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Substance use among college students represents a significant and growing public health challenge in China (1). Current data indicates cigarette use prevalence ranges from 7.8% to 13% among Chinese college students (2), while electronic cigarette use has shown an upward trend with rates between 3.1% and 5.5% (3-4). Alcohol consumption is particularly prevalent, with 34.2% to 49.3% of students reporting current alcohol use (5). Childhood trauma has emerged as a crucial determinant of substance use behaviors (6), encompassing distinct categories: emotional abuse (verbal assaults and intimidation), physical abuse (acts causing bodily harm), sexual abuse (traumatic sexual experiences causing psychological distress), emotional neglect (inadequate emotional support and nurturing), and physical neglect (insufficient provision of basic necessities). While research in China has extensively documented associations between childhood trauma subtypes and adult substance use (7), investigations focusing on adolescent and young adult populations remain limited. This comprehensive cross-sectional study, encompassing 63 universities in Jilin Province, employed logistic regression analyses to evaluate the impact of various childhood trauma types on substance use patterns while controlling for relevant confounding variables. Our findings demonstrate that participants who experienced severe emotional abuse, sexual abuse, or physical neglect during childhood exhibited significantly elevated risks of substance use. Moreover, we observed a dose-response relationship between cumulative trauma exposure and substance use likelihood, highlighting the critical need for trauma-informed interventions and targeted support strategies for this vulnerable population.
This cross-sectional study employed cluster sampling through an online survey conducted from October 26th to November 18th, 2021, encompassing 63 universities and colleges in Jilin Province, China. Student participants represented various provinces across China. Data collection utilized a Quick Response (QR) code distributed to all participants, with online informed consent obtained prior to questionnaire completion. Study inclusion criteria comprised: 1) age above 15 years; 2) correct responses to at least three of four attention check questions; 3) physiologically plausible height and weight values; 4) absence of logical contradictions, missing answers, or irrelevant responses; and 5) no apparent pattern-based responding. After the screening, 96,151 participants qualified for analysis (male=40,039, 41.64%; mean age=19.59). The study received approval from the Jilin University ethics committee (No: 20210929). Sociodemographic data, including gender, age, residence, per capita disposable income, ethnicity, and educational status, were collected and adjusted as confounders in the logistic model. The Childhood Trauma Questionnaire (CTQ), a 28-item assessment tool, evaluated experiences of emotional abuse, physical abuse, sexual abuse, emotional neglect, and physical neglect. Respondents rated each item on a 5-point Likert scale from “Never True” to “Very often true,” enabling detailed assessment of trauma frequency (8). The CTQ demonstrated good internal consistency with a Cronbach’s alpha of 0.73. Substance use assessment included current smoking status, with follow-up questions distinguishing between e-cigarettes and traditional cigarettes (9-10). Alcohol consumption was categorized binarily as users versus non-users. Statistical analyses were conducted using SAS software (version 9.4, SAS Institute Inc., Cary, NC, USA). Logistic regression analyses calculated adjusted odds ratios (aORs) comparing substance use prevalence between individuals with varying levels and types of abuse experiences versus those without trauma exposure. All childhood trauma subtypes were simultaneously included in the regression model to account for their independent effects.
Table 1 presents the sociodemographic characteristics of the study population. Overall, 13.24% of participants reported using cigarettes and/or electronic cigarettes, while 59.64% reported alcohol consumption. Among substance users, 4.37% reported concurrent use of cigarettes and electronic cigarettes. Table 2 elucidates the differential impact of childhood trauma subtypes on various forms of substance use, including smoking, cigarette use, e-cigarette use, and alcohol consumption. Participants who experienced severe emotional abuse, sexual abuse, and physical neglect during childhood demonstrated significantly elevated risks of substance use, with adjusted odds ratios (aORs) of 1.22 [95% confidence interval (CI): 1.04, 1.42] for emotional abuse, 1.54 (95% CI: 1.32, 1.80) for sexual abuse, and 1.11 (95% CI: 1.04, 1.19) for physical neglect. Our analysis further reveals the complex relationship between cumulative childhood trauma experiences and substance use behaviors (Table 3). Using participants who reported no childhood trauma as the reference group, we observed a dose-response relationship between the number of trauma types experienced and substance use likelihood. For individuals reporting a single trauma experience, the odds were elevated for smoking (aOR=1.15, 95% CI: 1.09, 1.21), e-cigarette use (aOR=1.15, 95% CI: 1.06, 1.25), and alcohol consumption (aOR=1.20, 95% CI: 1.16, 1.24). This pattern intensified with increasing trauma exposure: two trauma experiences (smoking: aOR=1.25, 95% CI: 1.19, 1.32; e-cigarette use: aOR=1.32, 95% CI: 1.22, 1.43; alcohol use: aOR=1.23, 95% CI: 1.19, 1.27), three trauma experiences (smoking: aOR=1.52, 95% CI: 1.41, 1.64; e-cigarette use: aOR=1.82, 95% CI: 1.64, 2.02; alcohol use: aOR=1.50, 95% CI: 1.42, 1.58), four trauma experiences (smoking: aOR=1.60, 95% CI: 1.44, 1.78; e-cigarette use: aOR=1.90, 95% CI: 1.64, 2.20; alcohol use: aOR=1.69, 95% CI: 1.56, 1.83), and five trauma experiences (smoking: aOR=1.82, 95% CI: 1.62, 2.05; e-cigarette use: aOR=2.48, 95% CI: 2.12, 2.89; alcohol use: aOR=2.03, 95% CI: 1.82, 2.26).
Variables All Women Men (N=96,151, 100%) (N=56,112, 58.36%) (N=40,039, 41.64%) Mean/N SD/% Mean/N SD/% Mean/N SD/% Age Mean (SD) 19.59 1.74 19.56 1.70 19.64 1.81 Ethnicity Han ethnic group 86,050 89.49 49,817 88.78 36,233 90.49 Others 10,101 10.51 6,295 11.22 3,806 9.51 Education background Undergraduate 90,554 94.18 53,047 94.54 37,507 93.68 Master 5,375 5.59 2,938 5.24 2,437 6.09 Doctoral 222 0.23 127 0.23 95 0.24 Area type prior to university/college enrollment Urban 48,899 50.86 29,109 51.88 19,790 49.43 Rural 47,252 49.14 27,003 48.12 20,249 50.57 Per capita disposable income (CNY) <6,000 28,601 29.75 17,327 30.88 11,274 28.16 6,000–13,999 31,195 32.44 18,521 33.01 12,674 31.65 14,000–22,999 16,051 16.69 9,304 16.58 6,747 16.85 23,000–35,999 9,404 9.78 5,409 9.64 3,995 9.98 36,000–70,000 6,483 6.74 3,459 6.16 3,024 7.55 >70,000 4,417 4.59 2,092 3.73 2,325 5.81 Substance use Any substance use 58,473 60.81 27,702 49.37 30,771 76.85 Cigarette use No 83,416 86.76 53,970 96.18 29,446 73.54 Electronic cigarette 470 0.49 194 0.35 276 0.69 Conventional cigarette 8,059 8.38 886 1.58 7,173 17.92 Both 4,206 4.37 1,062 1.89 3,144 7.85 Alcohol use Non-drinker 38,803 40.36 28,609 50.99 10,194 25.46 ≤1 time a month 43,623 45.37 22,849 40.72 20,774 51.88 2–4 times a month 10,844 11.28 3,721 6.63 7,123 17.79 2–4 times a week 1,867 1.94 627 1.12 1,240 3.10 ≥4 times a week 1,014 1.05 306 0.55 708 1.77 Childhood trauma Never experienced childhood trauma 38,534 40.08 24,903 44.38 13,631 34.04 Any type of trauma 57,617 59.92 31,209 55.62 26,408 65.96 Emotional abuse 12,786 13.30 7,830 13.95 4,956 12.38 Physical abuse 6,457 6.72 2,970 5.29 3,487 8.71 Sexual abuse 13,864 14.42 6,836 12.18 7,028 17.55 Physical neglect 39,219 40.79 20,242 36.07 18,977 47.40 Emotional neglect 37,665 39.17 20,270 36.12 17,395 43.45 Abbreviation: SD=standard deviation; CNY=Chinese Yuan. Table 1. Sample sociodemographic characteristics, childhood trauma and substance use of 96,151 participants.
Childhood trauma experience Substance use
Smoker vs. non-smokerCigarette use
Smoker vs. non-smokerE-cigarette use
Smoker vs. non-smokerAlcohol use
Drinker vs. non-drinkeraOR (95% CI) P aOR (95% CI) P aOR (95% CI) P aOR (95% CI) P Ever experienced childhood trauma Emotional abuse None 1 1 1 1 Mild 1.16 1.11–1.22 <0.001 1.09 1.01–1.17 0.019 1.23 1.12–1.36 <0.001 1.17 1.12–1.23 <0.001 Moderate 1.22 1.09–1.37 0.001 1.25 1.07–1.46 0.004 1.36 1.12–1.67 0.002 1.25 1.11–1.39 0.001 Severe 1.22 1.04–1.42 0.013 1.63 1.34–1.98 <0.001 1.73 1.36–2.21 <0.001 1.23 1.06–1.44 0.006 Physical abuse None 1 1 1 1 Mild 1.10 1.02–1.20 0.018 1.08 0.97–1.20 0.170 1.17 1.01–1.35 0.038 1.11 1.03–1.21 0.010 Moderate 0.98 0.87–1.10 0.725 0.98 0.85–1.12 0.742 1.02 0.85–1.23 0.826 1.00 0.89–1.12 0.988 Severe 0.98 0.85–1.13 0.799 0.99 0.84–1.18 0.942 0.95 0.76–1.20 0.685 0.99 0.86–1.14 0.880 Sexual abuse None 1 1 1 1 Mild 1.39 1.32–1.46 <0.001 1.25 1.17–1.33 <0.001 1.35 1.23–1.48 <0.001 1.39 1.32–1.46 <0.001 Moderate 1.50 1.39–1.62 <0.001 1.48 1.35–1.61 <0.001 1.57 1.38–1.77 <0.001 1.50 1.40–1.62 <0.001 Severe 1.54 1.32–1.80 <0.001 1.27 1.06–1.51 0.008 1.55 1.24–1.95 0.001 1.39 1.20–1.62 <0.001 Physical neglect None 1 1 1 1 Mild 1.11 1.07–1.15 <0.001 1.18 1.12–1.25 <0.001 1.11 1.02–1.20 0.012 1.09 1.05–1.13 <0.001 Moderate 1.21 1.16–1.27 <0.001 1.26 1.18–1.35 <0.001 1.24 1.13–1.37 <0.001 1.21 1.15–1.26 <0.001 Severe 1.11 1.04–1.19 0.003 1.35 1.24–1.47 <0.001 1.26 1.11–1.43 0.001 1.03 0.97–1.10 0.320 Emotional neglect None 1 1 1 1 Mild 1.10 1.06–1.14 <0.001 0.86 0.81–0.90 <0.001 0.90 0.83–0.97 0.009 1.10 1.06–1.14 <0.001 Moderate 1.08 1.01–1.14 0.020 0.92 0.85–1.00 0.061 0.98 0.87–1.11 0.718 1.07 1.01–1.14 0.020 Severe 0.96 0.90–1.02 0.173 1.07 0.98–1.16 0.141 1.23 1.09–1.39 0.001 0.91 0.86–0.97 0.004 Abbreviation: aOR=adjusted odds ratio; CI=confidence interval.
* Adjusted for age, gender, ethnicity group, place of residence, and per capita disposable income.Table 2. Adjusted odds ratios of substance use among participants with childhood trauma experience.
Cumulative childhood trauma experiences Frequency Any substance use
vs. no substance useSmoker vs. non-smoker E-cigarette use vs. non-e-cigarette use Drinker vs. non-drinker N % aOR (95% CI) P aOR (95% CI) P aOR (95% CI) P aOR (95% CI) P Never 38,534 40.08 1 1 1 1 One 24,559 25.54 1.20 1.16–1.24 <0.001 1.15 1.09–1.21 <0.001 1.15 1.06–1.25 0.001 1.20 1.16–1.24 <0.001 Two 20,730 21.56 1.26 1.21–1.31 <0.001 1.25 1.19–1.32 <0.001 1.32 1.22–1.43 <0.001 1.23 1.19–1.27 <0.001 Three 7,294 7.59 1.55 1.46–1.64 <0.001 1.52 1.41–1.64 <0.001 1.82 1.64–2.02 <0.001 1.50 1.42–1.58 <0.001 Four 3,080 3.20 1.71 1.58–1.86 <0.001 1.60 1.44–1.78 <0.001 1.90 1.64–2.20 <0.001 1.69 1.56–1.83 <0.001 Five 1,954 2.03 2.16 1.94–2.41 <0.001 1.82 1.62–2.05 <0.001 2.48 2.12–2.89 <0.001 2.03 1.82–2.26 <0.001 Abbreviation: aOR=adjusted odds ratio; CI=confidence interval.
* Adjusted for age, gender, ethnicity group, place of residence, and per capita disposable income.Table 3. Oddsratios of substance use among participants with cumulative childhood trauma.
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Our study examines the complex relationship between childhood trauma and substance use behaviors among Chinese adolescents and young adults, providing critical insights that advance both research understanding and intervention strategies. The findings from our comprehensive analysis, particularly those presented in Table 2 and Table 3, expand current knowledge by revealing sophisticated patterns and associations across diverse forms of childhood trauma and substance use behaviors (11).
The influence of childhood trauma on substance use behaviors demonstrated in our results aligns with established research highlighting the persistent effects of adverse childhood experiences (11-12). Emotional abuse emerged as a robust predictor across all substance use categories, including smoking, cigarette use, e-cigarette use, and alcohol consumption. The progressive increase in odds ratios corresponding to emotional abuse severity emphasizes the necessity for interventions targeting multiple dimensions of emotional maltreatment. Similarly, the pronounced impact of severe physical abuse on all forms of substance use reinforces the enduring consequences of physical maltreatment (13). Physical neglect exhibited a notable graded association with substance use behaviors, while sexual abuse emerged as a particularly potent predictor, demonstrating a clear dose-response relationship across all substance use outcomes. Furthermore, the distinct patterns observed in the association between emotional neglect and various substance use forms underscore the complexity of this relationship, warranting deeper investigation into the underlying mechanisms.
The cumulative risk hypothesis provides a theoretical framework explaining our findings, positing that the combined effect of multiple risk factors exceeds the sum of individual risk exposures (14). Our analysis, detailed in Table 3, reveals a clear dose-response relationship between the number of trauma experiences and substance use behaviors, demonstrating that exposure to multiple forms of childhood trauma significantly increases the likelihood of substance use. From a neurobiological perspective, cumulative trauma exposure may induce structural and functional alterations in key brain regions responsible for stress regulation, particularly the amygdala and prefrontal cortex, leading to compromised emotional regulation capabilities and subsequently elevated substance use risk (14). The substantially increased odds of substance use among individuals with multiple trauma experiences underscore the critical importance of implementing targeted interventions and preventive strategies for this vulnerable population.
This study was subject to several limitations warrant consideration. The reliance on self-reported data introduces potential recall and social desirability biases, while the cross-sectional design precludes definitive causal inferences. Future research would benefit from longitudinal cohort studies that track participants over extended periods to elucidate the temporal relationship between trauma exposure and substance use patterns. Time-lagged analyses could further illuminate the dynamic progression from trauma exposure to subsequent substance use behaviors. Additionally, while our large sample size enhances statistical power and generalizability, it also presents methodological challenges. In samples of this magnitude, even minor differences can achieve statistical significance, necessitating careful interpretation of effect sizes alongside P values.
Our findings underscore childhood trauma as a significant predictor of substance use behaviors, emphasizing the necessity for multi-tiered intervention strategies. Healthcare providers should implement trauma-informed care protocols, recognizing the profound impact of childhood trauma on substance use patterns. Early identification and intervention are crucial, particularly in clinical settings where trauma histories may influence treatment outcomes (15). Mental health professionals must consider both psychological and somatic manifestations when evaluating and treating patients with trauma histories. From a policy perspective, priority should be given to developing comprehensive programs that prevent childhood trauma and mitigate its effects through family support initiatives, trauma education, and expanded mental health services. Implementation of evidence-based policies supporting early intervention and sustained support for trauma-affected individuals can significantly reduce substance use burden and enhance population health outcomes.
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