Research article
Adverse Childhood Experiences and Chronic Obstructive Pulmonary Disease in Adults

https://doi.org/10.1016/j.amepre.2008.02.002Get rights and content

Background

Chronic obstructive pulmonary disease (COPD) is an important cause of morbidity and mortality in the U.S. However, little is known about the influence of childhood stressors on its occurrence.

Methods

Data were from 15,472 adult HMO members enrolled in the Adverse Childhood Experiences (ACE) Study from 1995 to 1997 and eligible for the prospective phase. Eight ACEs were assessed: abuse (emotional, physical, sexual); witnessing domestic violence; growing up with substance-abusing, mentally ill, or criminal household members; and parental separation or divorce. The number of ACEs (ACE Score) was used to examine the relationship of childhood stressors to the risk of COPD. Three methods of case ascertainment were used to define COPD: baseline reports of prevalent COPD, incident hospitalizations with COPD as a discharge diagnosis, and rates of prescription medications to treat COPD during follow-up. Follow-up data were available through 2004.

Results

The ACE Score had a graded relationship to each of three measures of the occurrence of COPD. Compared to people with an ACE Score of 0, those with an ACE Score of ≥5 had 2.6 times the risk of prevalent COPD, 2.0 times the risk of incident hospitalizations, and 1.6 times the rates of prescriptions (p<0.01 for all comparisons). These associations were only modestly reduced by adjustment for smoking. The mean age at hospitalization decreased as the ACE Score increased (p<0.01).

Conclusions

Decades after they occur, adverse childhood experiences increase the risk of COPD. Because this increased risk is only partially mediated by cigarette smoking, other mechanisms by which ACEs may contribute to the occurrence of COPD merit consideration.

Introduction

Chronic obstructive pulmonary disease (COPD) is a heterogeneous group of disorders classified into three subtypes: asthmatic, bronchitic, and emphysematous. In 2000, an estimated 10 million U.S. adults reported physician-diagnosed COPD, of whom approximately 726,000 were hospitalized.1 While smoking is the primary risk factor for COPD,2 multiple factors other than smoking play a role in COPD development and progression,3, 4, 5, 6 including nutrition7 and childhood exposures to respiratory infection.8 Pathways involved in the pathogenesis of COPD include reduced lung growth during childhood through young adulthood, a premature decline in lung function when it should be stable in young adulthood, and accelerated decline in lung function after age 35.9 Improved understanding of childhood influences on the natural history of lung function may lead to interventions to prevent or slow the irreversible loss of lung function during adulthood.10, 11

Asthma was originally called asthma nervosa,12 yet evidence remains scant for a causal link between traumatic stress during childhood and lung disease in adults.13 Using retrospective cohort data from the first half of the Adverse Childhood Experiences (ACE) Study, this paper reported graded relationships between the number of categories of ACEs (ACE Score) and early smoking initiation (by age 14),14 the prevalence of smoking in adults,14 and the prevalence of self-reported chronic bronchitis or emphysema.15 The relationship of the ACE Score to health-related outcomes theoretically parallels the total exposure of the developing central nervous system and other organ systems to the activated stress response16; biologic plausibility for this thesis is reinforced by data demonstrating a relationship of childhood abuse to differences in brain structure and function, hypothalamic–pituitary–adrenal (HPA) axis physiology, and autonomic nervous system function.17, 18

This paper assesses the relationship of the ACE Score to the occurrence of COPD using prevalence and prospective data from the ACE Study cohort.19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35 Three methods of case ascertainment were used: (1) prevalent COPD based on patient histories at baseline; (2) incident hospitalizations from ICD-9–coded hospital discharge records that listed chronic bronchitis, emphysema, or asthma as a discharge diagnosis; and (3) use of prescription medications for the treatment of COPD during follow-up.

Section snippets

Study Population

The ACE Study has been described in detail elsewhere.14, 29 Members of the Kaiser Foundation Health Plan in San Diego CA who attended its Health Appraisal Clinic (HAC) were invited to participate. At the HAC they completed a standardized evaluation that included an assessment of health history and health-related behaviors, a clinical review of systems, and psychosocial evaluations.14, 15, 29 The ACE Study was approved by the IRB of Kaiser Permanente.

Each member who attended the HAC from August

Characteristics of Study Population

The study population included 8355 women (54%) and 7117 men (46%). The mean age (SD) was 56 (15) years. Seventy-six percent of participants were white, 12% Hispanic, 4% black, 7% Asian, <1% Native American, and 2% other. Forty percent were college graduates, 36% had some college education, and 17% were high school graduates; only 7% had not graduated from high school. Half (51%) of the participants were never smokers, 8% were current smokers, and 41% were former smokers. The prevalence of

Discussion

This study is the first to exploring the relationship of the ACE Score to a disease outcome (e.g., COPD) using data from the prospective phase of the ACE Study. The risk of self-reported prevalent disease, and, in the prospective data, of incident hospitalizations and the rates of prescriptions to treat COPD increased in a consistently graded fashion as the ACE Score increased. Notably, the strength of the relationships between the ACE Score and each of these measures of the occurrence of COPD

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