Original ResearchGender-specific association between childhood adversities and smoking in adulthood: findings from a population-based study
Introduction
Cigarette smoking is the leading preventable cause of premature death,1 and is associated with numerous negative health outcomes, including cancer,2 cardiovascular diseases and chronic respiratory conditions.3 The prevalence of smoking has declined over the past 40 years; however, these declines have plateaued over the last 10 years.4 One in every five Americans continue to smoke.4 The estimated economic burden of smoking exceeded US$193 billion in annual health-related losses, including $96 billion in medical costs and $97 billion in lost productivity.5 Given the high mortality, morbidity and economic costs associated with smoking, a better understanding of its risk factors is important for public health.
There is a converging body of research suggesting that adverse childhood experiences (ACEs) such as childhood maltreatment and parental divorce can lead to negative health outcomes. Child maltreatment can include physical, sexual and emotional abuse and/or neglect. Child abuse is linked to numerous adult health conditions including heart disease,6, 7, 8, 9 cancer,10, 11 osteoarthritis,12 functional somatic symptoms,13, 14, 15 migraine,16 asthma, bronchitis/emphysema and ulcers.17
An emerging body of literature suggests that childhood parental divorce is linked to negative health outcomes, including acute and chronic health problems,18 somatic symptoms19 and mortality.20, 21 The research literature indica-tes that the impact of parental divorce on health differs by gender. Males have a greater likelihood of substance abuse,22 depression,18 suicidal ideation15 and mortality.21 Luecken and Lemery23 suggest that parental divorce may be a proxy for disrupted early caregiving, and that the perceived negativity associated with divorce may play a role in increasing vulnerability to poor health outcomes.
Previous evidence suggests that childhood abuse and other adversities may be linked to poor health outcomes due to problematic health behaviours such as smoking. Childhood physical abuse,24, 25, 26, 27, 28, 29 sexual abuse24, 25, 26, 27, 28, 29, 30, 31, 32, 33 and verbal abuse,24, 26, 29 have been associated with elevated levels of smoking in adulthood. Additionally, increased odds of smoking have been associated with parental divorce24, 26, 29, 34 and parental alcohol and/or drug addictions.24, 26, 29
The literature suggests that the relationship between child maltreatment and smoking is potentially confounded by several risk factors: (1) other ACEs; (2) adult socio-economic indicators; (3) adult health behaviours; (4) social support; and (5) adult mental health. Recent studies have shown that childhood adversities are inter-related.35 Childhood abuse commonly co-occurs with other ACEs, such as parental addiction and parental divorce.7, 24, 35, 36, 37, 38 Parental divorce is associated with increased odds of child maltre-atment.35
Health risk factors tend to cluster in individuals exposed to multiple ACEs.7 In addition, a strong, graded relationship has been found between the number of ACEs and the number of health risk factors for leading causes of death, including smoking, severe obesity, physical inactivity, depressed mood, alcoholism and drug use in adulthood.7
A significant dose–response relationship between a number of ACEs and smoking persistence has been shown for individuals.39 In that study, a persistent smoker was defined as an adult who reported current smoking and had at least one smoking-related disease or illness, including heart disease, chronic lung disease and diabetes.39 In addition, health behaviours such as inactivity, excessive alcohol consumption and obesity, are associated with smoking in adulthood.40, 41, 42 A recent study conducted by Brown et al.10 revealed that in comparison with individuals with no ACEs, those with six or more ACEs were more than twice as likely to die at or before 65 years of age.
Previous research has found that the prevalence of smoking is higher among males,4 the unmarried,43, 44 those who are in the 25–44 year birth cohort1, 4 and those with lower socio-economic status (SES).4, 45, 46, 47 Education has been identified as one of the most commonly used SES indicators47 and one of the strongest predictors of smoking patterns.48 Educational level is inversely related to smoking.45, 49 Both race and ethnicity have been associated with variations in smoking rates.4 Many of the factors that are positively associated with ever smoking are also negatively associated with quitting. Mental health, sociodemographic characteristics and social support appear to impact smoking cessation. Increased age, being married or living with a partner, higher SES and higher levels of educational attainment are the sociodemographic characteristics that have been positively associated with smoking cessation.44, 50 Previous research suggests that social support and smoking cessation are associated. Positive associations have been found between partner and friend support and smoking cessation.51, 52
Childhood abuse has been associated with depression and anxiety in adolescence and adulthood.10, 24, 53 In turn, significant associations have been found between depression and/or anxiety and smoking.39, 54, 55 Recent studies have suggested that mental health indicators, such as depression, are potential mediators of the relationship between child abuse and smoking.25, 39, 56 Depression has also been identified as a barrier to successful smoking cessation,39, 51, 57 and a significant mediator and predictor of smoking persistence.39 Nicotine may help regulate emotions and stress.7, 24 Nicotine impacts the dopamine system, which in turn activates the reward system of the brain. Primate studies suggest maltreatment increases the likelihood of self-administration of nicotine.24 These findings suggest the regulatory and calming effect of smoking may be particularly attractive to those who have suffered early adversities.7, 24
Both smoking and ACEs such as childhood maltreatment have been identified as public health problems with enormous implications for health outcomes throughout the lifespan.58, 59 The objective of this study was to build upon the previous literature which explores the link between these two factors, including Anda et al.'s24 landmark study that first documented the association between ACEs and smoking, and, more recently, studies by Ford et al.26 and Vander Weg29 that replicated this influential work using population-based data. These seminal studies, however, did not conduct gender-specific analyses. The World Health Organization (WHO) emphasizes the importance of considering each gender separately to better understand factors associated with the motivation to initiate and to cease smoking.60 Furthermore, WHO underlines the importance of taking ‘into account gender differences when designing policies, anti-tobacco messages and other interventions’.61
Therefore, to inform a more gender-nuanced understanding of the independent association of multiple ACEs and smoking initiation and continuation, the objective of this study was to examine the association between each of six ACEs and both smoking initiation and smoking cessation for males and for females separately. The six early adversities examined, included parental separation or divorce, household problematic drinking; household substance abuse; sexual abuse; physical abuse; and verbal abuse, while controlling for other childhood experiences, demographics and mental health variables.
This study contributes uniquely to the literature as it is the first population-based study to examine the relationship between individual ACEs and smoking outcomes differentially by gender. Gender-specific analyses can assist in promoting a better understanding of the differences that exist in smoking behaviours. As WHO emphasizes, a gendered understanding of these factors is particularly important in light of increasing targeting of women by the tobacco industry.61
Section snippets
Data source and sample
The data used in this study were derived from the Centers for Disease Control and Prevention's49 2010 public use Brief Risk Factor Surveillance Survey (BRFSS). The BRFSS is a cross-sectional, telephone survey managed by state health departments in collaboration with the Centers for Disease Control and Prevention.49 The questionnaire focuses on preventative health practices and risk behaviours linked to chronic diseases, injuries and preventable infectious diseases affecting the adult
Results
As shown in Table 1, male and female respondents differed significantly on almost every characteristic examined. Females were more likely than males to have never smoked, to be older, to be White, to be poorer, to have completed some postsecondary education, and to have anxiety disorders or depressive disorders. In childhood, females were more likely to have lived with an alcoholic and to have been sexually abused than males, but less likely to have lived with a drug abuser or to have been
Discussion
To the authors' knowledge, this is the first nationally representative, population-based study that has examined gender-specific differences between individual ACEs and smoking behaviours in adulthood. Although previous population-based studies have controlled for age, gender, race or ethnicity, educational status26 and income,29 the current study controlled for a wider range of known risk factors for smoking, including: (1) other ACEs; (2) adult socio-economic indicators; (3) adult health
Conclusion
Despite its limitations, this study presents important gender-specific findings based on individual ACEs and smoking outcomes using population-based data. These findings underscore the importance of gender-specific analysis of health risk behaviours. Future research should continue to explore how ACEs impact health risk behaviours and health outcomes differentially by gender. The findings of this study have several important implications for public health practice. If future research finds that
Acknowledgements
The authors would like to thank Marla Battiston and Katie Hunter for assistance with manuscript preparation.
Ethical approval
This study was based on secondary analysis of public use data sets from which all identifying information has been stripped. Therefore, ethics review was not sought.
Funding
This research was conducted, in part, thanks to the first author's support from the Sandra Rotman Chair Endowment.
Competing interests
None declared.
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2021, Child Abuse and NeglectCitation Excerpt :Similar to adult studies, the occurrence of ACEs has been related to child and adolescent externalizing such as hyperactivity and conduct problems (Appleyard, Egeland, van Dulmen, & Alan Sroufe, 2005; Baglivio et al., 2014) and internalizing behaviors (Flouri & Panourgia, 2011), including manifestations such as adolescent suicide (Borges, Angst, Nock, Ruscio, & Kessler, 2008; Goodday, Shuldiner, Bondy, & Rhodes, 2019). Though most of the research in this field has looked at males and females together, there is evidence that ACEs affect boys and girls differently e.g. females are more likely to experience sexual abuse while boys are more likely to experience verbal abuse (Cunningham et al., 2014), but also that the same ACEs may have a different impact across males and females e.g. sexual and verbal abuse during childhood were significantly associated with smoking for women but not for men (Fuller-Thomson, Filippelli, & Lue-Crisostomo, 2013). While there are several studies on the impact of ACEs on internalizing and externalizing behaviors in both young people and adults, an area that has been less studied in relation to ACEs is their potential impact on adaptive behaviors such as the development of prosocial behaviors (e.g. helping others, sharing, and being kind to peers).
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2020, Eating BehaviorsCitation Excerpt :Several previous studies on the association between ACEs and other health outcomes (e.g., smoking, mental health problems and cancer) have also reported more pronounced associations in women (Alcalá, Tomiyama, & von Ehrenstein, 2017; Cunningham et al., 2014; Fisher et al., 2009; Fuller-Thomson, Filippelli, & Lue-Crisostomo, 2013; Haatainen et al., 2003; Isohookana, Riala, Hakko, & Räsänen, 2013). While no explanation is readily available in relation to the sex difference reported in this study, one possible interpretation based on findings reported in the previous literature is that women are more vulnerable to the effects of ACEs, and thus ACEs might have been more likely to manifest as negative health behaviors in women compared to men (Alcalá et al., 2017; Cunningham et al., 2014; Fisher et al., 2009; Fuller-Thomson et al., 2013; Haatainen et al., 2003; Isohookana et al., 2013). From a different perspective the weaker associations observed among Japanese men might be related to the fact that they tend to eat meals that are prepared by their spouse.
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