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. Author manuscript; available in PMC: 2021 Sep 1.
Published in final edited form as: J Community Psychol. 2020 Aug 13;48(7):2364–2374. doi: 10.1002/jcop.22420

Trauma exposure, PTSD symptoms, and tobacco use: Does church attendance buffer negative effects?

Amanda R Mathew 1, Eric Yang 2, Elizabeth F Avery 1, Melissa M Crane 1, Brittney S Lange-Maia 1,2, Elizabeth B Lynch 1,2
PMCID: PMC7654728  NIHMSID: NIHMS1641000  PMID: 32789875

Abstract

Aims:

Traumatic stress and Post-Traumatic Stress Disorder (PTSD) are overrepresented in urban African American communities, and associated with health risk behaviors such as tobacco use. Support and resources provided by churches may reduce trauma-related health risks. In the current study, we assessed weekly church attendance as a moderator of relations between a) traumatic event exposure and probable PTSD, and b) probable PTSD and tobacco use.

Methods:

Data were drawn from a health surveillance study conducted in seven churches located in Chicago’s West Side. Participants (N=1,015) were adults from churches as well as the surrounding community.

Results:

Trauma exposure was reported by 62% of participants, with 25% of those who experienced trauma reporting probable PTSD. Overall, more than one-third of participants (37.2%) reported current tobacco use. As compared to non-weekly church attendance, weekly church attendance was associated with lower likelihood of PTSD (OR = 0.41; 95% CI 0.26–0.62; p < .0001) and lower tobacco use overall (OR = 0.22; 95% CI 0.16–0.30; p < .0001), but did not moderate the effect of trauma exposure on risk of PTSD, or the effect of PTSD on tobacco use.

Conclusion:

Findings support church attendance as a potential buffer of trauma-related stress.

Keywords: Trauma, PTSD, tobacco, smoking, church attendance, community-based research

Traumatic stress and Post-Traumatic Stress Disorder (PTSD) carry significant public health burdens, and occur frequently among those living in in urban, under-resourced environments. In particular, rates of traumatic stress exposure among predominantly African American groups in urban settings have been reported to reach 65–88% (Alim et al., 2006; Gillespie et al., 2009), with the most common exposures including accidents, interpersonal violence, and sexual assault. Lifetime prevalence of PTSD among African Americans exposed to trauma in urban settings is approximately 50% (Alim et al., 2006; Gillespie et al., 2009), and may be elevated relative to White Americans (Roberts, Gilman, Breslau, Breslau, & Koenen, 2011). The West Side of Chicago is one such urban environment: the population is predominantly African American, due to a history of discriminatory housing and lending policies, and the area is characterized by high rates of premature mortality and social disadvantage (Laflamme et al., 2015).

Traumatic stress and PTSD are robustly associated with health risk behaviors, such as tobacco use. Those who have been exposed to trauma, particularly interpersonal violence, are more likely to be current tobacco users (Crane, Hawes, & Weinberger, 2013; Crane, Pilver, & Weinberger, 2014; Ford et al., 2011; Taha, Galea, Hien, & Goodwin, 2014). Recent reviews have found that individuals with PTSD use tobacco products at elevated rates (Pericot-Valverde, Elliott, Miller, Tidey, & Gaalema, 2018) and are twice as likely to smoke cigarettes as those without PTSD (Kearns et al., 2018). Further, smokers with PTSD smoke more heavily, are more nicotine dependent (Feldner, Babson, & Zvolensky, 2007; Hapke et al., 2005), and are less likely to quit (Beckham, Calhoun, Dennis, Wilson, & Dedert, 2012) than smokers without PTSD.

A growing body of literature has explored assets of urban African American communities that may buffer effects of stress, and potentially attenuate the links between trauma exposure, PTSD, and tobacco use. Church involvement is associated with better physical (Bruce et al., 2017; Gillum & Ingram, 2006; Obisesan, Livingston, Trulear, & Gillum, 2006) and mental health (Assari & Moghani Lankarani, 2018; Chatters, Nguyen, Taylor, & Hope, 2018; Li, Okereke, Chang, Kawachi, & VanderWeele, 2016; Reese, Thorpe, Bell, Bowie, & LaVeist, 2012; VanderWeele, Li, Tsai, & Kawachi, 2016). In particular, church involvement may function as a protective factor after exposure to traumatic stress (Schaefer, Blazer, & Koenig, 2008). Those who have experienced traumatic stress may engage in congregational support or pastoral care to make meaning and sense of the trauma experienced (Bryant-Davis & Wong, 2013; Walker, Reid, O’Neill, & Brown, 2009). Religious involvement may in turn help to promote positive coping and prevent development of PTSD (Fares et al., 2017; San Roman et al., 2019; Sharma et al., 2017), although results are mixed (Bryant-Davis et al., 2015; Kucharska, 2019). Further, church attendance is also associated with lower rates of tobacco use in numerous population-based surveys (Bowie et al., 2017; Brown et al., 2014; Gillum, 2005; Whooley, Boyd, Gardin, & Williams, 2002). However, limited community-based research has explored how church attendance may influence relations between traumatic stress and negative health outcomes in an urban African American population.

In the current study, we assessed weekly church attendance as a moderator of relations between a) traumatic event exposure and probable PTSD, and b) probable PTSD and tobacco use among predominantly African American participants in a community-based study. We hypothesized that weekly church attendance would interact with traumatic event exposure to predict lower rates of PTSD, and would interact with probable PTSD status to predict lower odds of being a current tobacco user.

Methods

Participants and Procedures

Data from this study was drawn from a larger cross-sectional health surveillance study designed to gather detailed information on cardiometabolic risk and social determinants of health from church members and the surrounding community at seven predominantly African American churches on Chicago’s West Side (citation redacted). The study was conducted in collaboration with church pastors and coordinators within a community-based participatory research framework (Wallerstein & Duran, 2006). Participants were recruited in 2018 using convenience sampling methods, including flyers, announcements during church services, and outreach from church coordinators, who worked as research staff. Eligible participants were age 18 and older, confirmed their identity (either by church coordinators confirming their church membership status or providing a photo ID), and optionally provided contact information to allow for follow-up through ancillary studies. All participants provided informed consent and were compensated up to $35 for their study participation. All procedures were approved by the governing Institutional Review Board.

Measures

Self-report questionnaire.

Participants provided basic demographic information, including age, gender, and race/ ethnicity. Participants were asked, “How often do you attend church?,” with response options of never, less than once a month, 1–2 times a month, or weekly. Participants were also asked, “Do you currently smoke cigarettes or use other tobacco products (at least once a day)?,” with response options Yes or No.

Life Events Checklist.

Trauma exposure was assessed with the Life Events Checklist (Weathers et al., 2013), a list of 17 potentially traumatic events (e.g., sexual assault, motor vehicle accident, combat). For each event, respondents indicate whether the event directly happened to them or they had witnessed the event, learned about it or it happened as part of their job. All events that had happened to them or were witnessed were summed to create a total score between 0–17, and participants were categorized based on experience of 0, 1–3, or ≥ 4 traumatic events. We also computed an interpersonal trauma score based on endorsement of traumatic events of an interpersonal nature (i.e., physical assault, assault with a weapon, sexual assault, other unwanted or uncomfortable sexual experiences, combat or exposure to a war‐zone, captivity, serious injury and/or harm and/or death you caused to someone else; Ehring & Quack, 2010). All events of an interpersonal nature that happened to them or were witnessed were summed to create an interpersonal trauma score with a possible range of 0–7.

Primary Care PTSD Screen for DSM-5.

Participants who reported exposure to one or more traumatic events completed the Primary Care PTSD Screen for DSM-5 (Prins et al., 2016), a 5-item screening measure to assess current symptoms of PTSD, consistent with DSM-5 criteria. Items assess current PTSD symptoms in each symptom cluster (i.e., intrusion symptoms, avoidance, negative alterations in mood and cognitions, and alterations in arousal and reactivity) with a dichotomous (yes/no) response format. Endorsement of three or more items indicated probable PTSD (Prins et al., 2016).

Analytic Strategy

We first conducted univariate descriptive analyses and examined differences in demographics, tobacco use, and trauma exposure by church attendance status. Continuous variables were compared across categories using t-tests or wilxcon tests. Categorical variables were compared using chi-squared tests. We next constructed two sets of logistic regression models to assess relations between a) cumulative trauma exposure (4+ events vs. 1–3 events) and probable PTSD among those who had at least 1 traumatic event, and b) probable PTSD and tobacco use among the whole sample. For the second model, participants were grouped into three categories: no trauma, one or more traumatic events without PTSD (trauma, no PTSD), and one or more traumatic events with probable PTSD (trauma with PTSD). Each logistic regression model examined the role of church attendance status (weekly church attendance vs. less than weekly church attendance or no church attendance) as a main effect. Lastly, an interaction term (predictor by church attendance status) was added to each model to examine any moderating effects of church attendance.

Results

Sample Characteristics

Of the full sample from the parent screening study (N = 1106), 91 participants were missing data on church attendance status, leaving a sample of N = 1015 described in Table 1 below. Several additional participants were missing data on tobacco use (n = 7) and level of education (n = 5); thus, data from 1,003 participants was available for analyses presented in Table 3. PTSD status was only assessed among participants who endorsed one or more traumatic event, resulting in a sample size of N = 627 for analyses presented in Table 2.

Table 1.

Demographic, Tobacco, and Trauma-Related Sample Characteristics

Total (N=1,015) Weekly church attenders (N=595) Non-weekly church attenders (N=420) P-Value
Age, M (SD) 52.6 (15.7) 56.2 (15.6) 47.5 (14.5) <0.001
Age groups, N (%) <0.001
 18–29 128 (12.6) 53 (8.9) 75 (17.9)
 30–44 154 (15.2) 81 (13.6) 73 (17.4)
 45–64 522 (51.4) 280 (47.1) 242 (57.6)
 65–79 182 (17.9) 152 (25.5) 30 (7.1)
 ≥80 29 (2.9) 29 (4.9) 0 (0.0)
Female, N (%) 592 (58.3) 400 (67.2) 192 (45.7) <0.001
Hispanic ethnicity, N (%) 19 (1.9) 6 (1.0) 13 (3.2) 0.017
African American race, N (%) 968 (95.4) 576 (96.8) 392 (93.3) 0.010
Education, N (%) <0.001
 < High school 135 (13.4) 50 (8.5) 85 (20.3)
 High school diploma 374 (37.0) 182 (30.8) 192 (45.8)
 > High school 501 (49.6) 359 (60.7) 142 (33.9)
Current tobacco use, N (%) 375 (37.2) 124 (21.0) 251 (60.3) <0.001
Traumatic event exposure, N (%) 0.055
 No events 385 (37.9) 228 (38.3) 157 (37.4)
 1–3 events 306 (30.2) 193 (32.4) 113 (26.9)
 4+ events 324 (31.9) 174 (29.3) 150 (35.7)
Number of traumatic events, median (Q1, Q3) 1 (0, 5) 1 (0, 4) 2 (0, 6) <0.001
Number of interpersonal traumas, median (Q1, Q3) 2 (1, 3) 2 (1, 3) 2 (2, 4) <0.001
Trauma/PTSD, N (%) <0.001
 No trauma 385 (37.9) 228 (38.3) 157 (37.4)
 Trauma, no PTSD Symptoms 470 (46.3) 305 (51.3) 165 (39.3)
 Trauma with PTSD Symptoms 160 (15.8) 62 (10.4) 98 (23.3)
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Table 3.

Trauma, PTSD, and church attendance as predictors of tobacco use (N = 1,003)

Effect OR 95% CI P-value
Trauma with PTSD vs. No trauma 2.18 1.40 3.38 <0.001
Trauma, no PTSD vs. No trauma 1.12 0.81 1.55 0.08
Church attendance (weekly vs. non-weekly) 0.22 0.16 0.30 <0.0001
Age 1.01 0.998 1.02 0.12
Female sex 0.44 0.32 0.59 <0.0001
Education (high school vs. more than high school) 2.55 1.85 3.52 <0.001
Education (less than high school vs. more than high school) 2.15 1.38 3.35 <0.001
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Table 2.

Trauma exposure and church attendance as predictors of PTSD (N=627)

Effect OR 95% CI P-value
Trauma exposure (4+ events vs. 1–3 events) 3.05 2.03 4.58 <0.0001
Church attendance (weekly vs. non-weekly) 0.41 0.26 0.62 <0.0001
Age 0.98 0.97 0.997 0.02
Female sex 1.76 1.17 2.65 <0.01
Education (high school vs. more than high school) 1.35 0.87 2.09 0.82
Education (less than high school vs. more than high school) 1.65 0.91 3.01 0.21
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As shown in Table 1, participants were on average 52.6 ± 15.7 years old, 58.3% were female, and the majority of participants (95.4%) identified their race/ ethnicity as Black/ African American. More than one-third (37.2%) of participants reported current tobacco use, with lower rates of tobacco use among weekly church attenders (21.0%) versus non-weekly attenders (60.3%).

Participants were distributed roughly into thirds by categorical trauma exposure, with 37.9% reporting no trauma exposure, 30.2% reporting exposure to one to three traumatic events, and 31.9% reporting exposure to four or more traumatic events. Weekly church attenders reported fewer mean lifetime traumas than non-weekly attenders, and fewer interpersonal traumas (p < 0.001 for each). The most commonly reported traumatic event was a transportation accident, experienced by 37.6% of participants.

Among participants who reported any trauma exposure (N = 630), 25.4% reported current PTSD symptoms. This rate differed significantly by church attendance status, with weekly church attenders less likely to report current PTSD symptoms (16.9%) than non-weekly attenders (37.3%).

Trauma Exposure-PTSD Associations by Church Attendance Status (Weekly vs. Non-weekly)

As shown in Table 2, there was a main effect of both cumulative trauma exposure (4+ events vs. 1–3 events; OR = 3.05, 95% CI 2.03–4.58) and church attendance status (OR = 0.41, 95% CI 0.26–0.62) on likelihood of PTSD, but the interaction between cumulative trauma exposure and church attendance status was not significant (p > .20). After adjusting for number of traumas, those who attended church on a weekly basis were about 60% less likely to have PTSD than people who did not attend church on a weekly basis.

Models were also run with interpersonal trauma exposure in place of cumulative trauma exposure (results not shown), and the same pattern of findings was observed.

PTSD-Tobacco Use Associations by Church Attendance Status (Weekly vs. Non-weekly)

As shown in Table 3, participants with PTSD were more than twice as likely to use tobacco as participants with no trauma (OR = 2.18, 98% CI 1.40–3.38). Participants who reported traumatic event exposure without PTSD did not differ in tobacco use from participants with no trauma (OR = 1.12, 95% CI 0.81–1.55). The interactions of trauma/ PTSD with church attendance status were not significant (p’s > .20). After adjusting for trauma/ PTSD status, church attendance was associated with approximately 80% lower likelihood of tobacco use (OR = 0.22, 95% CI 0.16–0.30).

In an additional model in which participants with trauma, no PTSD served as the reference group, we found that participants with PTSD were nearly twice as likely to use tobacco as those who reported traumatic event exposure without PTSD (OR = 1.94, 95% CI 1.27–2.98; p < .01).

A similar pattern of findings was observed when the sample size was restricted to those with exposure to one or more traumatic events, as in the previous model (N=627; results not shown). The interaction of PTSD with church attendance status was not significant (p = 0.813). After adjusting for PTSD status, church attendance was associated with a lower likelihood of tobacco use (OR = 0.23, 95% CI 0.14–0.32; p < .01).

Discussion

In the current study, we examined interrelationships of church attendance with PTSD and tobacco use within a community-based sample of predominantly African American adults. As compared to non-weekly church attendance, weekly church attendance was associated with a much lower likelihood of PTSD and tobacco use, but did not moderate the effect of trauma exposure on risk of PTSD, or the effect of PTSD on tobacco use. Despite similar rates of trauma exposure, weekly church attenders had about a 60% lower risk of PTSD and an 80% lower likelihood of current tobacco use, as compared to non-attenders. Associations were similar among participants with both high and low levels of trauma exposure, suggesting a protective effect of church attendance, regardless of the experience of traumatic stress.

Weekly church attendance was associated with strikingly decreased prevalence of PTSD for those with both high and low trauma exposure, relative to those who attend church less frequently. This is consistent with other research showing a buffering effect of church attendance (Bruce et al., 2017; Gillum & Ingram, 2006; Li et al., 2016; Obisesan et al., 2006; Reese et al., 2012; VanderWeele et al., 2016). For example, in one study the psychological distress associated with financial hardship was moderated or nonexistent in individuals who attend church frequently (Bradshaw & Ellison, 2010). In another study the relationship between stress and inflammation was lessened in individuals with higher religiosity (Tavares, Ronneberg, Miller, & Burr, 2019). Regardless of church attendance, higher levels of trauma exposure were associated with greater likelihood of screening positive for PTSD. That is, church attendance did not change the relationship between trauma exposure and PTSD but just decreased the overall likelihood of experiencing PTSD.

Overall, 62% of participants reported at least one trauma exposure, with 25% of those who experienced trauma reporting probable PTSD (17% among weekly church attenders and 37% among non-weekly attenders). As compared to prior studies of predominantly African American groups in urban settings (Alim et al., 2006; Gillespie et al., 2009), we identified a similar rate of traumatic event exposure, but a lower rate of PTSD, possibly due to our church-based sampling strategy or lower endorsement of PTSD symptoms among older respondents (Reynolds, Pietrzak, Mackenzie, Chou, & Sareen, 2016). Despite this, PTSD rates were greatly elevated relative to national population-based estimates (6.7%; Kessler et al., 2005), likely reflecting disproportionate exposure to poverty and social risk within the current sample (Laflamme et al., 2015).

Our results were consistent with prior findings that church attendance is associated with lower rates of tobacco use (Bowie et al., 2017; Brown et al., 2014; Gillum, 2005; Whooley et al., 2002), while PTSD is associated with higher rates of tobacco use (Pericot-Valverde et al., 2018). We extended these findings by showing that the church attendance appears to reduce the likelihood of tobacco use to the same degree among all participants, regardless of their level of exposure to traumatic stress. Further, the highest rates of tobacco use in our sample were found among participants with probable PTSD, but not those with trauma exposure in the absence of PTSD. Although previous studies have found that trauma exposure alone confers risk for tobacco use (Crane et al., 2013; Crane et al., 2014; Ford et al., 2011; Taha et al., 2014), PTSD is more likely to serve a causal role in heavy tobacco use and nicotine dependence (Breslau, Davis, & Schultz, 2003; Pericot-Valverde et al., 2018). PTSD is characterized by more negative emotional states and psychological risk factors (i.e., Anxiety Sensitivity) than trauma exposure alone, which may motivate tobacco use for coping motives (Mathew, Cook, Japuntich, & Leventhal, 2015).

Tobacco use was high overall (37.2%), and reached 60.3% among non-weekly church attenders. This strikingly high rate likely reflects the elevated health risk behaviors among those who are disadvantaged and have a lower educational attainment – a segment of the population that is underrepresented in standard large-scale surveys (Rolle, Beasley, Kennedy, Rock, & Neff, 2016). Tobacco use among African Americans differs from that of whites in important ways: African Americans initiate tobacco use at older ages (Nelson 2008), are more likely to use tobacco on an occasional or non-daily basis (Trinidad et al., 2009), use a greater variety of tobacco products (Kennedy, Caraballo, Rolle, & Rock, 2016), and have lower rates of cessation (Holford, Levy, & Meza, 2016; Kulak, Cornelius, Fong, & Giovino, 2016). African Americans also face a disproportionate burden of tobacco-related disease (Fairley et al., 2010; CDC, 2013; ACS, 2016). Our findings underscore the need for evidence-based, culturally informed, and patient-oriented interventions for African American tobacco users to reduce this health disparity (Cox, Okuyemi, Choi, & Ahluwalia, 2011; Liu et al., 2013; Sheffer, Hooper, & Ostroff, 2018).

Given that current results were drawn from a cross-sectional survey, our findings are hypothesis-generating in nature. Further longitudinal research is needed to examine changes in PTSD symptoms and tobacco use over time as a function of church attendance status. If our findings are confirmed, it would suggest that weekly church attendance exerts a buffering effect against the impact of traumatic stress on mental health and health risk behavior. More research is also needed regarding which specific elements of church attendance may protect against PTSD and tobacco use. Potential mechanisms include the provision of public health information and medical services (Corbie-Smith et al., 2010), opportunities for social support and social integration (Chatters, Taylor, Woodward, & Nicklett, 2015), and doctrinal teachings that may promote the avoidance of unhealthy behaviors to prevent harm to self and others (Bowie et al., 2017).

The current study was strengthened by use of targeted, community-based methods to reach participants which are able to capture higher risk subpopulations that are unrepresented in traditional survey-based research (Shah et al., 2014). In addition to the cross-sectional design of the current study, we were limited by a single-item measure of tobacco use, which precluded analyses of differences by product use (i.e., cigarettes versus other tobacco products), heaviness of use, or nicotine dependence. Further, data for the current study was drawn from a larger health screening study which was conducted within a church setting. Thus, all respondents had some degree of connection to the church, regardless of their current church attendance, for example via job training programs or food pantries. Our results may not generalize to individuals without any church involvement. Lastly, we cannot rule out the possibility of a self-selection effect (i.e., that individuals with PTSD may have chosen to reduce or discontinue their church attendance as a function of their mental health condition) or social desirability (i.e., that church members may underreport mental health symptoms). Although there is growing awareness and acceptance of mental health concerns within the African American community, stigma remains around mental health conditions, and not all churches may be welcoming environments for individuals with PTSD.

In summary, we found weekly church attendance was associated with strikingly reduced likelihood of two negative health outcomes linked to trauma exposure – PTSD and tobacco use – supporting its role as a potential buffer of trauma-related stress. Our findings add to a growing body of literature supporting the positive health effects associated with church attendance, and highlight the potential role of African American churches in health promotion efforts within under-resourced urban communities.

Figure 1.

Figure 1.

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Dependent variables by trauma exposure/ PTSD and church attendance status

Footnotes

Conflict-of-Interest Statement

Authors disclose no conflicts of interest.

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