Associations of Adverse Childhood Experiences with Patterns of Tobacco and Alcohol Use among Middle-Aged and Older Adults in China: A Population-Based Study

Background Adverse childhood experiences (ACEs) have been associated with tobacco and alcohol use, yet little is known about their associations with combined patterns of use in later life. Drawing on a life-course perspective, this study investigated how threat- and deprivation-related ACEs were associated with tobacco and alcohol use patterns among middle-aged and older adults in China. Methods This population-based cross-sectional study included 13,926 adults aged ≥ 45 years from the China Health and Retirement Longitudinal Study. ACEs were grouped into threat-related ACEs (physical abuse, household substance abuse, domestic violence, unsafe neighborhood, and bullying) and deprivation-related ACEs (emotional neglect, household mental illness, incarcerated household member, parental separation or divorce, and parental death). Exposure to each dimension was categorized as 0 or ≥ 1 ACE. Latent class analysis identified tobacco and alcohol use patterns based on current smoking and drinking status, age at initiation (< 18 vs. ≥18 years), the Heaviness of Smoking Index (≤ 2 vs. >2), and heavy alcohol use (≥ 14 units/week for men; ≥7 for women). Multinomial logistic regression estimated adjusted relative risk ratios (aRRR) and 95% confidence intervals (CIs). Results Five tobacco and alcohol use patterns were identified: non-use (53.15%), adult-onset smoking only (12.49%), adult-onset drinking only (8.58%), adult-onset higher-risk co-use (17.29%), and early-onset higher-risk co-use (8.49%). Relative to the non-use pattern, neither ACE dimension was significantly associated with the smoking-only or drinking-only patterns. Threat-related ACEs were associated with both adult-onset higher-risk co-use (aRRR 1.27, 95% CI 1.05 to 1.53) and early-onset higher-risk co-use (aRRR 1.35, 95% CI 1.08 to 1.70). Deprivation-related ACEs were associated with early-onset higher-risk co-use (aRRR 1.27, 95% CI 1.04 to 1.55) but not with adult-onset higher-risk co-use. Conclusions ACEs were associated with higher-risk tobacco and alcohol co-use among middle-aged and older adults in China, after adjustment for sociodemographic factors. These findings underscore the importance of a life-course perspective in understanding substance co-use in later life, although longitudinal studies are warranted to clarify the temporal relationships underlying these associations and to inform the development of targeted strategies for substance-use risk reduction in aging populations.