Divergent Pathways from Adverse Childhood Experiences to Substance Use: Mental Health As a Differential Mechanism across Smoking and Vaping

Background: Adverse childhood experiences (ACEs) have long been associated with predicting behavioral health outcomes, yet less is known about whether their effects operate similarly across different substance use behaviors. This study examined mental health as a potential mechanism linking ACE exposure to smoking, and vaping in a national sample.

Methods: Data were drawn from the 2024 Behavioral Risk Factor Surveillance System (BRFSS). ACE exposure was measured using 13 items and categorized into four groups (0, 1–4, 5–7, and ≥8 ACEs). Frequent poor mental health, defined as ≥14 days of poor mental health in the past 30 days, was examined as a mediator. Outcomes included current smoking and current vaping. Survey-weighted logistic regression models were used to account for the complex sampling design and to adjust for sociodemographic covariates (age, sex, race/ethnicity, and education).

Results: All survey-weighted logistic regression models were statistically significant overall (all p < .001). In the model predicting frequent poor mental health, compared with respondents reporting no ACEs, those with 5–7 ACEs had higher odds (OR = 1.45, 95% CI [1.22, 1.73], p < .001), as did those with ≥8 ACEs (OR = 2.13, 95% CI [1.69, 2.69], p < .001).

In the smoking model, respondents with 5–7 ACEs (OR = 1.39, p = .020) and ≥8 ACEs (OR = 1.41, p = .014) had higher odds of current smoking compared with those reporting no ACEs. Frequent poor mental health was also associated with higher odds of current smoking (OR = 1.83, p < .001). While in the vaping model, respondents with ≥8 ACEs had odds of current vaping compared with those reporting no ACEs (OR = 0.69, p = .002). Frequent poor mental health was also associated with odds of vaping (OR = 0.78, p < .001).

Conclusion and Implication: Findings suggest that trauma-related pathways are not uniform across substance use behaviors. Mental health may help explain the relationship between ACEs and smoking and vaping. These results emphasize the need for trauma-informed interventions that recognize heterogeneous behavioral responses to adversity.