Adverse Childhood Experiences and Adult Tobacco Use: Exploring the Role of Depression and Anxiety

Background/Purpose: Tobacco use is a leading cause of mortality and morbidity worldwide. Research suggests that adverse childhood experiences (ACEs) increase the risk of tobacco use, though the mechanisms of effect are unclear. It is plausible that the ACE-tobacco connection is partly explained by antecedent or comorbid mental health conditions such as mood and anxiety disorders. To explore this possibility, data from the Chicago Longitudinal Study (CLS) were used examine the following questions:

1. Do rates of depressive symptoms and anxiety vary among tobacco users and non-users?
2. Does greater exposure to ACEs increase the likelihood of depressive symptoms, anxiety, and tobacco use?
3. Does the link between ACEs and tobacco use vary according to the presence of depressive symptoms and anxiety?

Methods: This study includes 1,142 CLS participants who responded to an adult survey between ages 22-24. Responses were used to create a measure of lifetime tobacco use, which was also partitioned into 3 outcome subgroups: daily current use, occasional current use, and no current use. Survey data yielded the following dichotomous measures of depression and anxiety in the past month: any depressive symptoms; frequent depressive symptoms; any anxiety; frequent anxiety. Finally, outcomes were created to denote covariation between all measures of tobacco use and (a) frequent depressive symptoms, (b) frequent anxiety, (c) no depressive symptoms, and (d) no anxiety. Data from Child Protective Service records and retrospective accounts on a Life Events Checklist were used to create 8 ACE items, which were summed into a cumulative index.

Bivariate cross-tabulations were performed to assess the frequency distribution of depressive symptoms and anxiety among tobacco users and non-users. Controlling for background characteristics, multivariate logistic regressions were used to test if rates of tobacco use, depressive symptoms, and anxiety varied by cumulative exposure to ACEs. A final set of multivariate analyses examined whether ACE-tobacco associations varied along with the presence of frequent depressive symptoms and anxiety as well as the absence of depressive symptoms or anxiety.

Results: As expected, symptoms of depression and anxiety were significantly elevated among tobacco users compared to non-users. A dose-response relationship emerged between the number of ACEs and the likelihood of lifetime tobacco use and daily current use, but not occasional current use. Results also revealed a graded association between the number of ACEs and the incidence and frequency of depressive symptoms and anxiety. Finally, when frequent depressive symptoms or anxiety were present, there was a positive association between the number of ACEs and the likelihood of tobacco use. Yet when depressive symptoms or anxiety were absent, tobacco use did not vary by level of exposure to ACEs.

Conclusions: Findings suggest that ACEs clearly contribute to tobacco use, depression, and anxiety, but that associations among these outcomes are complex. Further research is needed to determine if ACEs are part of a shared etiology of tobacco use and mental health symptoms, or if there is a temporal order to these ACE-linked consequences. Disentangling these connections will result in significant implications for prevention, intervention, and public health policy.