In the early 1900s, diseases such as tuberculosis and polio were the leading cause of death in the United States.[1] Advances in medicine and public health have increased life expectancy, but modern research has shown that the risk factors for chronic diseases has also increased. There have been extensive debates on the underlying determinants of risk factors and lifestyles, which remain poorly understood. For example, most people know that smoking causes lung cancer, yet we do not know the primary step that may explain why people start smoking, and why they have trouble quitting. Are there parallels between early childhood stress, smoking, and COPD? Establishing the importance of early childhood stress on the health outcomes of an individual has been difficult. This deleterious impact may be due to an unhealthy environment that impedes the resolution of early life development, as well as modifications in brain anatomy. These can lead to adoption of unhealthy coping behaviors throughout the lifespan as well as maladaptive psychological functioning.
Maltreatment in childhood may lead adults to adopt risky behaviors in certain domains such as smoking, alcohol abuse, drug use, and sexual behavior. Although child abuse is shown to lead to higher rates of medical care, the survivors of this abuse use preventive medical services less often. Abuse survivors are less likely than adults who are not abused to follow these regimens appropriately. Due to the history of trauma in psychological impairment, whether continuing to smoke cigarettes despite the presence of illness or symptoms, often caused by smoking are associated with reports of childhood trauma.
Introduction
When a child is wounded, the pain and long-term negative effects they experience reverberate as a shadow of characteristics and behaviors. This is due to Adverse Childhood Experiences (ACEs). Traumatic events or stressors during childhood and early adolescence create a pathway to a long list of behavioral, health, and social outcomes. ACEs are associated not only with risk for mental disorders in childhood, but confer a lasting vulnerability to psychopathology that persists into adulthood. referenceACE scores are cumulative, interrelated impacts on childhood development and impact a variety of health and social priorities in our country (Anda,2). As the ACE score increases, there is a causal increase of numerous health and social problems.
Figure 1: ACE Pyramid
In 1995, the first ACE study demonstrated the effect of childhood maltreatment and household dysfunction on adult smoking, obesity, and excessive alcohol use. The CDC-Kaiser Permanente ACE study and subsequent surveys showed that an estimate of 59% of people have 1 or more ACEs, and approximately 9% had 5 or more. Figure 1, The ACE pyramid represents the conceptual framework for the study and was designed to assess what was considered to be “scientific gaps” about the risk factors. The gaps have two arrows linking ACEs to risk factors that lead to health and social consequences higher on the pyramid. The study was designed to provide data that would answer if these risk factors are not randomly distributed but influenced by the development of them. Through the research inspired by CDC-Kaiser Permanente there has been scientific information to fill the gaps. People with four ACEs- including living with an alcoholic parent, racism, bullying, witnessing violence outside the home, physical abuse and parental divorce- have a huge risk of adult onset of chronic health problems such as heart disease, cancer, diabetes, suicide, and alcoholism. Other studies have evaluated individual ACEs as primary exposures and compared outcomes amongst people with or without ACE exposures. This method has the limitation of different referent groups for each individual ACE analysis, and thus no comparison can be made if the magnitude of associations between outcomes and individual ACEs.Findings from earlier studies demonstrate a high prevalence of ACEs in a nonrandom selection, establishing the prevalence of ACEs can provide help to target local prevention efforts.
In recent years, smoking among teenagers and adolescence has spiked and the decline of adult smoking has developed new insights into tobacco dependence. The long-term use of tobacco and nicotine has been linked with the efforts of self-medication to cope with emotional, neurobiological and social effects caused by ACEs.reference Since connections between ACEs and COPD are limited, this paper will show how we can use smoking as a bridge.
Results
The decline in smoking in the United States owes its success to the work of practitioners and legislation. Warning labels were added to the packs of cigarettes and the sales of tobacco products to minors were prohibited. There has even been advertisement education to the public about the health risks of smoking, which persuade people to quit smoking. Despite efforts to understand the factors that contribute to the initiation and continuation of smoking is critical to the policies and practices that have an effect on reducing smoking. While never and current smoking behaviors have been studied, smokeless tobacco use remains poorly examined; it is infrequently the focus of analyses or it is combined with smoking to create a global measure of tobacco use. Both smokeless tobacco and cigarette use are included in this study to examine if ACEs impact tobacco use behaviors in the same way.
Smoking studies, have evaluated new methods, aggregating individual ACEs into direct and environmental categories. This method allows the comparison of smoking risks amongst a person with direct ACEs, environmental ACEs, and both ACE categories, to persons without any ACEs. While comparing a person who experienced a specific individual ACE to those without a specific ACE could potentially diminish the association of the ACE and outcome because of the limitation in magnitude. Yet, explaining the association between these categories and adverse outcomes could be useful in improving public knowledge without requiring an in-depth explanation of each individual ACE.
Some researchers have referred to persistent smokers as “hard-core” smokers who may never attempt to quit regardless of their health status. They have found that younger, less educated, and less advantaged socioeconomic groups have workers’ self-efficacy beliefs about the ability to quit, which relates to a lower rate of smoking cessation. It appears that health beliefs and demographics, such as surrounding environments, may interfere with the transmitters to stop smoking. Mental illness is another barrier to the cessation of smoking. A recent study has found that adults who possess psychiatric disorders are more likely to be smokers. The interference such as depression has been seen to maximize withdrawal-related symptoms and discomfort allowing a smoking relapse.
One explanation for the observed associations between ACEs and tobacco use is that ACEs correlate with childhood exposure to tobacco use by adults. For example, about a third of adults who suffer from alcohol use disorders are also nicotine dependent and about a third of adults with a lifetime diagnosis of mental illness currently smoke. As a result, children with multiple adverse childhood experiences may also have a greater likelihood of being exposed to individuals who use tobacco, which itself has been associated with tobacco use. Following this logic, it would be unsurprising that smokeless tobacco is less consistently and less strongly associated with ACEs, given that it is less commonly used and thus less likely to be modeled by caretakers. Also, because substance use by adults measures were among those associated with smokeless tobacco use, it is possible that modeling of drug use, in general, is particularly important for smokeless tobacco uptake. First, because the data are cross-sectional, the directionality of relationships cannot be ascertained and recall bias cannot be ruled out. Second, while the ACE scale includes a variety of experiences, it does not include items assessing peer victimization, peer isolation or rejection, community violence and low childhood socioeconomic status, which may also impact health and have been suggested for inclusion in an expanded ACE scale. Third, this study is not representative of the entire United States. The states that could be included for analyses do not adequately capture the sociodemographic and tobacco use variability that exists in the United States. Consequently, generalizations must be made with caution. Fourth, while weight and adjustments created by Behavioral Risk Factor Surveillance System (BRFSS) attempt to make the survey representative of the underlying population, non-response bias has still been a documented problem thus the present analysis may not be fully representative. Regression models were included in categorical ACEs and categorical smokers. The ACE categories consisted of: verbal abuse, physical abuse, sexual abuse, witnessed domestic violence, household substance abuse, mentally ill household member, parental separation or divorce, and incarcerated household member.Smoking on the other hand was reduced to two categories current smokers and former/never smoked. Other variables in each model included age, sex, race/ethnicity, body mass, education, income, marital status and asthma. Each ACE category and score was significantly associated with the increased risk of smoking, and increased likelihood of COPD. Finally, because the frequency of reporting current use of smokeless tobacco products is relatively low, the present study may not be adequately powered to detect all associations between ACEs and smokeless tobacco use. As such, future work should consider using larger samples or lifetime use of smokeless tobacco products.
The theoretical concept of ACEs as a framework for the prevention of public health problems suggests that stressful or traumatic childhood experiences are a common pathway to social, emotional, and cognitive impairments that lead to the increased risk of disease, disability and premature mortality. Neurobiology suggests that ACEs exert their effects through the disruption of neurodevelopment in ways that may have a lasting effect on brain structure and functions, including the limbic system, which can lead to disordered affect regulation, the display of acting out, externalizing disorders, or behavior problems. The ACE score is a powerful grade that creates a relationship of lasting negative effects in the limbic system and related brain functions. The ACE score does not tally incidents within a category, but the occurrence during childhood of any one category of adverse experience is scored as one point. There is no further scoring for multiple incidents within a category, an alcoholic or drug user within a household may share the same score. For example, ACEs may affect family structure support, adaptability, isolation, self-esteem, and scholastic performance. In turn, these factors have been linked to aspects of smoking behavior. The complexity of the many possible pathways leading from ACEs to smoking behavior is illustrated in the Chicago Longitudinal Study, which showed that two sets of mediating variables explained the associations between childhood maltreatment and smoking. The first set included school mobility, juvenile delinquency, reading achievement, and socioemotional skills. The second set included substance abuse, adult arrest conviction, highest grade completed, and life satisfaction.
The association of ACEs with smoking persistence was sustained even after accounting for the presence of past or current depression, a condition related to continued smoking with heart disease. Despite the cross-sectional nature of this finding, there is evidence that ACEs play a role in the development of health risk behaviors. The psychoactive properties of nicotine and other addictive drugs have a temporarily negative effect and adaptive function in coping with the aftermaths of trauma regardless the health risks. Certain psychological outcomes associated with maltreatment, such as poor self-esteem and external loss of control, may be the mechanisms that their early negative experiences result in later in life. The prevalence among smokers of having at least one ACE is 63%, and the current number of smoking increased as the numbers if ACEs increased. Adults who reported having five or more ACEs were 5 times as likely of starting smoking at an early age, three times as likely to have smokes and two times the odds of being a current smoker. This observation has profound implications that illustrate the effects on nicotine and understanding the nature of smoking in many people. When you match the prevalence of adult bronchitis and emphysema against ACEs, there is a strong dose-response relationship. The conversion of emotional stressors into an organic disease through intermediary mechanisms of emotionally beneficial behavior.
Another possible causal link between ACEs and smoking behavior could have potential implications for clinical practice. Although there are no current treatments that specifically address smoking cessation in the context of ACEs, studies are needed to establish the utility of treatments specifically targeted to this population of patients. The trials of current smokers with ACEs randomized to usual treatment or to usual treatment plus therapy directed at the underlying ACEs could prove the merit of looking for ACEs among smokers. Regardless, clinicians are urged to address tobacco use at every clinical encounter.
Gender’s association with psychological distress can be seen as a very common distinction between the individual and general impact of one’s ACE score to their risk of smoking and COPD. Among women, psychological distress mediated a significant portion of the association; there was 21% for emotional abuse, 16% for physical abuse, 15% for physical neglect, and 10% for parental separation or divorce. On the other hand, among men the associations between ACE and smoking were not significant. People who have experienced ACEs and psychological distress may smoke as a method to compensate for the deficiencies in social and emotional development, and a way to self-medicate biological dysregulations.
Smoking can be viewed as a viable coping option because of its sedative properties- for example, its ability to modify mood, regulate negative affect and improve concentration. Studies have shown that nicotine reduces anger in smokers and nonsmokers with high hostility, and depression. Studies conducted suggest that the relationship between childhood abuse and substance dependence may be partially mediated by mood and anxiety disorders. Others implicate social phobias as the mediator between ACEs and drug dependence.
NAME OF AUTHOR examined the relationship between ACEs, psychological distress and adult smoking; determined if sex differences were significant; and determined if psychological distress mediated the relationship between ACEs and adult smoking amongst males and females. The Mental Component Summary (MCS) identified and explained the relationship between ACEs and adult current smoking based on psychological distress as an indicator.
After adjustments were made for socio-demographic characteristics, parental smoking during childhood, and alcohol abuse in the past month, the odds of adult smoking was at least 1.4 times greater amongst women who have been emotionally or physically abused. The odds of current adult smoking among women increased as the ACE score rose, this association was not significant after adjustments. In the unadjusted models, the MCS score was lower among those with any ACE compared to those without the given ACE suggesting increased psychological distress. All adjusted models for women were significant except that in which the independent variable was a childhood exposure to incarcerated household members. Amongst men, all adjusted associations were significant except for those with an independent variable of parental separation/ divorce or incarcerated household member. As the ACE score increased in both adjusted and unadjusted models, the level of psychological distress also increased. Approximately 22% of the relationship between emotional abuse and adult smoking was mediated through psychological distress as was 17% of the relationship between physical abuse and adults smoking, 14% of the relationship between parental separation/divorce and adult smoking. The findings also confirmed results suggesting sex differences in smoking behavior and patterns. Although negative effect is related in smoking amongst men and women, the relationship is stronger in women. Stressful childhood life events may disproportionately influence a women’s decision to use drugs, which can result from coping styles. Another cause can be the openness or willingness of women to talk about emotional and physical abuse, while men are more likely to report physical neglect.
ACEs have recently emerged as a set of exposures that have a strong impact on a wide array of public health and social problems, including strong relationships with smoking, and incidence of chronic pulmonary disease (COPD). While smoking is the primary risk factor for COPD, multiple factors other than smoking play a role in its development and progression. This can include nutrition and childhood exposures to respiratory infection. Pathways involved in COPD include reduced lung growth during childhood through adulthood, premature decline in lung function and accelerated decline in lung function.
The Department of Preventive Medicine in California, studied the effects of smoking on patients in southern California and its relativity to COPD. The ACE score ranged from 8 to 9 and the analysis conducted were conducted with the summed score. The three criteria used to define COPD were, the prevalent COPD based on self-reports, incident hospitalizations from discharge records, and prescription medication for the treatment of COPD during a follow-up. When they studied current smokers, they found that smoking has a strong, graded relationship to ACEs. There was a 250% increase in the likelihood of an ACE score of 6 being a current smoker compared to the ACE score of 0.
To further reduce smoking rates, we must better tailor smoking-cessation to the needs of smokers who have not been persuaded by traditional “stop smoking” ads. Practitioners will need to consider the history of abuse and presence of depression in patients who continue smoking despite the conditions that contradict this action. Programs that address the underlying problems caused by ACEs may prove to be more useful than traditional strategies in reaching this “difficult” population. The universal screening of ACEs is necessary for comprehensive medical records. Patients are more likely to be comfortable with the screening for child abuse and believe the assistance of a practitioner in dealing with the issues that arose.
Discussion
Many of our most intractable public health problems are the result of behaviors like smoking, overeating, and substance use which provide immediate partial relief from the emotional problems caused by traumatic childhood experiences. The chronic life stress of these developmental experiences is unrecognized and unappreciated. The findings of the ACE study provide a credible basis for the new paradigm of medical, public health and social service practices. Consequently, interventions to prevent adversities in childhood, potentially targeting vulnerable population groups, or providing additional coping resources and increasing resilience to those facing them, may help further curb tobacco use. Furthermore, because individuals with a history of ACEs may have stressful or traumatic origins for their tobacco use, interventions among these populations may benefit from addressing these underlying stressors and trauma.
While ACEs have been tied to other chronic conditions such as depression, heart disease, cancer, diabetes, and stroke, research on their relationship to COPD is limited. The ACE Study data are cross-sectional and do not collect specific information. Most literature suggests that majority of psychiatric disorders associated with smoking occur prior to smoking initiation. A study should be designed to specifically examine the stress-smoking relationship amongst adolescence, negative life events and effects related to increase in smoking overtime. There could be a cohort effect because many participants most likely began smoking when it was socially acceptable than it is now. Therefore the relative contribution of ACEs may increase or decrease the rates of smoking overtime. Lastly, another component for further study could be a follow-up study of adults with documented childhood abuse often underrepresented events. The exact mechanism linking ACEs with adult smoking has not been fully elucidated. As such, when addressing smoking cessation in clinical practice, it may be important to understand the underlying role of childhood trauma. Having knowledge about childhood trauma history in clinical practice may provide the opportunity to integrate trauma focused interventions. To create effective intervention and prevention programs, research should be conducted to further link ACEs to smoking. Identifying potential modifiable risk factors for smoking as well as building resilience and social support for abused children may decrease the prevalence of smoking of those exposed to maltreatment.