Adverse childhood experiences and smoking status in five states

doi:10.1016/j.ypmed.2011.06.015

Preventive Medicine

Volume 53, Issue 3, 1 September 2011, Pages 188-193

https://doi.org/10.1016/j.ypmed.2011.06.015 Get rights and content

Abstract

Objective

Our objective was to examine the associations between adverse childhood experiences (ACEs) and smoking behavior among a random sample of adults living in five U.S. states.

Methods

We used data from 25,809 participants of the 2009 Behavioral Risk Factor Surveillance System to assess the relationship of each of the 8 adverse childhood experiences and the adverse childhood experience score to smoking status.

Results and conclusions

Some 59.4% of men and women reported at least one adverse childhood experience. Each of the eight adverse childhood experiences measures was significantly associated with smoking status after adjustment for demographic variables. The prevalence ratios for current and ever smoking increased in a positive graded fashion as the adverse childhood experience score increased. Among adults who reported no adverse childhood experiences, 13.0% were currently smoking and 38.3% had ever smoked. Compared to participants with an adverse childhood experience score of 0, those with an adverse childhood experience score of 5 or more were more likely to be a current smoker (adjusted prevalence ratio (aPR): 2.22, 95% confidence interval [CI]: 1.92–2.57) and to have ever smoked (aPR: 1.80, 95% CI: 1.67–1.93). Further research is warranted to determine whether the prevention of and interventions for adverse childhood experiences might reduce the burden of smoking-related illness in the general population.

Highlights

► Eight adverse childhood experiences (ACEs) were related to smoking behavior. ► Some 59.4% of men and women reported at least one ACE. ► Each ACE was significantly associated with current smoking status. ► The number of ACEs was significantly associated with current smoking status.

Introduction

Despite impressive declines in the prevalence of cigarette smoking among adults in the United States from 42.4% of adults in 1965 to 20.6% in 2009 (Centers for Disease Control and Prevention, 2010d), smoking continues to exact a heavy toll on morbidity and mortality in the United States (Centers for Disease Control and Prevention, 2010c, Danaei et al., 2009, McGinnis and Foege, 1993, Mokdad et al., 2004). Furthermore, the economic costs attributable to smoking were estimated at $96 billion per year in direct medical expenses as well as more than $97 billion annually in lost productivity during 2000-2004 (Centers for Disease Control and Prevention, 2010c).

The decline in smoking in the United States owes much of its success to efforts of clinicians, public health initiatives, and legislation. The release of the Surgeon General's Report in 1964 generated a number of activities to reduce the prevalence of smoking (U.S. Public Health Service, 1964). Warning labels were added to packs of cigarettes, sale of tobacco products to minors was prohibited, advertising campaigns educated the public about the health risks of smoking and dissuaded people from initiating smoking or advised them to quit smoking, and smoking in public places has been prohibited in some states, municipalities, and individual workplaces. A recent review suggests that a physician's advice to a patient to quit smoking is effective among a certain percentage of patients (Bodner and Dean, 2009). The use of nicotine patches or other pharmaceutical products also helps some patients to quit smoking (Moore et al., 2009).

Despite the success of these efforts, 20.6% of adults in the United States continue to smoke; this estimate has not changed much from the prevalence of 20.9% in 2005 (Centers for Disease Control and Prevention, 2010d). Understanding the factors that contribute to the initiation and continuation of smoking is critical to designing policies and practices that will be effective in reducing the prevalence of smoking. In 1999, Anda et al. (1999) reported that adverse childhood experiences (ACEs) were a novel contributing factor to smoking initiation in adolescence and smoking continuation in adulthood. In that study, the prevalence of having at least one ACE was 63%, and the prevalence of current smoking increased as the numbers of ACEs increased. Adults who reported having five or more ACEs had 5 times the odds of having started smoking at an early age, 3 times the odds of having ever smoked, and 2 times the odds of being a current smoker.

Since then, several additional cross-sectional studies have reported that ACEs are associated with smoking behavior with reported odds ratios of 3.5 for ever smoking, 4.0 for current smoking, and 1.55 to 2.0 for smoking initiation after various adjustments (Jun et al., 2008, King et al., 2006, Nichols and Harlow, 2004, Spratt et al., 2009). Furthermore, a panel study of African Americans found that child maltreatment in terms of neglect, physical abuse, and sexual abuse predicted smoking status (Topitzes et al., 2010).

Prospective data from the Kaiser-CDC (Centers for Disease Control and Prevention) ACE Study cohort supports the cross-sectional data. Follow-up of the Kaiser-CDC ACE Study cohort has shown that the number of ACEs was positively related to the incidence of smoking-related lung disease. Hospitalization rates for chronic obstructive pulmonary disease (COPD) and rates of prescription medications used to treat COPD increased as the ACE score increased (Anda et al., 2008). Similarly, hospitalization and death rates from lung cancer increased as the ACE score increased (Brown et al., 2010). In both of these studies, the relationship of the ACE score to COPD and lung cancer were partially mediated by smoking.

Because the initial findings about ACEs and smoking came from a study of enrollees of a large health maintenance organization in California, confirming these observations among a more diverse group in the general population is important to gauge the need for new clinical and public health practices to deal with smoking behaviors that are influenced by ACEs. Therefore, we examined the associations between ACEs and smoking status in a large sample of adults living in five geographically and demographically diverse U.S. states.

Section snippets

Methods

We used data from the 2009 Behavioral Risk Factor Surveillance System (BRFSS) (Centers for Disease Control and Prevention, 2010a). The BRFSS is conducted in all 50 states, the District of Columbia, and three territories. In each state, an independent probability sample from noninstitutionalized adults aged ≥ 18 years with telephones was selected by using disproportionate stratified sampling (Centers for Disease Control and Prevention, 2006). All states used an identical core questionnaire

Results

Of the 29,212 participants in the five states that administered the ACE questionnaire, 26,229 (90%) provided responses to all 11 questions used to create the ACE score. Of these 26,229 participants, 26,139 had information to establish smoking status. After excluding participants with missing values for a covariate, 25,809 participants were included in the analysis.

Reporting at least one ACE was relatively common: 40.6% reported no ACE, 22.4% reported one, 13.1% reported two, 8.8% reported

Discussion

Population-based data from the BRFSS demonstrated a strong link between ACEs and smoking status. Moreover, as the ACE score increased, the risk of current smoking and ever smoking increased. Our analyses provide support for the previous findings of the Kaiser-ACE Study. Adverse childhood experiences (ACEs) have recently emerged as a set of exposures that have a strong impact on a wide array of public health and social problems (Anda et al., 2010) including strong relationships with smoking

Conflict of interest statement

The authors declare that there are no conflicts of interest.

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Tobacco use remains one of the most used substances among adults globally and substantially impacts individuals and society. Adverse childhood experiences (ACEs) contribute to tobacco use. However, the association between cumulative ACEs and tobacco use behaviors (TUB) has not been established in the literature. In this review, we aimed to estimate the prevalence of ACEs among adult tobacco users and evaluated the relationship between cumulative ACEs and TUB.
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^☆: Disclaimer: The findings and conclusions in this article are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

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Adverse childhood experiences and smoking status in five states☆

Abstract

Objective

Methods

Results and conclusions

Highlights

Introduction

Section snippets

Methods

Results

Discussion

Conflict of interest statement

Am. J. Prev. Med.

Am. J. Prev. Med.

Am. J. Prev. Med.

Child Adolesc. Psychiatr. Clin. N. Am.

Child Abuse Negl.

Child Abuse Negl.

Am. J. Prev. Med.

J. Adolesc.

J. Adolesc. Health

Child Abuse Negl.

Drug Alcohol Depend.

Neurosci. Biobehav. Rev.

Child Abuse Negl.

Child Abuse Negl.

Depression and the dynamics of smoking. A national perspective

JAMA

Adverse childhood experiences and smoking during adolescence and adulthood

JAMA

Family and personal protective factors moderate the effects of adversity and negative disposition on smoking among Chinese adolescents

Subst. Use Misuse

Wireless Substitution: Early Release of Estimates From the National Health Interview Survey, July–December 2009

Advice as a smoking cessation strategy: a systematic review and implications for physical therapists

Physiother. Theory Pract.

Adverse childhood experiences are associated with the risk of lung cancer: a prospective cohort study

BMC Public Health

Behavioral Risk Factor Surveillance System Operational and User's Guide Version 3.0

Behavioral Risk Factor Surveillance System

BRFSS policy memo 97.1 cognitive testing

Smoking & Tobacco use