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Letters |

Smoking and Adverse Childhood Experiences—Reply

Robert F. Anda, MD, MS; Janet B. Croft, PhD; Wayne H. Giles, MD, MS; David F. Williamson, MS, PhD; Gary A. Giovino, PhD; Vincent J. Felitti, MD; Dale Nordenberg, MD
JAMA. 2000;283(15):1958-1960. doi:10.1001/jama.283.15.1957.
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In Reply: Dr Reynolds and Ms Frank are concerned that 2 variables had not been taken into consideration in our analysis: low self-esteem and poor quality of parenting. Those indeed are important influences: the first is reflected in a high adverse childhood experience score (depression is related to low self-esteem), and the second is a common cause of high adverse childhoood experience scores. Youth who experience the kinds of adversity assessed by the Adverse Childhood Experience Study are likely be more susceptible to the effects of peer pressure1 or to have peers who smoke; they also may be more susceptible to the influence of tobacco marketing. Childhood abuse is associated with ongoing emotional or mental health problems,2,3 including depression and low self-esteem, both of which influence smoking initiation in adolescence.1 Parental opposition to smoking is also important, but may be more effective in low-stress situations. Moreover, it seems likely that multiple adverse childhood experiences are a good proxy for poor quality of parenting.

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