Shanta R. Dube

Insights into causal pathways for ischemic heart disease: adverse childhood experiences study.

Background—The purpose of this study was to assess the relation of adverse childhood experiences (ACEs), including abuse, neglect, and household dysfunction, to the risk of ischemic heart disease (IHD) and to examine the mediating impact on this relation of both traditional IHD risk factors and psychological factors that are associated with ACEs. Methods and Results—Retrospective cohort survey data were collected from 17 337 adult health plan members from 1995 to 1997. Logistic regression adjusted for age, sex, race, and education was used to estimate the strength of the ACE–IHD relation and the mediating impact of IHD risk factors in this relation. Nine of 10 categories of ACEs significantly increased the risk of IHD by 1.3- to 1.7-fold versus persons with no ACEs. The adjusted odds ratios for IHD among persons with ≥7 ACEs was 3.6 (95% CI, 2.4 to 5.3). The ACE–IHD relation was mediated more strongly by individual psychological risk factors commonly associated with ACEs than by traditional IHD risk factors. We observed significant association between increased likelihood of reported IHD (adjusted ORs) and depressed affect (2.1, 1.9 to 2.4) and anger (2.5, 2.1 to 3.0) as well as traditional risk factors (smoking, physical inactivity, obesity, diabetes and hypertension), with ORs ranging from 1.2 to 2.7. Conclusions—We found a dose-response relation of ACEs to IHD and a relation between almost all individual ACEs and IHD. Psychological factors appear to be more important than traditional risk factors in mediating the relation of ACEs to the risk of IHD. These findings provide further insights into the potential pathways by which stressful childhood experiences may increase the risk of IHD in adulthood.

Violent Childhood Experiences and the Risk of Intimate Partner Violence in Adults Assessment in a Large Health Maintenance Organization

Information about the relationship of experiencing abuse or witnessing domestic violence in childhood to the risk of intimate partner violence (IPV) in adulthood is scant. The relationship of childhood physical or sexual abuse or growing up with a battered mother to the risk of being a victim of IPV for women or a perpetrator for men was studied among 8,629 participants in the Adverse Childhood Experiences Study conducted in a large HMO. Each of the three violent childhood experiences increased the risk of victimization or perpetration of IPV approximately two-fold. A statistically significant graded relationship was found between the number of violent experiences and the risk of IPV. Among persons who had all three forms of violent childhood experiences, the risk of victimization and perpetration was increased 3.5-fold for women and 3.8-fold for men. These data suggest that as part of risk assessment for IPV in adults, screening for a history of childhood abuse or exposure to domestic violence is needed.

Adverse childhood experiences and personal alcohol abuse as an adult.

Adult alcohol abuse has been linked to childhood abuse and family dysfunction. However, little information is available about the contribution of multiple adverse childhood experiences (ACEs) in combination with parental alcohol abuse, to the risk of later alcohol abuse. A questionnaire about childhood abuse, parental alcoholism and family dysfunction while growing up was completed by adult HMO members in order to retrospectively assess the independent relationship of eight ACEs to the risk of adult alcohol abuse. The number of ACEs was used in stratified logistic regression models to assess their impact on several adult alcohol problems in the presence or absence of parental alcoholism. Each of the eight individual ACEs was associated with a higher risk alcohol abuse as an adult. Compared to persons with no ACEs, the risk of heavy drinking, self-reported alcoholism, and marrying an alcoholic were increased twofold to fourfold by the presence of multiple ACEs, regardless of parental alcoholism. Prevention of ACEs and treatment of persons affected by them may reduce the occurrence of adult alcohol problems.

Electronic nicotine delivery systems: adult use and awareness of the ‘e-cigarette’ in the USA

Background Electronic nicotine delivery systems (ENDS), also referred to as electronic cigarettes or e-cigarettes, were introduced into the US market in 2007. Despite concerns regarding the long-term health impact of this product, there is little known about awareness and use of ENDS among adults in the USA. Methods A consumer-based mail-in survey (ConsumerStyles) was completed by 10 587 adults (≥18 years) in 2009 and 10 328 adults in 2010. Data from these surveys were used to monitor awareness, ever use and past month use of ENDS from 2009 to 2010 and to assess demographic characteristics and tobacco use of ENDS users. Results In this US sample, awareness of ENDS doubled from 16.4% in 2009 to 32.2% in 2010 and ever use more than quadrupled from 2009 (0.6%) to 2010 (2.7%). Ever use of ENDS was most common among women and those with lower education, although these were not the groups who had heard of ENDS most often. Current smokers and tobacco users were most likely to try ENDS. However, current smokers who had tried ENDS did not say they planned to quit smoking more often than smokers who had never tried them. Conclusions Given the large increase in awareness and ever use of ENDS during this 1-year period and the unknown impact of ENDS use on cigarette smoking behaviours and long-term health, continued monitoring of these products is needed.

Cumulative Childhood Stress and Autoimmune Diseases in Adults

Objective: To examine whether childhood traumatic stress increased the risk of developing autoimmune diseases as an adult. Methods: Retrospective cohort study of 15,357 adult health maintenance organization members enrolled in the Adverse Childhood Experiences (ACEs) Study from 1995 to 1997 in San Diego, California, and eligible for follow-up through 2005. ACEs included childhood physical, emotional, or sexual abuse; witnessing domestic violence; growing up with household substance abuse, mental illness, parental divorce, and/or an incarcerated household member. The total number of ACEs (ACE Score range = 0-8) was used as a measure of cumulative childhood stress. The outcome was hospitalizations for any of 21 selected autoimmune diseases and 4 immunopathology groupings: T- helper 1 (Th1) (e.g., idiopathic myocarditis); T-helper 2 (Th2) (e.g., myasthenia gravis); Th2 rheumatic (e.g., rheumatoid arthritis); and mixed Th1/Th2 (e.g., autoimmune hemolytic anemia). Results: Sixty-four percent reported at least one ACE. The event rate (per 10,000 person-years) for a first hospitalization with any autoimmune disease was 31.4 in women and 34.4 in men. First hospitalizations for any autoimmune disease increased with increasing number of ACEs (p < .05). Compared with persons with no ACEs, persons with ≥2 ACEs were at a 70% increased risk for hospitalizations with Th1, 80% increased risk for Th2, and 100% increased risk for rheumatic diseases (p < .05). Conclusions: Childhood traumatic stress increased the likelihood of hospitalization with a diagnosed autoimmune disease decades into adulthood. These findings are consistent with recent biological studies on the impact of early life stress on subsequent inflammatory responses. ACE = adverse childhood experience; AD = autoimmune disease; Th1 = T-helper 1; Th2 = T-helper 2; CRP = C-reactive protein; CRH = corticoid releasing hormone.

The association of depression and anxiety with obesity and unhealthy behaviors among community-dwelling US adults

OBJECTIVE The aim of this study was to examine the extent to which depression and anxiety are associated with smoking, obesity, physical inactivity and alcohol consumption in the US population using the Patient Health Questionnaire 8 (PHQ-8) and two questions on lifetime diagnosis of anxiety and depression. METHODS Data were analyzed in 38 states, the District of Columbia and two territories using the 2006 Behavioral Risk Factor Surveillance System (n=217,379), a large state-based telephone survey. RESULTS Overall, adults with current depression or a lifetime diagnosis of depression or anxiety were significantly more likely than those without each diagnosis to smoke, to be obese, to be physically inactive, to binge drink and drink heavily. There was a dose-response relationship between depression severity and the prevalence of smoking, obesity and physical inactivity and between history of depression (never depressed, previously depressed, currently depressed) and the prevalence of smoking, obesity, physical inactivity, binge drinking and heavy drinking. Lifetime diagnosis of depression and anxiety had an additive association with smoking prevalence. CONCLUSION The associations between depression, anxiety, obesity and unhealthy behaviors among US adults suggest the need for a multidimensional and integrative approach to health care.

Growing up with Parental Alcohol Abuse: Exposure to Childhood Abuse, Neglect, and Household Dysfunction.

OBJECTIVE This study is a detailed examination of the association between parental alcohol abuse (mother only, father only, or both parents) and multiple forms of childhood abuse, neglect, and other household dysfunction, known as adverse childhood experiences (ACEs). METHOD A questionnaire about ACEs including child abuse, neglect, household dysfunction, and exposure to parental alcohol abuse was completed by 8629 adult HMO members to retrospectively assess the relationship of growing up with parental alcohol abuse to 10 ACEs and multiple ACEs (ACE score). RESULTS Compared to persons who grew up with no parental alcohol abuse, the adjusted odds ratio for each category of ACE was approximately 2 to 13 times higher if either the mother, father, or both parents abused alcohol (p < 0.05). For example, the likelihood of having a battered mother was increased 13-fold for men who grew up with both parents who abused alcohol (OR, 12.7; 95% CI: 8.4-19.1). For almost every ACE, those who grew up with both an alcohol-abusing mother and father had the highest likelihood of ACEs. The mean number of ACEs for persons with no parental alcohol abuse, father only, mother only, or both parents was 1.4, 2.6, 3.2, and 3.8, respectively (p < .001). CONCLUSION Although the retrospective reporting of these experiences cannot establish a causal association with certainty, exposure to parental alcohol abuse is highly associated with experiencing adverse childhood experiences. Improved coordination of adult and pediatric health care along with related social and substance abuse services may lead to earlier recognition, treatment, and prevention of both adult alcohol abuse and adverse childhood experiences, reducing the negative sequelae of ACEs in adolescents and adults.

Awareness and Ever-Use of Electronic Cigarettes Among U.S. Adults, 2010–2011

INTRODUCTION Electronic cigarettes, or e-cigarettes, were introduced into the U.S. market in recent years. However, little is known about the health impact of the product or the extent of its use. This study assessed the prevalence and correlates of awareness and ever-use of e-cigarettes among U.S. adults during 2010-2011. METHODS Data were obtained from the HealthStyles survey, a national consumer-based survey of U.S. adults aged ≥18 years old. In 2010, data collection for the HealthStyles survey was both mail-based (n = 4,184) and web-based (n = 2,505), and in 2011, web-based (n = 4,050) only. Estimates of awareness and ever-use of e-cigarettes were calculated overall and by sex, age, race/ethnicity, educational attainment, household income, region, and smoking status. RESULTS In 2010, overall awareness of e-cigarettes was 38.5% (mail survey) and 40.9% (web survey); in 2011, awareness was 57.9% (web survey). Ever-use of e-cigarettes among all respondents was 2.1% in the 2010 mail survey, 3.3% in the 2010 web survey, and 6.2% in the 2011 web survey. Ever-use of e-cigarettes was significantly higher among current smokers compared with both former and never-smokers, irrespective of survey method or year. During 2010-2011, ever-use increased among both sexes, those aged 45-54 years, non-Hispanic Whites, those living in the South, and current and former smokers. CONCLUSIONS Awareness and ever-use of e-cigarettes increased among U.S. adults from 2010 to 2011. In 2011, approximately 1 in 5 current smokers reported having ever-used e-cigarettes. Continued surveillance of e-cigarettes is needed for public health planning.

The relationship of exposure to childhood sexual abuse to other forms of abuse, neglect, and household dysfunction during childhood

OBJECTIVE This study assesses the relationship of childhood sexual abuse (CSA) to nine other categories of Adverse Childhood Experiences (ACEs), including childhood abuse, neglect, and multiple types of household dysfunction. METHODS Retrospective cohort study data were collected from 17,337 adult health plan members who responded to a survey questionnaire. Regression models adjusted for age, race, and education were used to estimate the strength of the association of CSA to each of the other nine ACEs and a graded relationship between measures of the severity of CSA and the number of other ACEs (ACE score). RESULTS CSA was reported by 25% of women and 16% of men. In comparison with persons who were not exposed to CSA, the likelihood of experiencing each category of ACE increased 2- to 3.4-fold for women and 1.6- to 2.5-fold for men (p < 0.05). The adjusted mean ACE score showed a significant positive graded relationship to the severity, duration, and frequency of CSA and an inverse relationship to age at first occurrence of CSA (p < 0.01). CONCLUSIONS CSA is strongly associated with experiencing multiple other forms of ACEs. The strength of this association appears to increase as the measures of severity of the CSA increases. The understanding of the interrelatedness of CSA with multiple ACEs should be considered in the design of studies, treatment, and programs to prevent CSA as well as other forms of ACEs.

Trends in Awareness and Use of Electronic Cigarettes Among US Adults, 2010–2013

INTRODUCTION Electronic cigarette (e-cigarette) marketing has increased considerably since the product entered the US market in 2007, thereby warranting additional surveillance to monitor recent trends in population-level awareness and utilization. We assessed the prevalence, characteristics, and trends in e-cigarette awareness and use among nationally representative samples of US adults during 2010-2013. METHODS Data came from the 2010-2013 HealthStyles survey, an annual consumer-based web survey of US adults aged ≥ 18 years. Sample sizes ranged from 2,505 (2010) to 4,170 (2012). Descriptive statistics were used to assess e-cigarette awareness, ever use, and current use (use within the past 30 days) overall and by sex, age, race/ethnicity, education, income, US region, and cigarette smoking status. Trends were assessed using logistic regression. RESULTS During 2010-2013, increases (p < .05) were observed for e-cigarette awareness (40.9%-79.7%), ever use (3.3%-8.5%), and current use (1.0%-2.6%). Awareness increased among all socio demographic subpopulations during 2010-2013 (p < .05); an increase in ever use of e-cigarettes occurred among all sociodemographic groups except those aged 18-24 years, Hispanics, and those living in the Midwest (p < .05). During 2010-2013, ever use increased among current (9.8%-36.5%) and former (2.5%-9.6%) cigarette smokers (p < .05), but it remained unchanged among never smokers (1.3%-1.2%). CONCLUSIONS Awareness and use of e-cigarettes increased considerably among US adults during 2010-2013. In 2013, more than one-third of current cigarette smokers reported having ever used e-cigarettes. Given the uncertain public health impact of e-cigarettes, continued surveillance of emerging use patterns is critical for public health planning.