Adverse childhood experiences and smoking persistence in adults with smoking-related symptoms and illness

Little is known about why people continue to smoke after learning that they have diseases and conditions that contraindicate smoking. Using data from the Adverse Childhood Experiences (ACE) Study, we examined the relation between ACEs and smoking behavior when smoking-related illnesses or conditions are present, both with and without depression as a mediator.

Participants were more than 17,000 adult HMO members who retrospectively reported on eight categories of ACEs (emotional, physical, and sexual abuse; witnessing interparental violence; parental divorce; and growing up with a substance-abusing, mentally ill, or incarcerated household member). The number of maltreatment categories was summed to form an ordinal variable called the ACE Score. We measured current smoking, conditions that contraindicate smoking (heart disease, chronic lung disease, and diabetes), and symptoms of these illnesses (chronic bronchitis, chronic cough, and shortness of breath). Logistic regression models compared the ACE Score of smokers with smoking-related illnesses to participants who reported these illnesses but were not current smokers (n = 7483).

Significant dose-response relations between the ACE Score and smoking persistence were found (odds ratio = 1.69; confidence interval = 1.34-2.13 for participants with ≥4 ACEs). Depression was a significant independent predictor of smoking persistence as well as a mediator. Depression only slightly attenuated the relation between the ACE Score and persistent smoking, however.

Medical practitioners should consider the maltreatment history and depression status of their patients when a smoking-related diagnosis fails to elicit smoking cessation. Programs should be developed that better address the underlying motivations for continuing to smoke in the face of health problems that contraindicate smoking.