Date of Award

Fall 2023

Document Type

Open Access Dissertation


Epidemiology and Biostatistics

First Advisor

Anthony Alberg


Cigarette smoking is the leading cause of preventable morbidity and premature mortality in the U.S. and other high-income nations. E-cigarette use or vaping is an addictive behavior. During the past 5 years, the prevalence of e-cigarette use has increased markedly in U.S. adolescents and young adults. The public health implications of this increased prevalence are unclear. Adverse childhood experiences (ACEs) are associated with cigarette smoking in adulthood. However, the pathway from experiencing ACEs in childhood to smoking cigarettes or using e-cigarettes in adulthood is not clearly understood. Additional factors experienced between childhood and adulthood might either increase or decrease the strength of the association between ACEs and subsequent cigarette smoking and e-cigarette use. We hypothesized that selected social determinants of health (SDHs) during early adulthood or adulthood might moderate the strength of the relationship between ACEs and cigarette smoking/e-cigarette use or may be a consequence of and thereby mediate the risk of becoming a cigarette smoker or e-cigarette user. The purpose of this research was to characterize the inter-relationship of self-reported early life ACEs and current SDH factors on the prevalence of current cigarette smoking and e-cigarette use. The three specific aims were: Aim 1: to carry out a systematic review of published evidence on the association between ACEs and current cigarette smoking and current e-cigarette use, Aim 2: to assess if SDHs, such as socioeconomic status (education, income, employment), and health care access (health coverage, health provider access) are associated with cigarette smoking and e-cigarette use, and Aim 3: to determine the path-specific effects of SES on the pathway from ACEs to cigarette smoking/e-cigarette use. The Aim 1 systematic review demonstrated that ACEs were strongly and statistically significantly associated with current cigarette smoking and the association was stronger with each incremental increase in the number of ACEs, e.g., those with ≥4 ACEs had 2.23 times higher odds of being current cigarette smokers. For e-cigarettes, there is a much smaller body of evidence (n=3 studies). The associations with the ACEs categories were all statistically significant but the associations were weak (ORs 1.10 to 1.15), with no clear evidence of a trend as the number of ACEs experienced increased. For example, those who had ≥4 ACEs had 1.15 times higher odds of being a current vaper. In conclusion, the Aim 1 results identified a strong, consistent body of evidence indicating that ACEs should be considered an established risk factor for adult cigarette smoking. The evidence-based is too small to make firm conclusions concerning the association between ACEs and current e-cigarette use but the evidence to data indicates there is a weak association that does not vary markedly by level of ACEs exposure. The Aim 2 findings were consistent in pointing toward an important role for lower SES and lack of access to health care as important risk factors for current cigarette smoking and e-cigarette use. The SDH variables were also strongly and consistently associated with reduced likelihood of quitting cigarette smoking; for e-cigarettes, however, lower SES was associated with increased likelihood of quitting. Aside from this one inconsistency, taken together the evidence supports the conclusion that SDH variables tended to be strongly associated with increased prevalence of current tobacco use and decreased prevalence of quitting tobacco use. Finally, in the Aim 3 results we observed that among those who were exposed to one or more ACEs, low SES significantly mediated the likelihood of being a cigarette smoker or e-cigarette user. In conclusion, this research documents that ACEs are a strong and important risk factor cigarette smoking that is presently underappreciated. ACEs also appear to be a risk factor for e-cigarette use, but further research is needed to better characterize this association. Lack of access to healthcare was identified as a risk factor for both cigarette smoking and e-cigarette use, including for likelihood of being a current smoker and for lower likelihood of quitting smoking. Lower SES was observed to be a potent risk factor for current use of cigarettes and e-cigarettes, and was also associated with lower likelihood of quitting smoking cigarettes. A puzzling finding was that lower SES was associated with increased likelihood of quitting e-cigarettes, possibly due to using of e-cigarettes for smoking cessation. These findings were integrated in a novel way to document that low SES had a significant mediating role in the pathway from ACEs to cigarette smoking and to e-cigarette use, advancing understanding of the complex inter-relationships of these variables to influence the likelihood of cigarette smoking and e-cigarette use. In addition to emphasizing the importance of the pathway from ACEs to cigarette smoking and e-cigarette use, the findings suggest that further research is warranted, including research designed to overcome limitations of the present study and to research to investigate physiological pathways that may be triggered by childhood trauma and social disadvantages and may thus contribute to the cumulative risk for cigarette smoking and vaping.


© 2024, Kankana Sengupta

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