Complex Associations 

Between Pain and Smoking

Lori Bastian, MD, MPH

Research Associate and 

Primary Care Physician

VA Connecticut (Newington)

Professor of Medicine

Division Chief, General Internal Medicine

Associate Dean for Career Development

University Connecticut Health Center
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Outline

 Examine the published literature on the 

association of smoking status and pain 

 Review a patient case

 Describe preliminary data on the impact of 

smoking cessation and pain levels

 Discuss clinical and research implications
Poll Question #1

Who is in the audience?

A. Researchers

B. Clinicians

C. Other

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Poll Question #2

Patients that smoke cigarettes report:

A. similar pain levels compared to patients that don’t 

smoke

B. Higher pain levels compared to patients that don’t 

smoke

C. Lower pain levels compared to patients that don’t 

smoke

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The pain/smoking association 

is complex

 Studies show pain prevalence and intensity 

are higher among current smokers

 Yet, nicotine has analgesic properties

 Pathophysiology is different for cigarette 

smoking and nicotine therapy

Shi Y et al Anesthiology 2010; 113:977

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Smokers with lung cancer 

report higher pain levels

 We published the first study on smoking and 

cancer pain

 Surveyed 893 patients with lung cancer 

 76% Stage IIIB/IV and 41% mod/severe pain

 17% persistent smokers

 Persistent smokers were 1.6 times more likely 

to report moderate or severe pain compared to 

non-smokers and former smokers.

Daniel (Bastian) et al Journal of Pain 2009;10:323. 
Smokers with Head & Neck 

cancer have higher pain

 112 patients with head & neck cancers 

 34% current smokers 

 Smokers reported higher general pain and 

oral pain levels even after controlling for 

stage of diagnosis 

 Smokers reported significantly greater 

interference from the pain 

Logan HL et al J Pain 2010;11:528

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What about other cancers?

 224 patients with breast (35%), lung 

(33%), bladder (6%), ovarian (6%), colon 

(4%) and other cancers 

 63% female

 Persistent smokers (after a cancer 

diagnosis) reported more severe pain and 

more interference from pain than nonsmokers

Ditre JW et al Pain 2011;152:60

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Smokers treated for Cancer 

pain report higher pain

 486 patients treated for cancer pain

 20% smokers

 Smokers had higher pain intensity and 

depression 

 Among 192 patients on opioid therapy, 

smokers continued to report higher pain

Novy DM et al. J Pain 2012;13:1058

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Mr. B

Age 76

stage IV lung cancer 

Hospice patient

Persistent smoker with 

70 pack/year history

Shortness of breath and 

pain with any activity

Oxygen not allowed in 

home because of fire 

risk

Clinical 

Recommendation:

Nicotine replacement 

therapy

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Mr. B, 2 weeks later

 Wearing 21mg nicotine patch and reduced 

cigarettes to 3 per day (only smokes outside)

 Able to shave and walk in house using oxygen

 Pain and breathing improved

 Family working on quitting, too.** They no longer 

smoke in the house or near patient.

Clinical Recommendation:

Add Nicotine inhaler for urges

**Social-network effect. Christakis, BMJ 2004;329:184.
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Mr. B, 3 months later

 Quit smoking and uses oxygen and electric 

scooter to get around outside of his house

 Requires less opioid medications for pain

 His wife also quit smoking

 Hospice nurse (a smoker) was reluctant to 

encourage cessation but was impressed that 

patients’ quality of life improved after he quit 

Key Point: Health Care workers can be a barrier to 

smoking cessation for patients with cancer.
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Case Highlights

 Mr. B’s pain and quality of life improved

 Family members were motivated to quit

 Initially, his hospice nurse was reluctant to 

address smoking cessation, she said “did not 

seem fair”

 Important to inform the patient, family 

members, and clinicians that there are 

benefits to quitting.
Poll Question #3

 Is there a role for smoking cessation in the 

management of cancer pain?

 Yes 

 No

 Unsure 

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Is this complex association 

unique to cancer patients?

 No

 Brief review of smoking and non-cancer pain 

 Like with cancer pain, studies are 

observational and do not determine causality.

Fishbain DA et al Pain Medicine 2012; 13:1212

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Hypothesized Feedback Loop

 Does smoking increase pain? Or does pain 

increase urge to smoke?

 Reciprocal relationship between pain and 

smoking that operates as a positive feedback 

loop, leading to greater pain, increased 

smoking, and the maintenance of nicotine 

dependence 

Ditre JW & Brandon TH J Abnorm Psychol 2008;117:467

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Smokers have more severe 

back pain

 National Spine Network database (U.S.) 

 11,494 men and 13,961 women

 16.7% smokers

 Smokers were more likely to report severe 

pain and to report symptoms of depression

 Smokers also reported less improvement 

after back surgery compared to non-smokers 

Vogt MT et al Spine 2002; 27:313

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Smokers have more back pain

 Meta-analysis of 40 studies

 Current Smokers had an increased 

prevalence of low back pain compared to 

non-smokers OR=1.30 (95% CI 1.16-1.45) 

 Former smokers OR=1.24 (95% CI 1.11-

1.38) 

 Lower rates for former smokers suggests that 

smoking cessation will reduce back pain

Shiri R et al. Am J Med 2010;123:87e7-87e35

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Smokers report more pain 

locations & more analgesic use

 7,124 survey respondents from population 

database in Germany

 Ages 18-79 

 Heavy smokers (>20cigs/d) 8.6% women and 

17.1% men

 Heavy Smokers report more pain locations 

and higher pain intensity in past 7 days

 Heavy Smokers have more analgesic use 

John U, et al Prev Med 2006;43:477 & John U, et al Drug Alc Dep 2006;85:49.

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Smokers with fibromyalgia 

report greater pain intensity

 984 patients evaluated in the Mayo Clinic 

Fibromyalgia Program

 14.7% current smokers

 Smokers reported greater pain intensity and 

higher scores on the Fibromyalgia Impact 

Questionnaire 

Weingarten TN et al Clin J Pain 2009;25:39

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Combination of smoking and 

depression 2 times risk of pain

 18,439 Health & Retirement Study 

 15% depression

 34% troubled by pain

 Smoking increased the likelihood of incident 

pain only in those subjects who also reported 

depression 

Shi Y et al Pain 2010; 151:366

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Effects of Depression and 

Smoking on opioid use

 1,241 in out-patient pain treatment program

 25% current smokers

 Smokers had higher depressive symptoms 

and pain and greater morphine equivalent 

dose 

 Multivariable model, smoking associated with 

greater opioid use

Hooten WM et al. Pain 2011; 152:223

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Older smokers have more 

intense pain

 1,141 patients (ages 65-103) in Sweden

 54% women and 38% chronic pain

 9% smokers

 Female smokers have higher pain prevalence 

and pain intensity

 Male smokers have higher pain intensity

Jakobsson U et al Pain Practice 2013; in press

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Smokers with chronic pain 

have greater pain intensity

 230 patients in Mayo Chronic Pain Clinic

 15% smokers

 Smokers report greater pain intensity and 

pain interference with functioning

 Nicotine dependence was also associated 

with greater pain.

Weingarten TN et al Pain Physician 2008;11:643

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Veterans with Chronic Pain

 6,377 Veterans ages 19-97 (9% female)

 36.7% current smokers

 Smokers were 1.4 times more likely to have 

any abuse of prescription drugs adjusting for 

depression and pain

 Smokers were 1.8 times more likely to have 

frequent prescription drug abuse

Becker WC et al Pain Medicine 2009; 10:531

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Smoking cessation in patients 

with chronic pain

 112 patients in chronic pain clinic

 50% smokers

 Smokers were encouraged to quit by their 

pain clinic physician and 91% reduced the 

number of cigarettes they smoked

 Reduction in number of cigarettes was 

associated with improved breathing, feeling 

better, and less pain.

Kaye AD et al Ochsner J 2012;12:17

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Effect of smoking cessation on 

pain in older adults

 6,258 smokers in Health & Retirement Study

 50% female and 31% pain

 44% quit smoking between 1993 and 2006

 In this longitudinal study, no association was 

found for the effect of smoking cessation on 

pain in older adults (OR=0.87 95%CI 0.70-1.08)

Shi Y et al Nicotine &Tobacco Res 2011;13;919

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Impact of smoking cessation 

on pain outcomes

 To date, only observational studies have 

peen published.

 Next step is to examine the effect of smoking 

cessation on pain in randomized clinical trials

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Smoking Cessation Trial at the 

Durham VA in North Carolina

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Funding support: VA HSR&D IIR 05-202

Bastian et al. Comparative Effectiveness 

Research 2012;2:45.
Key Investigators from 

Durham NC

 Laura Fish, PhD

 Jennifer Gierisch, PhD, MPH

 Steve Grambow, PhD

 Karen Stechuchak, MS

 Lesley Rohrer, MPH

 Funding support: VA HSR&D IIR 05-202 

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Smoking cessation for 

chronically ill veterans

Veteran’s environment and social support (in 

particular family support) impacts their motivation 

and self efficacy to stop smoking.

Higher cessation rates have been noted among 

smokers who report receiving greater positive 

support relative to negative support.
Examples of Family Support

Positive Support

 Affirmation “Good Job”

 Encouragement for 

discussing a plan with the 

person’s provider

 Support for person’s 

efforts to try and quit

Negative Support

 Nagging or complaining 

about their smoking

 Calling them idiots or 

telling them they are 

disgusting

 Making ultimatums

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Family Matters Trial

A telephone-based family-supported 

intervention that teaches how to minimize 

negative support and maximize positive 

support could improve cessation.

A comparative effectiveness trial to test a 

family-supported telephone counseling 

intervention compared to standard telephone 

counseling for increasing smoking cessation 

among veterans with chronic illness.
Sample

Sample size = 471 veterans

Diagnosed with chronic illness at Durham VA

Heart disease, cancer, hypertension, COPD, 

diabetes

Currently smoking

Planning to quit in the next 30 days

Able to identify one person (relative/friend) to

support them while they quit smoking. 
Proactive recruitment

Patients identified using computerized 

medical record. 

Mailed an introductory letter informing them 

of the study and encouraging them to quit. 

Patients are called to assess eligibility 

criteria and invited to enroll in the Family 

Matters study. 

 
2t l h eep one-b d i t ti ased intervention

 Family support: Family support:  Standard couns

 Letter from MD Self-help materials

 Standard couns

 Letter from MD

p  Self-help mater

 Choice of NRT Five family-supported

telephone counseling

p

 Choice of NRT Five standard t

telephone counseling counseling sess

sessions; including an 8-page family support 

b kl t ith ti iti t

counseling sess

booklet with activities to 

enhance positive support and minimize negative 

support
Baseline Characteristics

Variable Family-support 

(n=235) 

Standard 

(n=236) 

Age, mean 59 59 

Female 9% 8% 

Cardiac 43% 42% 

Cancer 33% 35% 

Other chronic 

illness*

23% 23% 

*Hypertension, 

COPD, Diabetes
Smoking history 

Variable Family-support 

(n=235) 

Standard 

(n=236) 

Quit attempt after 

diagnosis

74% 75% 

Self-efficacy for 

quitting (scale 1-7)

5.8 5.7

Heaviness of 

Smoking(scale 0-6) 

2.8 2.8

Lives with a smoker 38% 32% 
Depression and Pain

Variable Family-support 

(n=235) 

Standard 

(n=236) 

Depressive Sx

(Brief CES-D > 10)

53% 56% 

Mean Pain level

(Pain scale 0-10)

5.1 5.2

Poor/Fair Selfrated Health

59% 60% 
Results of Comparative 

Effectiveness Trial

Variable Familysupport 

(n=235) 

Standard 

(n=236) 

Smoking cessation

5 months*

20% 22% 

Smoking cessation

12 months*

22% 22% 

*86% follow-up at 5 months and 81% follow-up at 12 months
Factors associated with Pain

Variable Pain at 5 

months

Unadjusted

Pain at 5 

months

Adjusted

Arm NS NS

Age -0.11 -0.05 

Abstinent at 5m 

Cancer

Baseline pain

-1.07 

NS

0.68 

NS

NS

0.60 

CES_D score 0.18 NS

Rated fair/poor health 1.73 NS
Research Implications

 Need more prospective studies to examine 

impact of smoking cessation on pain severity

 Family Matters was 90% men and there may 

be gender differences (i.e., women may be 

more affected by this association than men)

 Potential study populations: chronic pain, 

back pain, fibromyalgia, and cancer

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Clinical Implications

 Qualitative study on physician attitudes

 Focus group of 7 physicians (specialists)

 Physicians identified many barriers to 

smoking cessation in a pain treatment clinic

 Don’t have time for counseling

 Hard to “zone in on the smoking part”

 Patients smoke to cope with pain and they are 

under too much stress to try and quit

Hooten WM et al Pain Practice 2011;11:552

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Clinician Advice Matters

 Compared to smokers who receive no advice 

from a clinician, smokers who receive such 

advice are 1.7–2.2 times as likely to quit 

smoking.

 3-minute MD advice results in a 10% quit rate.

 Focus on the clinical benefits of quitting. If you 

are treating their low back pain, inform them of 

the potential pain improvement with quitting.

Fiore et al. Treating Tobacco Use and Dependence. Clinical Practice Guideline. 

USDHHS, PHS, 2000

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Spock

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