"This Is the Peer Reviewed Version of the Following Article: [Drug and Alcohol Review, 2019, 38 (5), Pp
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"This is the peer reviewed version of the following article: [Drug and Alcohol Review, 2019, 38 (5), pp. 465 - 472], which has been published in final form at [https://doi.org/10.1111/dar.12958] This article may be used for non‐commercial purposes in accordance with Wiley Terms and Conditions for Self‐Archiving Harmless? A hierarchical analysis of poppers use correlates among young gay and bisexual men Daniel Demant, PhDa,b* & Oscar Oviedo-Trespalacios, PhDc a Lecturer, Australian Centre for Public and Population Health Research, Faculty of Health, University of Technology Sydney, Ultimo, Australia b Visiting Fellow, School of Public Health and Social Work, Faculty of Health, Queensland University of Technology (QUT), Brisbane, Australia c Research Fellow, Centre for Accident Research and Road Safety-Queensland (CARRS-Q), Institute of Health and Biomedical Innovation (IHBI), Faculty of Health, Queensland University of Technology (QUT), Brisbane, Australia *Corresponding Author Dr Daniel Demant Lecturer in Public Health Australian Centre for Public and Population Health Research Faculty of Health University of Technology Sydney 235-253 Jones Street, Ultimo, New South Wales 2007, Australia Tel: +61 02 9514 5499 Email: [email protected] ORCiD Daniel Demant: 0000-0003-3330-2972 Oscar Oviedo-Trespalacios: 0000-0001-5916-3996 Running title: Poppers use among young gay and bisexual men Abstract Introduction: Poppers (alkyl nitrites) are recreational substances commonly used during sexual activity. The current legal status of poppers is complex and wide-ranging bans are increasingly under discussion. Research has identified disproportionate levels of poppers use in sexual minority men. While research on poppers use among sexual minority men exists, little is known about poppers use patterns and correlations with psycho-social and other factors among gay and bisexual young men. Methods: A cross-sectional survey was conducted with 836 Australian gay and bisexual young men aged 18 to 35 years. Descriptive statistics and hierarchical segmentation analyses were conducted to identify poppers use patterns, and correlates of recent poppers use (past three months) with personal characteristics, use of other substances, as well as mental and psycho-social health including minority stress, LGBT-community connectedness and participation. Results/Conclusion: High levels of lifetime (38%, n=315) and recent (24%, n=204) poppers use were reported. However, few participants reported dependency symptoms, risky consumption or problems arising from using poppers. The final model included three variables (visiting sex-on-premises venues, licensed LGBT venues, and using other substances) and predicted 85% (n=174) of recent poppers use. No correlations with other concepts or characteristics could be identified. This analysis further supports the hypothesis that poppers may be substances with a comparably low risk profile. A regulation of poppers with a harm reduction approach may present a valuable public health intervention. Keywords: Substance Use, Alkyl Nitrites, Men Who Have Sex With Men, Minority Health Introduction ‘Poppers’ is a common term used to refer to recreational substances with an active ingredient from the alkyl nitrite class (1), most commonly amyl nitrite (C5H11ONO) but also butyl (C4H9NO2), isobutyl (C4H9NO), isopropyl (C3H7NO2) or pentyl nitrite (C5H11NO2). These substances are clear liquids with a strong scent that are inhaled through the nostrils (2). Effects set in within a few seconds and last for a few minutes depending on dosage and user (3). Poppers were originally intended to aid in the treatment of heart conditions, particularly angina, but became increasingly popular due to other effects. Depending on expectancies of poppers use in individuals and the context in which these are used, effects may include mild euphoria and a heightened state of sexual arousal (4), as well as relaxant effects on certain muscles including the sphincter and vagina (5). Poppers are most commonly used before or during sexual activity (6) but have always been used outside of sexual contexts, and an increase in non-sexual recreational use among young people has been registered in different jurisdictions (7). While poppers are used by populations of all sexual identities, research has shown that gay and bisexual men are disproportionately more likely to use these. A recent international survey (8) reported that, in comparison to heterosexual men, those identifying as gay or bisexual had adjusted odds ratios of lifetime poppers use of 5.1 and 1.88, respectively. Last month use was also significantly higher with 1.5% among heterosexual men compared to 16.2% and 4.5% among gay and bisexual men, respectively. Similarly, two Australian studies reported high levels of recent use with up to 38% of sexual minority men reporting poppers use in the past six months (9,10). Older sexual minority men also appear to be more likely to use poppers than their younger counterparts with a recent study from Australia reporting that 23% of participants aged 16 to 24 years of age used poppers in the past 6 months compared to 41% among those aged 30 to 39 years (11). Overall, these results are consistent with a European study showing that poppers products are the third most commonly used substance among gay and bisexual men, after alcohol and tobacco (12). Poppers do not cause physical dependencies; however, studies suggest that some users may develop psychological dependencies and depend on the use of the substance to engage in satisfactory sexual activity (13-15). Side effects of poppers use are overall described as small, particularly in comparison to other substances, but may include skin lesions (around the nostrils and lips), reflex tachycardia, vasodilation, brief hypotension, dizziness, flushing, and methaemoglobinemia (16). Poppers may lead to severe hypotension, myocardial infarction and death when combined with phosphodiesterase- inhibiting medications (e.g., sildenafil) used to treat erectile dysfunction and pulmonary arterial hypertension (16,17). Past research reported correlations between poppers use and sexual risk behaviours as well as undiagnosed HIV infections and a heightened risk of seroconversion in men who have sex with men (10,18,19). Research on psychosocial consequences, LGBT community identification and mental wellbeing of poppers use among gay and bisexual men is scarce. However, a recent study from Australia reported that men who have sex with men who use poppers were less likely to show symptoms of depression, more likely to be engaged with other gay men, and more likely to consider themselves to be masculine (20). Poppers have historically been described as a part of the wider gay culture (21,22). A 2018 interim decision by the Therapeutic Goods Administration (2) to amend Australia’s Poisons Standard by rescheduling poppers from Schedule 4 (Prescription Only) to Schedule 9 (Prohibited Substance) was met with strong resistance from the community, calling the decision an attack or war on gay and bisexual men and their community (23,24). Partial or complete bans in other jurisdictions have attracted similar criticism in the past (25). The legal status of poppers is generally complex and contentious (2). While marketing poppers as a recreational substance is illegal in Australia, it is commonly sold in adult and online shops as ‘room deodoriser’, ‘leather cleaner’ or ‘VHS head cleaner’, falsely assuming that such labels will bypass existing regulations (2). Some jurisdictions have banned certain alkyl nitrites for any non-commercial use, such as isobutyl nitrite in the European Union due to evidence suggesting a higher prevalence of retinal damage compared to other alkyl nitrites (26) or amyl nitrite in the United States (27). As discussed above, many studies on the impact of poppers on sexual (risk) behaviour and physiological side effects have been published. However, research focusing on relationships between poppers use and psycho-social factors as well as other concepts such as LGBT community connectedness and participation in gay and bisexual men is limited, particularly among young sexual minority men. Previous research identified strong correlations between the use of substances and concepts such as participation in and connectedness to the LGBT community in sexual minority men from which implications for public health practice, including health promotion, and further research into substance use in this population were drawn (28-30). The aim of this study is, therefore, to identify patterns of poppers use in young gay and bisexual men, and to explore correlates of poppers use with participation in and connectedness to the LGBT community, mental and psychosocial wellbeing, as well as other substance use and personal characteristics. Materials and Methods Recruitment and participants A cross-sectional survey on substance use was completed by 836 sexual minority men between November 2016 and April 2017. Recruitment was conducted using paid and unpaid advertisement on social media platforms including Facebook® as well as through LGBT community organisations, LGBTIQ media, and commercial LGBTIQ-venues. Potential participants had to reside in Australia and were aged between 18 and 35 years to ensure sufficient commonalities. Research ethics approval was obtained from Queensland University of Technology’s Human Research Ethics Committee (approval number: 1600000636). Informed consent was sought from all participants. Measurements Demographics