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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