Abstract
Introduction
Previous research has examined cigarette smoking in trauma exposed populations. However, the relationships between trauma exposure and use of other tobacco products (eg, cigars, e-cigarettes) and specific trauma exposure characteristics that may be associated with tobacco use are understudied.
Aims and Methods
Using the 2012–2013 National Epidemiologic Survey on Alcohol and Related Conditions-III (N = 36 151 adults), we conducted weighted bivariate analyses of tobacco use among participants with no trauma exposure, trauma exposure, and trauma exposure with post-traumatic stress disorder (trauma + PTSD), stratified by tobacco product use. We also performed weighted logistic regressions testing relationships between trauma exposure and tobacco use, controlling for behavioral health (BH) conditions (mood, anxiety, substance use, personality disorders) and sociodemographics.
Results
Approximately 44% of participants had experienced trauma; 6% experienced trauma + PTSD. Trauma exposed participants had a higher prevalence of tobacco use (30%––46% vs. 22%) and poly-tobacco use (34%––35% vs. 28%) than unexposed participants. Cigarettes were the most used tobacco product; trauma + PTSD (19%), and trauma (15%) participants had a higher prevalence of e-cigarette use than unexposed participants (11%). Trauma exposure was associated with current tobacco use (AOR = 1.36 trauma + PTSD; 1.23 trauma) (but not former use), particularly among participants exposed to violence/abuse (AOR = 1.23). Personality and substance use disorders were strongly associated with current and former tobacco use.
Conclusions
Trauma exposure, PTSD, and experiences of violence/abuse are associated with current tobacco use. BH conditions may also play a role in current and former tobacco use. Recognizing and addressing trauma exposure and BH conditions among tobacco users may improve cessation rates in these populations.
Implications
This study contributes to research on tobacco use disparities in behavioral health populations by providing a comprehensive examination of tobacco use in trauma exposed individuals. Prior research has examined cigarette smoking, but not other tobacco product use in these populations. This study presents findings on multiple tobacco use behaviors (tobacco product, poly-tobacco use, cessation attempts) in trauma exposed populations and characteristics of trauma exposure (severity, type of traumatic event) associated with tobacco use. These findings underscore the importance of further examining the implications of trauma exposure for tobacco use and of screening and addressing trauma in cessation treatment.
Introduction
Behavioral health populations (BH), which include people living with psychological distress, mental health conditions (MH), and substance use disorders (SUD),1 have an elevated prevalence of tobacco use. For example, in 2017, cigarette smoking prevalence was an estimated 33.3% in MH populations and 25%–44% in SUD populations, compared to 14% in the general U.S. population.2–4 Exposure to trauma—experiencing or witnessing a life-threatening event, serious injury or illness, or sexual violence—can have serious, detrimental effects on BH.5–7 Trauma exposure is common in the United States, with approximately 83% of adults reporting trauma exposure during their lifetime.8 Post-traumatic stress disorder (PTSD), a BH condition characterized by prolonged re-experiencing of a traumatic event, avoidance of reminders of the event, negative affect, and hyperarousal, represents a severe response to trauma.5 Approximately 1%–7% of trauma exposed individuals develop PTSD,9,10 and the prevalence of both trauma exposure and PTSD are elevated in women and other marginalized sociocultural groups.11 For example, one study found that women are more than twice as likely as men to experience PTSD.11
Cigarette smoking prevalence among people with PTSD is twice that of the general population,12,13 and people with PTSD have lower smoking cessation rates than the general population.14–17 Some evidence suggests that trauma exposure alone (without PTSD) is associated with cigarette smoking, but findings have been mixed.18,19 Trauma exposure often co-occurs with other BH conditions (eg, depression, SUD), which are associated with tobacco use.6,7,20,21
Having a BH condition is also associated with the use of other (non-cigarette) tobacco products, including e-cigarettes, cigars, and pipes.21–23 There is also growing concern about poly-tobacco use, because using multiple tobacco products may have compounding negative health effects.24,25 However, few studies have examined other tobacco product use in people with PTSD,26 and, to date, none have examined this in trauma exposed individuals without PTSD, who represent the majority of trauma exposed populations.9,26 This is potentially problematic as trauma exposed and PTSD populations may differ in their tobacco use behaviors. PTSD, a diagnosable BH condition, represents a severe psychological response to trauma exposure and is strongly associated with tobacco use,5 but it is unclear as to whether those with trauma exposure absent PTSD have similar tobacco use patterns to the general population or mirror the patterns of PTSD populations.
Although tobacco use behaviors may differ between trauma exposed individuals who develop PTSD and those who do not, there has yet to be a comprehensive examination of tobacco use in both populations.27,28 Research on specific characteristics of trauma exposure that may influence tobacco use is also lacking. Additionally, despite trauma exposure being common in the United States,8 studies of trauma exposure and tobacco use have seldom been conducted using U.S.-based, nationally representative surveys.27–29
This study aimed to: (1) examine relationships between trauma exposure and current and former tobacco use (cigarettes, other tobacco products) in a nationally representative U.S. sample, (2) examine tobacco use patterns (products used, poly-use, past-year quit attempts, daily vs. non-daily tobacco use), among trauma exposed and unexposed populations, and (3) examine relationships between trauma exposure characteristics (type of trauma, number of traumatic event types experienced) and current and former tobacco use.
This study contributes an in-depth, nuanced examination of trauma exposure and tobacco use by incorporating analyses of trauma exposure severity (trauma exposure vs. PTSD), types of traumatic events, potential implications of a variety of BH conditions, and an exploration of the use of multiple tobacco product types among both trauma exposed and PTSD populations, which has yet to be represented in the literature. This can potentially contribute knowledge about the ways in which trauma exposed populations use a variety of tobacco products, while considering the complexities of trauma characteristics (eg, type of trauma, number of traumatic events) and BH comorbidities to better inform both tobacco cessation and BH treatments. Analyzing tobacco use patterns in trauma exposed individuals with no PTSD (the majority of trauma exposed individuals) along with people with PTSD may help to further elucidate factors contributing to tobacco use disparities.
Methods
Data Source
This study analyzed data from the 2012–2013 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC-III). The U.S.-based, nationally representative NESARC-III used complex multistage probability sampling, incorporating clustering and oversampling of Black/African American, Hispanic/Latino, and Asian/Asian American populations. Participants (N = 36 309; response rate = 60.1%) were civilian, noninstitutionalized adults aged 18 and older. Detailed sampling methodology has been published previously.30
Measures
Data included in these analyses were sociodemographic characteristics (age, sex, race/ethnicity, marital status, family income, and sexual orientation), tobacco use behaviors, trauma exposure, and BH conditions. Participants with incomplete trauma exposure data (N = 158) were omitted from the analyses.
Tobacco Use Status
The NESARC-III dataset included a tobacco use status variable, which classified participants as current, former, or never tobacco users. The tobacco use status variable classified participants as current tobacco users if they reported using one or more of the following five tobacco products in the past 12 months: cigarettes, cigars, pipes, smokeless tobacco (snuff, chewing tobacco), and/or e-cigarettes/e-liquid. Participants were classified as former tobacco users if they had ever used any of the five tobacco products but had not used them in the past 12 months. Participants were classified as never users if they reported never having used any of the five products. Poly-tobacco use (a variable defined by the authors) was defined as the current use of more than one tobacco product. We also examined daily versus non-daily tobacco use among current users. Participants were asked how often they used tobacco, and answer choices ranged from every day to once a month or less. We recoded this into a variable that measured daily (those who reported using tobacco every day) versus non-daily use (those who reported using tobacco less frequently than every day).
Past-year quit attempts were assessed in current users, who were asked if they had, in the past 12 months, “more than once [tried] to stop or cut down on [their] tobacco or nicotine use but found [they] couldn't do it.” Individuals who answered “yes” to this question were determined to have made more than one past-year quit attempt. This question was not asked of former tobacco users, and the frequency of past-year quit attempts was not assessed in this survey.
Trauma Exposure
To assess direct trauma exposure, all participants were asked, “In your entire life, have any of these stressful or traumatic events ever happened to you personally?” and were provided with a list of 20 potential events to assess their experiences (see NESARC-III flashcard 45A).31 To assess indirect trauma exposure, all participants were asked “In your entire life, have you ever personally witnessed any of these traumatic or stressful events happening to a friend, relative, or any other person?” and were provided with the same list of events. Participants were then asked which of the listed events they would “single out as the most stressful and upsetting” to them, and a variable was included in the NESARC-III dataset for most stressful trauma type, which was a mutually exclusive variable that recorded one trauma type for each participant.
Given that 20 traumatic event types were represented in the survey, the authors sought to condense this variable for statistical modeling. Using an adapted classification of traumatic events from the U.S. Department of Veterans Affairs National Center for Posttraumatic Stress Disorder,32 traumatic event types were grouped into six categories: (1) war and combat (four event types in this category), (2) violence and abuse (adulthood) (six event types), (3) disaster, mass violence, and terrorism (two event types), (4) childhood physical/sexual abuse (two event types), (5) other trauma (included serious/life-threatening illness or injury, saw dead body or body parts, kidnapped, refugee, juvenile detention/jail, and other [not specified]), unknown (seven total event types), and (6) indirect trauma (witnessed any of the aforementioned traumatic/stressful events happening to another person). We adapted our categories using the U.S. Department of Veteran's Affairs categorizations, because this provided the opportunity to include all trauma types in a concise manner, while also adapting from categories that are accepted at a federal government level. This categorization was devised under the supervision of one of the authors who is a clinical psychologist. See Supplementary Table 2 for details. A variable was also included in the NESARC-III dataset for the number of traumatic event types experienced (1, 2, 3, or 4 or more types of events).
PTSD diagnosis was an existing variable in the NESARC-III dataset and was assessed through self-reported experiences of Diagnostic and Statistical Manual of Mental Disorders (DSM-V) diagnostic criteria for PTSD.5 These items were asked in reference to the single traumatic event type that participants deemed “most stressful and upsetting.” Responses to these questions were aggregated by the NESARC-III researchers to ascertain whether participants met the DSM-V diagnostic criteria for PTSD. Further details about the existing PTSD variable in the dataset are documented in the NESARC-III data notes, which are publicly available on https://www.niaaa.nih.gov/research/nesarc-iii.
Other BH Conditions
Other BH conditions (which were also existing variables in the NESARC-III dataset) were measured through self-reported experiences of DSM-V BH symptoms, which were aggregated by the NESARC-III researchers to assess whether participants met criteria for diagnosable BH conditions. Individual lifetime diagnoses as described in the NESARC-III Diagnostic Variable Codebook were collapsed by the authors into four separate variables: lifetime mood (major depression, dysthymia, bipolar), anxiety (agoraphobia, social phobia, specific phobia, and generalized anxiety), and personality disorders (borderline, schizotypal, antisocial), which followed the higher-level disorder categories listed in the NESARC-III data notes and diagnostic codebook, as well as substance use (alcohol and/or drug) disorders (defined separately in NESARC-III but collapsed by the authors into a broader substance use disorder variable).
Statistical Analysis
We used survey weighting procedures in STATA 15 to conduct these analyses using the svyset command to accommodate the complex survey design used in the NESARC-III. We utilized the existing weighting variable provided in the dataset for all analyses, which represented a final person-level weight constructed to compensate for the probability of selection and nonresponse, differential response, and poststratification of nonresponse weights. As recommended in the NESARC-III methodology report, we specified the stratum variable included in the dataset and set the variance estimation to Taylor Linearization. We conducted weighted univariate and bivariate analyses of tobacco use status for three trauma exposure groups: no trauma exposure (“no trauma” group), trauma exposure with no PTSD (“trauma” group), and trauma exposure with PTSD (“trauma + PTSD” group). We then conducted stratified bivariate analyses of trauma exposure and tobacco use status by trauma exposure characteristics (type of trauma; number of discrete event types), sociodemographic variables, current tobacco use characteristics (poly-use; past-year quit attempts; type of tobacco product; daily/non-daily use), and BH conditions.
We conducted weighted logistic regressions to test relationships between trauma exposure and two tobacco use variables (current and former use), while controlling for age, sex, race/ethnicity, marital status, income, sexual orientation, trauma characteristics, and individual BH conditions (entered independently from trauma exposure status [ie, do not directly represent comorbidity]). For statistical modeling, former and never tobacco users were collapsed into a “noncurrent tobacco user tobacco user” category to compare with current use. The first logistic regression analysis examined the odds of being a current tobacco user, compared to a noncurrent user, and the second assessed the odds of being a former tobacco user, compared to a current user. Models were constructed iteratively, with the preliminary models containing sociodemographic characteristics and trauma characteristics but not BH conditions. Our final models contained these variables and BH conditions.
Results
NESARC-III Sample
The study sample was comprised of 36 151 participants; most participants were female (51.9%), married or living with someone (57.9%), and heterosexual (95.9%). The sample was 66.2% White, 14.7% Hispanic/Latino, and 11.8% Black/African American. Supplementary Table 1 contains further information about the study sample.
Trauma Exposure
Half of participants (50.4%) had never experienced trauma, 43.9% had experienced trauma but did not develop PTSD, and 5.7% experienced trauma and developed PTSD (see Table 1). Many trauma exposed participants had experienced four or more traumatic event types (36.0% of trauma vs. 60.9% of trauma + PTSD; p < .001). Indirect trauma was the most prevalent event type in the trauma group (30.5%; p < .001 vs. other trauma types), while childhood physical/sexual abuse was the most prevalent in the trauma + PTSD group (28.0%; p < .001 vs. other trauma types) (Supplementary Figure 1).
Table 1.
Sample Characteristics of NESARC-III Study Sample by Trauma Exposure and Tobacco Use Status (N = 36 151)
| No Trauma (N = 18 646; 50.4% of sample) | Trauma (N = 15 324; 43.9% of sample) | Trauma + PTSD (N = 2181; 5.7% of sample) | ||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Current | Former | Never | Current | Former | Never | Current | Former | Never | ||||||||||
| N | %a | N | %a | N | %a | N | %a | N | %a | N | %a | N | %a | N | %a | N | %a | |
| Total | 4197 | 22.3*** | 2512 | 15.6*** | 11937 | 62.1*** | 4807 | 30.4*** | 3024 | 22.3*** | 7493 | 47.4*** | 990 | 45.6*** | 362 | 17.8*** | 829 | 36.6*** |
| Age | ||||||||||||||||||
| <30 | 1146 | 29.0*** | 153 | 5.3*** | 3519 | 29.5*** | 1045 | 21.5*** | 124 | 3.6*** | 1621 | 20.2*** | 258 | 27.2*** | 22 | 6.3*** | 201 | 26.9*** |
| 30––39 | 914 | 20.7*** | 288 | 9.9*** | 2392 | 17.6*** | 1032 | 19.8*** | 308 | 9.4*** | 1465 | 16.8*** | 225 | 22.0*** | 45 | 10.3*** | 202 | 19.1*** |
| 40––49 | 758 | 17.1*** | 340 | 13.9*** | 2125 | 17.5*** | 958 | 21.1*** | 422 | 13.9*** | 1413 | 19.7*** | 247 | 24.3*** | 70 | 19.0*** | 179 | 22.9*** |
| 50––59 | 754 | 17.6*** | 480 | 19.1*** | 1628 | 14.6*** | 1083 | 23.0*** | 639 | 21.1*** | 1355 | 19.4*** | 170 | 17.6*** | 97 | 28.9*** | 139 | 16.8*** |
| 60+ | 625 | 15.7*** | 1251 | 51.8*** | 2273 | 20.7*** | 689 | 14.7*** | 1531 | 51.9*** | 1639 | 24.0*** | 90 | 8.9*** | 128 | 35.7*** | 108 | 14.3*** |
| Sex | ||||||||||||||||||
| Male | 2398 | 60.7*** | 1289 | 53.6*** | 4314 | 40.7*** | 2735 | 61.2*** | 1562 | 56.4*** | 2886 | 42.7*** | 326 | 35.7*** | 107 | 32.0*** | 180 | 23.7*** |
| Female | 1799 | 39.3*** | 1223 | 46.4*** | 7623 | 59.3*** | 2072 | 38.8*** | 1462 | 43.6*** | 4607 | 57.3*** | 664 | 64.3*** | 255 | 68.0*** | 649 | 76.4*** |
| Race/ethnicity | ||||||||||||||||||
| White | 2281 | 68.1*** | 1669 | 78.0*** | 4869 | 54.6*** | 3001 | 75.2*** | 2264 | 83.2*** | 3797 | 63.7*** | 611 | 72.5*** | 236 | 74.8*** | 380 | 59.5*** |
| Black/African American | 1019 | 12.9*** | 353 | 7.2*** | 2876 | 13.9*** | 992 | 10.9*** | 331 | 5.8*** | 1715 | 13.0*** | 199 | 11.8*** | 48 | 7.3*** | 198 | 14.3*** |
| American Indian/Alaska Native | 59 | 1.5*** | 20 | 0.8*** | 95 | 0.9*** | 100 | 2.4*** | 40 | 1.5*** | 119 | 1.7*** | 33 | 4.1*** | 17 | 6.7*** | 27 | 3.7*** |
| Asian/Native Hawaiian/Pacific Islander | 171 | 4.7*** | 97 | 3.6*** | 884 | 9.0*** | 108 | 2.5*** | 57 | 1.9*** | 442 | 7.1*** | 11 | 1.2*** | 4 | 1.0*** | 23 | 3.9*** |
| Hispanic/Latino | 667 | 12.9*** | 373 | 10.5*** | 3213 | 21.6*** | 606 | 9.0*** | 332 | 7.7*** | 1420 | 14.4*** | 136 | 10.5*** | 57 | 10.2*** | 201 | 18.6*** |
| Marital status | ||||||||||||||||||
| Married/living w/someone | 1688 | 50.6*** | 1397 | 69.7*** | 5633 | 57.1*** | 1930 | 51.8*** | 1655 | 69.3*** | 3593 | 59.6*** | 343 | 43.7*** | 159 | 56.2*** | 329 | 49.5*** |
| Widowed/divorced/separated | 1066 | 20.0*** | 796 | 21.8*** | 2368 | 14.5*** | 1475 | 24.7*** | 1051 | 24.1*** | 1888 | 18.9*** | 345 | 29.6*** | 157 | 33.9*** | 235 | 22.4*** |
| Never married | 1443 | 29.3*** | 319 | 8.5*** | 3936 | 28.5*** | 1402 | 23.6*** | 318 | 6.6*** | 2012 | 21.4*** | 302 | 26.7*** | 46 | 10.0*** | 265 | 28.2*** |
| Family income | ||||||||||||||||||
| <$20 000 | 1494 | 28.7*** | 581 | 16.0*** | 3373 | 22.2*** | 1698 | 29.0*** | 670 | 16.1*** | 1867 | 19.0*** | 481 | 42.2*** | 123 | 25.9*** | 292 | 28.1*** |
| $20 000––$39 999 | 966 | 21.7*** | 501 | 17.9*** | 2657 | 18.9*** | 1137 | 21.5*** | 580 | 16.9*** | 1520 | 16.7*** | 208 | 22.7*** | 65 | 15.0*** | 185 | 20.4*** |
| $40 000––$79 999 | 1226 | 31.5*** | 846 | 34.8*** | 3610 | 31.5*** | 1375 | 31.3*** | 1071 | 37.7*** | 2414 | 33.0*** | 243 | 26.2*** | 110 | 34.6*** | 242 | 32.1*** |
| >$80 000 | 511 | 18.0*** | 584 | 31.3*** | 2297 | 27.4*** | 597 | 18.2*** | 703 | 29.4*** | 1692 | 31.3*** | 58 | 9.0*** | 64 | 24.6*** | 110 | 19.5*** |
| Sexual orientation | ||||||||||||||||||
| Heterosexual | 3960 | 94.6*** | 2435 | 97.4*** | 11508 | 96.6*** | 4514 | 94.8*** | 2916 | 96.9*** | 7186 | 96.5*** | 875 | 90.1 | 339 | 94.2 | 761 | 91.9 |
| Gay/lesbian | 77 | 1.8*** | 31 | 1.0*** | 130 | 1.0*** | 114 | 2.1*** | 58 | 1.7*** | 113 | 1.3*** | 27 | 2.0 | 9 | 3.1 | 24 | 2.6 |
| Bisexual | 73 | 1.6*** | 10 | 0.3*** | 107 | 0.8*** | 134 | 2.3*** | 30 | 0.9*** | 102 | 1.2*** | 65 | 5.9 | 9 | 1.7 | 33 | 4.3 |
| Not sure/missing | 87 | 2.1*** | 36 | 1.3*** | 192 | 1.6*** | 45 | 0.8*** | 20 | 0.6*** | 92 | 1.0*** | 23 | 1.9 | 5 | 1.0 | 11 | 1.2 |
| Current tobacco users | ||||||||||||||||||
| Type of product used | ||||||||||||||||||
| Cigarette | 3696 | 86.2*** | –– | –– | –– | –– | 4226 | 85.8*** | –– | –– | –– | –– | 920 | 92.0*** | –– | –– | –– | –– |
| Cigar | 459 | 11.8*** | –– | –– | –– | –– | 633 | 14.7*** | –– | –– | –– | –– | 117 | 12.2*** | –– | –– | –– | –– |
| Pipe | 70 | 1.7*** | –– | –– | –– | –– | 118 | 2.6*** | –– | –– | –– | –– | 24 | 3.1*** | –– | –– | –– | –– |
| Snuff/chewing tobacco | 423 | 12.7*** | –– | –– | –– | –– | 513 | 13.4*** | –– | –– | –– | –– | 69 | 9.4*** | –– | –– | –– | –– |
| E-cigarette | 416 | 11.2*** | –– | –– | –– | –– | 650 | 15.3*** | –– | –– | –– | –– | 168 | 18.8*** | –– | –– | –– | –– |
| Daily vs. non-daily use | ||||||||||||||||||
| Daily tobacco use | 3147 | 73.7*** | –– | –– | –– | –– | 3741 | 78.9*** | –– | –– | –– | –– | 812 | 82.8*** | –– | –– | –– | –– |
| Non-daily tobacco use | 1050 | 26.26*** | –– | –– | –– | –– | 1066 | 21.1*** | –– | –– | –– | –– | 178 | 17.2*** | –– | –– | –– | –– |
| Poly-tobacco user | 1029 | 28.2*** | –– | –– | –– | –– | 1417 | 33.7*** | –– | –– | –– | –– | 300 | 34.8*** | –– | –– | –– | –– |
| Current quit attempts | 1637 | 38.3*** | –– | –– | –– | –– | 1978 | 41.4*** | –– | – | – | – | 540 | 53.8*** | – | – | – | – |
aWeighted percentage.
***p < .001; **p < .01; *p < .05.
Trauma Exposure and Tobacco Use
The prevalence of current tobacco use in the trauma group (30.4%) was higher than the no trauma group (22.3%), but lower than the trauma + PTSD group (45.6%; p < .001). The no trauma group also had the highest prevalence of never use (62.1% vs. 47.4% trauma, 36.6% trauma + PTSD; p < .001). The trauma group had the highest prevalence of former tobacco use (22.3% vs. 15.6% no trauma, 17.8% trauma + PTSD; p < .001) (see Table 1).
BH Conditions, Trauma Exposure, and Tobacco Use Status
Other BH conditions were common among trauma exposed participants, and the trauma + PTSD group had an extremely high prevalence of other BH comorbidities (92.1%) (Supplementary Figure 2). Across tobacco use groups, the prevalence of any other BH condition (not including PTSD) was highest among current tobacco users (55.3% no trauma, 75.1% trauma, 96.0% trauma + PTSD; all p < .001 vs. other tobacco use groups). The most common BH condition across current users in all trauma exposure groups was SUD (43.4% of no trauma tobacco users with BH conditions; 58.3% of trauma, 75.2% of trauma + PTSD) (Table 2).
Table 2.
Trauma Exposure Characteristics and BH Comorbidities by Tobacco Use Status
| No Trauma | Trauma | Trauma + PTSD | ||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Current | Former | Never | Current | Former | Never | Current | Former | Never | ||||||||||
| N | %a | N | %a | N | %a | N | %a | N | %a | N | %a | N | %a | N | %a | N | %a | |
| Type of traumatic event | ||||||||||||||||||
| War/combat | – | – | – | – | – | – | 122 | 2.5*** | 110 | 4.2*** | 179 | 2.4*** | 25 | 3.4 | 18 | 5.3 | 32 | 4.6 |
| Violence/abuse | – | – | – | – | – | – | 746 | 14.0*** | 400 | 11.2*** | 1089 | 12.5*** | 219 | 19.7 | 75 | 16.9 | 184 | 21.2 |
| Disaster/mass violence/terrorism | – | – | – | – | – | – | 236 | 5.1*** | 160 | 5.1*** | 554 | 7.7*** | 13 | 1.8 | 4 | 1.6 | 17 | 1.7 |
| Childhood physical/sexual abuse | – | – | – | – | – | – | 513 | 10.3*** | 261 | 7.9*** | 703 | 8.8*** | 293 | 29.4 | 93 | 24.1 | 234 | 28.1 |
| Other trauma | – | – | – | – | – | – | 1827 | 38.8*** | 1218 | 41.7*** | 2694 | 36.9*** | 259 | 26.6 | 84 | 23.0 | 223 | 27.1 |
| Indirect trauma | – | – | – | – | – | – | 1363 | 29.2*** | 875 | 30.0*** | 2274 | 31.6*** | 181 | 19.2 | 88 | 29.1 | 139 | 17.3 |
| # of traumatic event types | ||||||||||||||||||
| One | – | – | – | – | – | – | 1091 | 21.5*** | 692 | 23.0*** | 2203 | 27.6*** | 89 | 8.5** | 31 | 8.2** | 109 | 12.1** |
| Two | – | – | – | – | – | – | 934 | 19.5*** | 701 | 23.2*** | 1811 | 24.1*** | 117 | 12.9** | 43 | 13.1** | 126 | 15.2** |
| Three | – | – | – | – | – | – | 783 | 16.3*** | 512 | 17.9*** | 1172 | 16.5*** | 137 | 12.7** | 60 | 14.9** | 153 | 19.5** |
| Four or more | – | – | – | – | – | – | 1999 | 42.7*** | 1119 | 35.9*** | 2307 | 31.7*** | 647 | 65.9** | 228 | 63.8** | 441 | 53.2** |
| Lifetime BH conditions | ||||||||||||||||||
| Any BH condition | 2233 | 55.3*** | 1080 | 44.4*** | 3451 | 30.4*** | 3548 | 75.1*** | 1794 | 58.6*** | 1794 | 48.7*** | 946 | 96.0*** | 324 | 88.5*** | 738 | 88.9*** |
| Mood disorder | 738 | 17.8*** | 426 | 17.1*** | 1488 | 12.9*** | 1517 | 31.9*** | 777 | 24.1*** | 1838 | 24.2*** | 671 | 69.6* | 215 | 59.5* | 547 | 66.8* |
| Anxiety disorder | 505 | 12.9*** | 294 | 12.3*** | 1018 | 9.0*** | 1041 | 22.2*** | 626 | 20.1*** | 1207 | 16.4*** | 602 | 62.9* | 193 | 53.7* | 432 | 51.7* |
| Personality disorder | 492 | 11.7*** | 161 | 6.4*** | 626 | 5.0*** | 1438 | 30.0*** | 557 | 17.1*** | 1051 | 12.7*** | 722 | 73.1*** | 193 | 48.1*** | 444 | 51.5*** |
| Substance use disorder | 1733 | 43.4*** | 659 | 27.4*** | 1672 | 15.4*** | 2709 | 58.3*** | 1125 | 37.9*** | 1677 | 23.1*** | 736 | 75.2*** | 216 | 58.6*** | 331 | 38.1*** |
aWeighted percentage.
***p < .001; **p < .01; *p < .05.
Current Tobacco Users
Current tobacco users in the no trauma and trauma groups were predominantly male (60.7% no trauma; 61.2% trauma) and had a $40 000––$79 999 income (31.5% no trauma; 31.3% trauma). In contrast, current users in the trauma + PTSD group were predominantly female (64.3%) and had a <$20 000 income (42.2%). See Table 1 for further details.
Most current tobacco users across trauma exposure groups reported smoking cigarettes (86.2% of no trauma current users, 85.8% of trauma, and 92.0% of trauma + PTSD); e-cigarettes were the second most commonly used product among trauma exposed participants (15.3% of trauma, 18.8% of trauma + PTSD; p < .001 vs. no trauma); cigars were the second most used product in the no trauma group (11.8% of no trauma p < .001 vs. other trauma groups). Poly-tobacco use was common across all groups but higher in the trauma groups (28.2% no trauma, 33.7% trauma, 34.8% trauma + PTSD p < .001). Trauma + PTSD current users also had the highest prevalence of daily tobacco use (82.8% vs. 73.7% no trauma, 78.9% trauma; p < .001). Trauma + PTSD current users had the highest prevalence of having made more than one past-year quit attempt (53.8% of trauma + PTSD vs. 41.4% trauma, 38.3% no trauma; p < .001) (see Table 1).
Regression Analyses
In the preliminary regression model testing relationships between trauma exposure and current (vs. noncurrent) tobacco use (excluding BH conditions), both trauma and trauma + PTSD were associated with current use (AOR = 1.28 trauma, AOR = 1.95 trauma + PTSD; p < .001 vs. no trauma) (data not shown). After accounting for BH conditions in the full model, the relationships between trauma exposure and trauma + PTSD and current use remained significant but were attenuated (AOR = 1.23 trauma [p < .001], AOR = 1.36 trauma + PTSD [p = .001]). Experiencing (adulthood) violence/abuse (AOR = 1.23; p = .002) and experiencing four or more traumatic event types (AOR = 1.17; p = .002) were associated with current use. Personality disorder (AOR = 1.52; p < .0001) and SUD (AOR = 2.66; p < .001) were associated with current use (Table 3). Sociodemographic characteristics associated with current use were bisexual identity (AOR = 1.37; p = .02 vs. heterosexual), being 30–39 years old (AOR = 1.15; p = .02 vs. <30 years), and being divorced/separated/widowed (AOR = 1.38; p < .001 vs. married/living with someone).
Table 3.
Logistic Regression Analysis of Current Tobacco Use
| OR | 95% CI | |
|---|---|---|
| CURRENT TOBACCO USER | ||
| Trauma exposure status | ||
| No trauma | REF | |
| Trauma no PTSD | 1.23*** | 1.10–1.36 |
| Trauma + PTSD | 1.36** | 1.14–1.62 |
| Trauma type | ||
| Indirect trauma | REF | |
| War/combat | 1.00 | 0.78–1.27 |
| Violence/abuse | 1.23** | 1.07–1.41 |
| Disaster/mass violence/terrorism | 0.93 | 0.77–1.14 |
| Childhood physical/sexual abuse | 1.14 | 0.98–1.33 |
| Other | 1.08 | 0.99–1.19 |
| Number of traumatic event types | ||
| One event | REF | |
| Two events | 0.94 | 0.85–1.04 |
| Three events | 0.99 | 0.86–1.14 |
| Four of more events | 1.17** | 1.06–1.30 |
| Age | ||
| <30 | REF | |
| 30–39 | 1.15* | 1.02–1.30 |
| 40–49 | 1.02 | 0.88–1.18 |
| 50–59 | 0.96 | 0.85–1.08 |
| 60+ | 0.40*** | 0.35–0.45 |
| Sex | ||
| Male | REF | |
| Female | 0.55*** | 0.51–0.59 |
| Race/ethnicity | ||
| White, non-Hispanic | REF | |
| Black, non-Hispanic | 0.77*** | 0.70–0.86 |
| Alaskan Native, American Indian, non-Hispanic | 0.89 | 0.69–1.15 |
| Asian, Hawaiian, or Other Pacific Islander, non-Hispanic | 0.50*** | 0.41–0.61 |
| Hispanic, any race | 0.54*** | 0.48–0.60 |
| Marital status | ||
| Married/living with someone | REF | |
| Widowed/divorced/separated | 1.38*** | 1.25–1.53 |
| Never married | 0.92 | 0.84–1.01 |
| Income | ||
| <$20 000 | REF | |
| $20 000––$40 000 | 0.79*** | 0.71–0.89 |
| $40 000––$80 000 | 0.52*** | 0.47–0.58 |
| >$80 000 | 0.32*** | 0.28–0.37 |
| Sexual orientation | ||
| Heterosexual | REF | |
| Gay/lesbian | 1.08 | 0.84–1.40 |
| Bisexual | 1.37* | 1.05–1.77 |
| Not sure or missing | 0.99 | 0.72–1.37 |
| Mood disorder | ||
| No | REF | |
| Yes | 1.04 | 0.95–1.13 |
| Anxiety disorder | ||
| No | REF | |
| Yes | 1.05 | 0.95–1.17 |
| Personality disorder | ||
| No | REF | |
| Yes | 1.52*** | 1.37–1.68 |
| Substance use disorder | ||
| No | REF | |
| Yes | 2.66*** | 2.43–2.91 |
| NONCURRENT TOBACCO USER | REF |
***p < .001; **p < .01; *p < .05.
In the preliminary regression model of former tobacco use (vs. current), (excluding BH conditions), trauma + PTSD (AOR = 0.73, p = .009) and experiencing four or more event types (AOR = 0.83, p = .004) were negatively associated with former use. In the full model, none of the trauma exposure variables were significantly associated with former use. Personality disorder (AOR = 0.79; p = .002) and SUD (AOR = 0.77; p < .001) were negatively associated with former use (see Table 4). Sociodemographic factors that were negatively associated with former use were Black/African American race/ethnicity (AOR = 0.64; p < .001 vs. White), being divorced/separated/widowed (AOR = 0.70; p < .001), or never married (AOR = 0.63; p < .001).
Table 4.
Logistic Regression Analysis of Former Tobacco Use
| OR | 95% CI | |
|---|---|---|
| FORMER TOBACCO USER | ||
| Trauma exposure status | ||
| No trauma | REF | |
| Trauma no PTSD | 0.96 | 0.82–1.12 |
| Trauma + PTSD | 0.86 | 0.68–1.10 |
| Trauma type | ||
| Indirect trauma | REF | |
| War/combat | 1.08 | 0.77–1.52 |
| Violence/abuse | 0.86 | 0.69–1.05 |
| Disaster/mass violence/terrorism | 0.98 | 0.77–1.23 |
| Childhood physical/sexual abuse | 1.08 | 0.85–1.36 |
| Other | 1.03 | 0.90–1.18 |
| Number of traumatic event types | ||
| One event | REF | |
| Two events | 1.05 | 0.91–1.20 |
| Three events | 1.03 | 0.85–1.24 |
| Four of more events | 0.90 | 0.79–1.03 |
| Age | ||
| <30 | REF | |
| 30–39 | 2.10*** | 1.68–2.64 |
| 40–49 | 2.85*** | 2.23–3.64 |
| 50–59 | 4.02*** | 3.22–5.02 |
| 60+ | 15.04*** | 11.96–18.91 |
| Sex | ||
| Male | REF | |
| Female | 1.48*** | 1.31–1.68 |
| Race/ethnicity | ||
| White, non-Hispanic | REF | |
| Black, non-Hispanic | 0.64*** | 0.56–0.74 |
| Alaskan Native, American Indian, non-Hispanic | 0.94 | 0.61–1.47 |
| Asian, Hawaiin, or Other Pacific Islander, non-Hispanic | 0.81 | 0.58–1.14 |
| Hispanic, any race | 1.28** | 1.10–1.50 |
| Marital status | ||
| Married/living with someone | REF | |
| Widowed/divorced/separated | 0.70*** | 0.61–0.80 |
| Never married | 0.63*** | 0.55–0.72 |
| Income | ||
| <$20 000 | REF | |
| $20 000––$40 000 | 1.32** | 1.09–1.60 |
| $40 000––$80 000 | 2.02*** | 1.74–2.35 |
| >$80 000 | 2.94*** | 2.43–3.56 |
| Sexual orientation | ||
| Heterosexual | REF | |
| Gay/lesbian | 1.24 | 0.90–1.72 |
| Bisexual | 0.70 | 0.44–1.12 |
| Not sure or missing | 0.84 | 0.55–1.30 |
| Mood disorder | ||
| No | REF | |
| Yes | 0.88 | 0.77–1.01 |
| Anxiety disorder | ||
| No | REF | |
| Yes | 1.01 | 0.87–1.17 |
| Personality disorder | ||
| No | REF | |
| Yes | 0.79** | 0.68–0.92 |
| Substance use disorder | ||
| No | REF | |
| Yes | 0.77*** | 0.68–0.86 |
| CURRENT TOBACCO USER | REF |
***p < .001; **p < .01; *p < .05.
Discussion
Our study examined tobacco use among trauma exposed adults in a U.S.-based, nationally representative sample and found that participants with trauma exposure and trauma + PTSD were more likely to be current tobacco users than unexposed participants. Moreover, experiencing violence and abuse (adulthood), as well as experiencing four or more traumatic event types, were associated with current tobacco use. Neither trauma exposure, nor trauma + PTSD were associated with former use. Two BH conditions, personality disorder and substance use disorder were strongly associated with current and former tobacco use.
Tobacco Use by Trauma Exposure Status
Tobacco use patterns varied by trauma exposure group. Compared with unexposed participants, trauma exposed participants had a higher prevalence of poly-tobacco use and daily tobacco use (particularly in the trauma + PTSD group), which represents a more severe tobacco use profile.25,33,34 Although most tobacco users used cigarettes, e-cigarette use was common among trauma exposed groups, especially in the trauma + PTSD group. The NESARC-III survey was conducted before the dramatic increase in e-cigarette use in the United States,35,36 suggesting that BH populations were early adopters of e-cigarettes. One study found that people with BH conditions are more likely to use e-cigarettes than people without BH conditions,22 suggesting that specific characteristics of e-cigarettes or product marketing strategies may appeal to BH populations. The elevated prevalence of other tobacco product use and poly-tobacco use in trauma exposed participants emphasizes the need for continued study of tobacco use patterns in these populations.
Trauma Exposure and Current Tobacco Use
Both trauma exposure and trauma + PTSD were associated with current tobacco use. Cigarette smoking in both groups has been studied previously, but findings on the association between trauma exposure alone (absent PTSD) and cigarette smoking have been mixed.19,37 Therefore, this finding expands on existing studies by showing that trauma exposure (absent PTSD) may be a risk factor for tobacco use. Additionally, experiencing violence or abuse was associated with current use. This trauma type was more common in trauma + PTSD participants than trauma (absent PTSD) participants, suggesting that experiences of violence or abuse may be associated with stronger psychological responses and a propensity for tobacco use than other trauma types. No other traumatic event types were associated with current use, and further study on tobacco use by traumatic event type is needed.
Trauma Exposure and Former Tobacco Use
Neither trauma exposure alone, nor trauma + PTSD were associated with former use after controlling for BH conditions. However, current tobacco users with trauma + PTSD were found to have a higher prevalence of making past-year quit attempts than other trauma exposure groups.12,28 Despite this finding, research has demonstrated that people with PTSD have poorer cessation rates than the general population.14–17 The 2020 Surgeon General's report on smoking cessation explains that population-level cessation is driven by the rate of quit attempts and the rate of quitting success among those who try to quit.38 The finding that current tobacco users with trauma + PTSD had the highest prevalence of quit attempts suggests that this population is taking actions to quit, but previous study findings imply that they may be less successful than other populations.12,38
Other BH Conditions, Trauma Exposure, and Tobacco Use
Having SUD was more strongly associated with current and former use than any of the trauma exposure characteristics. This relates to research showing that SUD and tobacco use commonly co-occur3,39 and that SUD may create barriers to tobacco cessation.40 Moreover, it has been well documented that trauma exposure and SUD frequently co-occur,20,21 as was found in this sample. Given that both PTSD and SUD were associated with current tobacco use, comorbid trauma exposure and SUD (which was common in this sample) may be a particularly strong driver of tobacco use.
There was also an association between personality disorder and tobacco use, which may be related to the high comorbidity between PTSD and personality disorder in this sample. The high rates of comorbidity may have been influenced by Borderline Personality Disorder, which is so closely linked in diagnostic characteristics and comorbidity to PTSD that some mental health researchers have recommended that Borderline Personality Disorder be considered a trauma-related disorder or complication of PTSD.41,42 PTSD and Borderline Personality Disorder commonly co-occur, with studies finding that between 24% and 58% of people with either PTSD or Borderline Personality Disorder have comorbid Borderline Personality Disorder/PTSD.43,44 Furthermore, the relationship between personality disorders and tobacco use in this study may have been influenced by a proclivity for substance use in Borderline Personality Disorder populations,45 which has been found to be especially prevalent in those with comorbid Borderline Personality Disorder and PTSD.43 To our knowledge, there have yet to be comprehensive examinations of tobacco use in Borderline Personality Disorder populations. However, given the clinical overlaps and common comorbidity between PTSD and Borderline Personality Disorder, as well as the proclivity for substance use in people with Borderline Personality Disorder, we theorize that the relationship between personality disorders and tobacco use in this sample may have been influenced in part by co-occurring Borderline Personality Disorder and PTSD.
A Trauma-informed Approach to Tobacco Cessation Treatment
A trauma-informed approach to tobacco cessation treatment may help reduce tobacco use in trauma exposed populations. This approach emphasizes understanding tobacco use as a coping response to trauma exposure, promotion of health care consumer agency, and stigma reduction during cessation treatment.46 It is also important that individuals seeking cessation services be screened for trauma exposure and referred to services specific to treating responses to trauma exposure.47 Given that trauma exposure is prevalent in the United States, and is likely to be under-reported, trauma-informed treatment would ideally be provided universally, regardless of self-reported trauma exposure status.47 Additionally, trauma-informed cessation resources may be further enhanced by tailoring resources to sociodemographic characteristics (eg, gender, race/ethnicity, sexual orientation).48 For example, given that we found that women with PTSD had higher rates of smoking than men (despite men in the general population having higher smoking rates4) and research has demonstrated that women are more likely to experience PTSD than men,11 trauma-informed cessation services may consider moving beyond a gender-neutral approach by specifically acknowledging women's unique traumatic experiences and the role of tobacco use in women's efforts to cope with trauma exposure.48 Considering potentially high comorbidity between trauma exposure and other BH conditions, trauma-informed cessation treatment should also include screening for and attending to other BH needs, in order to promote more successful cessation outcomes.
Limitations
This study has several limitations. The NESARC survey is cross-sectional, and therefore, causal relationships between trauma exposure and tobacco use cannot be established. NESARC relies on self-report; trauma exposure, tobacco use, and BH symptoms may have been underreported due to stigma or inability to recall. Additionally, the assessment of trauma exposure did not include multiple exposures to one event. Consequently, we were not able to analyze the relationship between tobacco use and the number of exposures to a single type of event. Moreover, NESARC did not assess gender identity, and therefore non-cisgender populations were not identified. NESARC-III was conducted in 2012–2013, and the results may not reflect more recent tobacco use patterns. Despite these limitations, NESARC-III is one of the few nationally representative U.S. surveys that measures tobacco use, trauma exposure, and BH conditions.
Conclusions
Trauma exposure in this sample was associated with current tobacco use as well as the elevated prevalence of poly-tobacco use and daily tobacco use, which presents a more severe, complex tobacco use profile than was found in unexposed participants. The severity in tobacco use profile was particularly prevalent among tobacco users with trauma + PTSD. Experiences of violence and abuse, as well as experiencing four or more traumatic event types were also associated with current use. Among current tobacco users with trauma + PTSD, the high frequency of quit attempts among current tobacco users suggests that this population is motivated to quit, but evidence has shown that this population faces barriers to cessation. BH conditions frequently co-occurred with trauma exposure in this sample, and SUD and personality disorder were strongly associated with both current and former tobacco use. Recognizing and addressing trauma exposure and the potential role of other comorbid BH conditions may improve cessation rates in these populations, thus contributing to reducing tobacco-related health disparities.
Supplementary Material
A Contributorship Form detailing each author's specific involvement with this content, as well as any supplementary data, are available online at https://academic.oup.com/ntr.
Disclaimer
The opinions expressed by the authors/speakers are their own and this material should not be interpreted as representing the official viewpoint of the U.S. Department of Health and Human Services, the National Institutes of Health or the National Cancer Institute.
Declaration of Interests
None declared.
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