify with a specific race , for example, Afro-Latinx adolescents.
We were also are unable to determine precisely the substances vaped by participants as the survey did not measure substances vaped , however the CHKS item is preceded by questions about past 30-day smoking and use of smokeless tobacco ; other types of substance use are asked about separately. Finally, we did not test causal mechanisms of the observed vaping disparities. At best, our independent variables of race/ethnicity and gender identity are proxies for the inequitable systems of power that shape health determinants and outcomes.A key strength is our use of a large, diverse, methodologically strong,greenhouse tables population-based sample of adolescents in schools. Our study is strengthened by examining vaping disparities with three categories of gender identity and seven categories of race/ethnicity – yielding detailed information for multiple racial/ethnic groups of transgender adolescents and adolescents unsure of their gender identity. Although some of our analytic categories were relatively small , these findings offer insights into vaping disparities for subgroups often left out or obscured in research and highlight their unique health-related needs. Finally, our use of an ordinal model to assess disparities in vaping frequency is a strength, as more frequent vaping may be more harmful than infrequent vaping.Our findings have implications for future research, including the need to examine the multilevel causal mechanisms of adolescent vaping disparities at the intersection of gender identity and race/ethnicity. Explicit examinations of how systems of power intersect to shape disparities are necessary to mitigate inequitable population-level differences in health behaviors and outcomes.50 Thus, future research on vaping disparities among transgender and other marginalized communities of young people should employ novel and community-engaged approaches that identify and interrogate these systems. Mixed methods community-based participatory research is one such approach. In MM-CBPR, researchers collaborate directly with communities to gather and synthesize both qualitative and quantitative data to generate locally valid results and catalyze action for social change and sustainable health improvements. In the context of adolescent health disparities prevention, this approach may be especially useful for identifying and/or implementing asset-based and youth-led interventions.For example, researchers could directly partner with teachers, service providers, parents, and transgender adolescents of color to gather insights based on survey data and in-depth interviews or focus groups into the individual, interpersonal, and contextual factors that influence adolescent vaping. Indeed, research has found that supportive school, community-based, and family contexts may buffer against substance use and support well-being among transgender adolescents– MM-CBPR is well-suited to examine these influences and identify multiple levers for intervention. There is also a need to examine gender identity disparities in adolescent vaping and co-use of tobacco products, such as combustible cigarettes. While explorations of vaping alone are important given recent increases in vaping prevalence, examinations of co-use and the health effects of co-use relative to vaping alone should be prioritized for prevention planning. Drug addiction is characterized by persistent drug use despite adverse consequences, perhaps in part because the instant pleasure garnered by using drugs is perceived to outweigh the long-term benefits of sobriety.
Consistent with this idea, laboratory studies routinely find that individuals with substance use disorders display greater preference for smaller, more immediately available rewards over larger, delayed alternatives than healthy controls . Moreover, research indicates that those who most strongly favor the immediate options on such laboratory-based choice tasks are also most likely to relapse during attempted abstinence . Nonetheless, few studies have attempted to elucidate the neural mechanisms underlying addicts’ inordinate preference for immediate rewards. Dopamine is heavily implicated in intertemporal choice , and indirect evidence suggests that deficient dopamine D2 /D3 -type receptor-mediated dopaminergic neurotransmission in the striatum may be an important contributing factor to this immediacy bias. Like steep temporal discounting, low striatal D2 /D3 receptor availability is observed among individuals with substance use disorders , and has been linked with an increased likelihood of relapse . Chronic exposure to methamphetamine or cocaine induces persistent reductions in striatal D2 /D3 receptor availability in rats and monkeys , and rats treated chronically with either of these drugs exhibit greater temporal discounting than controls . Humans with attention-deficit hyperactivity disorder or obesity—two other disorders that are associated with low striatal D2 /D3 receptor availability — also display greater temporal discounting than healthy controls . Greater temporal discounting has also been observed among carriers of the A1 allele of the ANKK1 Taq1A polymorphism , a genetic variant associated with low striatal D2 receptor density/binding in humans relative to A2 homozygotes . Although an association between low striatal D2 /D3 receptor availability and steep temporal discounting has been implied, this link has not been directly evaluated. We therefore examined striatal D2 /D3 receptor availability in relation to temporal discounting in research participants who met DSM-IV criteria for MA dependence and a group of healthy controls. MA-dependent individuals were selected as a group for study because case-control studies find that they display deficits in striatal D2 /D3 receptor availability and exaggerated temporal discounting . We hypothesized that striatal D2 / D3 receptor availability would be negatively correlated with discount rates among MA users, and possibly also among controls. Because tobacco use has also been linked with low striatal D2 /D3 receptor availability and steep temporal discounting , the association was explored as well in the control-group smokers. Because chronic MA abusers also display lower D2 /D3 receptor availability than non-users in extrastriatal brain areas , including several that have been implicated in intertemporal choice , exploratory analyses were performed to investigate whether extrastriatal D2 /D3 receptor availability might also be negatively correlated with discount rate.Procedures were approved by the University of California Los Angeles Office for Protection of Research Subjects. Participants were recruited using the Internet and local newspaper advertisements. All provided written informed consent and underwent eligibility screening using questionnaires, the Structured Clinical Interview for DSM-IV , and a physical examination. Twenty-seven individuals who met criteria for current MA dependence but were not seeking treatment for their addiction and 27 controls completed the study. D2 /D3 receptor availability data from approximately half of the MA users and controls have been reported previously , and smaller subsets were included in other studies from our laboratory regarding D2 /D3 receptor availability .