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Robert F. Anda, MD, MS; Janet B. Croft, PhD; Vincent J. Felitti, MD; Dale Nordenberg, MD; Wayne H. Giles, MD, MS; David F. Williamson, MS, PhD; Gary A. Giovino, PhD

JAMA. 1999;282:1652-1658.

Context  In recent years, smoking among adolescents has increased and the decline of adult smoking has slowed to nearly a halt; new insights into tobacco dependency are needed to correct this situation. Long-term use of nicotine has been linked with self-medicating efforts to cope with negative emotional, neurobiological, and social effects of adverse childhood experiences.

Objective  To assess the relationship between adverse childhood experiences and 5 smoking behaviors.

Design  The ACE Study, a retrospective cohort survey including smoking and exposure to 8 categories of adverse childhood experiences (emotional, physical, and sexual abuse; a battered mother; parental separation or divorce; and growing up with a substance-abusing, mentally ill, or incarcerated household member), conducted from August to November 1995 and January to March 1996.

Setting  A primary care clinic for adult members of a large health maintenance organization in San Diego, Calif.

Participants  A total of 9215 adults (4958 women and 4257 men with mean [SD] ages of 55.3 [15.7] and 58.1 [14.5] years, respectively) who responded to a survey questionnaire, which was mailed to all patients 1 week after a clinic visit.

Main Outcome Measures  Smoking initiation by age 14 years or after age 18 years, and status as ever, current, or heavy smoker.

Results  At least 1 of 8 categories of adverse childhood experiences was reported by 63% of respondents. After adjusting for age, sex, race, and education, each category showed an increased risk for each smoking behavior, and these risks were comparable for each category of adverse childhood experiences. Compared with those reporting no adverse childhood experiences, persons reporting 5 or more categories had substantially higher risks of early smoking initiation (odds ratio [OR], 5.4; 95% confidence interval [CI], 4.1-7.1), ever smoking (OR, 3.1; 95% CI, 2.6-3.8), current smoking (OR, 2.1; 95% CI, 1.6-2.7), and heavy smoking (OR, 2.8; 95% CI, 1.9-4.2). Each relationship between smoking behavior and the number of adverse childhood experiences was strong and graded (P<.001). For any given number of adverse childhood experiences, recent problems with depressed affect were more common among smokers than among nonsmokers.

Conclusions  Smoking was strongly associated with adverse childhood experiences. Primary prevention of adverse childhood experiences and improved treatment of exposed children could reduce smoking among both adolescents and adults.

Author Affiliations: National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Ga (Drs Anda, Croft, Giles, Williamson, and Giovino); Department of Preventive Medicine, Southern California Permanente Medical Group (Kaiser Permanente), San Diego (Dr Felitti); Department of Pediatrics, Emory University School of Medicine, Atlanta (Dr Nordenberg).

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