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11 Articles in Volume 14, Issue #10
Combating Opioid-Induced Constipation: New and Emerging Therapies
Updates on Smoking and Low Back Pain
Unraveling the Psychological Mechanisms Behind Smoking in Chronic Pain
Addressing Psychosocial Factors in Pain Management in the Emergency Department
Long-Term Outcomes and New Developments in Juvenile Fibromyalgia
Pain Management in the Elderly: Etiology and Special Considerations
Using Pharmacogenetic Testing in a Pain Practice
Editor's Memo: Care With Caution
Ask the Expert: HIPAA Rules
Ask the Expert: DMARDs and Opioids
Letters to the Editor: November/December 2014

Unraveling the Psychological Mechanisms Behind Smoking in Chronic Pain

Q&A with Joseph W. Ditre, PhD

The link between smoking and chronic pain is complex and multidirectional. To gain a perspective on how current knowledge on this relationship can be applied in clinical practice to help patients stop smoking, Practical Pain Management talked with Joseph W. Ditre, PhD, Assistant Professor of Psychology at Syracuse University, in Syracuse, NY. Dr. Ditre is a leading researcher in health psychology, with a focus on the intersection of addictive behaviors and comorbid medical disorders.

Q: How are smoking and chronic pain related?

A: We think of relationships between pain and smoking as being reciprocal in nature. Smoking has been purported to hasten the onset and increase the intensity of pain, and pain has been shown to motivate smoking behavior. This sort of vicious cycle could result in greater pain and make quitting smoking more difficult (Figure 1).1,2

Four mechanisms that may help to explain relations between pain and smoking include:

Nicotinic acetylcholine receptors (nAChRs) and acute analgesic effects of nicotine/tobacco—nAChRs are spread widely throughout the central and peripheral nervous systems, and self-administered nicotine has been shown to result in the activation of spinal cord descending pain inhibitory pathways. For patients in pain, acute analgesic effects of nicotine could make smoking more rewarding and harder to give up.

Endogenous opioid system—Pain-related effects of nicotine and other nAChR agonists may be mediated at least partially by the activation of endogenous opioid (endorphin) systems. For example, with regard to acute analgesic effects of nicotine, there is evidence that smoking can stimulate the release of b-endorphins, which have been referred to as the body’s natural painkillers. However, as described in a 2010 review by Shi et al, there also is evidence that chronic exposure to nicotine might result in the dysregulation of endogenous systems that influence a multitude of pain-relevant processes (eg, increased hyperalgesia, impaired baroreceptor function, and decreased b-endorphin levels).3

Cardiovascular responses—Smoking also may produce acute analgesic effects via pressor actions on the cardiovascular system that serve to alter peripheral blood flow. For example, nicotine has been shown to elevate blood pressure in both smokers and nonsmokers, and this increased cardiovascular reactivity has been associated with reduced pain responses.4

Expected smoking-related outcomes—Expectations or beliefs about how smoking may help one cope with or reduce pain could be just as important as some of the more biological mechanisms, especially when it comes to helping people quit. Whether they are explicitly aware of it or not, patients may be motivated to continue smoking, in part, due to the pain they are experiencing and their desire to reduce it or distract themselves from it. This refers to the patient’s perception of how smoking might help them manage or deal with pain, versus how nicotine may actually influence pain pathways.

Q: How can pain practitioners assess the psychological mechanisms behind smoking behaviors in their patients?

A: This to me is central when it comes to helping persons in pain quit smoking, and we have developed a measure to examine that. The 9-item Pain and Smoking Inventory is designed to assess 3 domains: 1) the extent to which pain motivates patients’ smoking behavior, 2) the extent to which patients believe that smoking helps them cope with pain, and 3) the extent to which patients see pain as a potential barrier to quitting smoking.5

An example item is: ‘My pain makes me less confident that I could stop smoking for good.’ Patients rate that question on a scale from 0 to 6, with 0 being not at all true and 6 being extremely true. The initial validation manuscript for this measure is in preparation.

Even if not assessed with this measure, clinicians should consider asking patients about how smoking may be related to their pain, and vice versa. This approach could provide an opening to further discuss some of the emerging research on pain and smoking (eg, ‘you might be surprised to learn that smoking has been associated with increased pain and that quitting smoking may help to improve your pain and functioning’). If taken to heart, this information could cause patients to look at their smoking behavior in a different light than maybe they had seen it before.

For example, many people are aware of the widespread harmful effects of tobacco smoking, but for patients who are seeking treatment for pain, there may be no better motivator to quit than coming to understand that continued smoking may interfere with their goals for reduced pain and better physical functioning. For smokers with chronic pain, tobacco smoking might be seen as one of the few things they can still enjoy, but what they might not know is that continued smoking could be perpetuating the exact thing they would like to rid themselves of most.

Michael Hooten, MD, and colleagues recently published a study demonstrating that pain patients seeking treatment readily report that they smoke tobacco to cope with, or distract themselves from, their pain.6 This makes a great deal of sense, especially given that smokers, in general, tend to smoke in response to a variety of aversive sensory, affective, and cognitive states. Whether smoking actually results in pain reduction or mood enhancement may be less important than whether patients’ expectations that smoking will reduce pain are sufficient to motivate them to keep smoking. In this way, expectations for how pain and smoking are interrelated could be of primary import in the context of smoking cessation.

Q: How can health care providers help patients with pain conditions quit smoking?

A: The current gold-standard treatment for tobacco cessation includes a combination of pharmacotherapy, such as nicotine replacement therapy or varenicline (Chantix), and behavioral or skills-based counseling interventions. Although each of these strategies has been shown to enhance smoking cessation, a combination tends to work better than any approach alone.

How to best approach smoking cessation among patients with chronic pain is an emerging area of great empirical interest within the broad domains of health psychology and behavioral medicine, and we are actively engaged in collaborative research on this topic.

Our approach to date has centered on incorporating psychoeducational components that explicitly link smoking with poor pain outcomes into existing evidence-based smoking interventions. This approach is supported by theoretical concepts of health behavior change, which suggest that smokers in pain may become more motivated to quit and remain abstinent if they perceive they will be at a salient risk for pain-related consequences if they smoke; this leads them to recognize that there is a discrepancy between their continued smoking and desired pain outcomes.

Interestingly, it may not be advisable to address smoking cessation in the same manner for all types of pain. For example, some studies indicate that rates of spinal fusion decrease by as much as 400% in the presence of systemic nicotine. Although these data suggest that spinal fusion candidates may benefit from quitting smoking, they also suggest that use of nicotine replacement therapy may be contraindicated. In this setting, patients are seeking a treatment that may be enhanced by quitting smoking, but they may be unable to use one of the best pharmacotherapies available to help them do so.

There also is evidence of complex interrelations between pain, tobacco smoking, and the consumption and efficacy of prescription opioid medications. We recently received funding from the National Institutes of Health to study relationships between smoking behavior, chronic pain, and the aberrant use of prescription opioids among older individuals with HIV. Our goal in this study will be to develop and pilot-test a novel intervention aimed at increasing patients’ intentions to quit smoking and decreasing their intentions to misuse prescription analgesic medications.

Taken together, these examples underscore the importance of addressing smoking cessation in the context of chronic or recurring pain and highlight the need to tailor interventions to specific treatment settings and patient populations.


Q: What role does depression play in this reciprocal relationship between smoking and chronic pain? Does treatment of depression help patients stop smoking?

A: Depression is common among both smokers and people with chronic pain; worsening symptoms of depression following an attempt to quit smoking have been related to poorer smoking cessation outcomes, and there is some data to suggest that increased pain reporting among smokers (relative to nonsmokers) may be mediated by depression severity.7,8 In our systematic review of this literature,1 we theorized that depression is a key mechanistic pathway involved in the reciprocal relationships between pain and tobacco smoking (Figure 2). Considering the high degree of overlap in depressive symptoms among both smokers and people with chronic pain, and given evidence that treating depression in the context of smoking cessation may enhance those outcomes, it seems reasonable to suggest that tailored interventions for smokers in pain might benefit from integrating components that address complex interrelationships between pain, depression, and tobacco smoking.

Q: What are the pros and cons of e-cigarettes?

A: Generally speaking, as it stands right now, there are probably too many unknowns for clinicians to recommend e-cigarettes as a primary approach to smoking cessation, although this is another area of highly active scientific inquiry. Although e-cigarettes may deliver nicotine in a less harmful way than regular tobacco cigarettes, debate and research regarding the safety of these products and how to best regulate them is ongoing.

One might expect that acute analgesic effects could be obtained across systems of nicotine delivery, and that the act of puffing on an e-cigarette might help distract someone from or reduce short-term pain in a manner similar to the smoking of regular tobacco cigarettes. However, there also is some concern that e-cigarettes may maintain or possibly even increase chronic exposure to nicotine, which as mentioned before, may intensify pain sensitivity. For example, there are many places where people can no longer smoke tobacco, and regular cigarettes tend to burn down (or self-limit) after a requisite number of puffs. In contrast, e-cigarettes may allow individuals to self-administer nicotine in places they otherwise could not, and at rates and quantities that could exceed what was typically possible with regular cigarettes.

Q: What else would you like to tell PPM readers?

A: The fact that there are numerous, potentially casual relationships between nicotine, tobacco smoking, and pain is what, in part, makes this topic so interesting and complex to study. It is essential to consider how tobacco smoking may cause or increase pain as well as how pain may motivate and maintain smoking behavior. Thus, a key element in helping patients quit smoking would be to recognize that pain may be a potent motivator of their smoking, and that pain experienced in the absence of smoking might be sufficient to promote relapse.


Last updated on: November 16, 2016
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