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Insider's View of Smokers' Perceptions and Resolve to Quit

January 5, 2018
Researchers challenge the old model of measuring smoking cessation based on perceived "lost pleasure" when gains in health status, including the impact on pain, offer greater motivation for patients to succeed.

With Terry Frank Pechacek, PhD, with commentary from David Cosio, PhD

Findings by Pechecak et al1 indicate that, contrary to the FDA’s existing benefit-cost analysis of tobacco regulations, which focuses on the loss of benefits, any analysis on the impact of smoking cessation should instead emphasize the gains in health status. Patients appear more responsive to the prospect of being freed from the addiction and better long-term wellness, than fears of missed gratification, according to the authors.

The overall health gains achieved and avoidance of pain arising from chronic diseases appear to be better motivators for smokers to give up cigarette smoking, concluded lead author, Terry Frank Pechacek, PhD, professor of health management and policy at Georgia State University School of Public Health in Atlanta, and co-authors.

Long-term health and less pain drive smokers to quit over concerns of lost pleasure.

Smokers Actually Want to Quit 

In this study,1 more than 80% of adults who were current smokers expressed discontent about their inability to quit, felt they were addicted to cigarettes, and regretted they had ever started smoking. Conversely, fewer than one in five adult smokers in the United States reported that they had no plans to quit sometime in the future, did not consider themselves addicted to cigarettes, and had no regret for having started to smoke.

These findings clear the way for the Food and Drug Administration (FDA) to include measures of “reduction in smokers’ discontent and an improvement in subjective well-being” in the cost-benefit analysis of proposed anti-smoking regulations, said Dr. Pechacek, “These new outcomes—replacing the focus on “lost pleasure” of smoking—will give regulators the rationale to hit harder in their efforts to warn smokers of the risks associated with smoking, especially now that e-cigarettes have become so popular with younger individuals.”

In 2016, the FDA added e-cigarettes, cigars, hookah, and pipe tobacco to the tobacco products for which it regulates the manufacturing, distribution, and marketing, but they backed away from including larger, more graphic warning labeling on tobacco packaging. 

 “With our results, a larger proportion of smokers may have a net welfare gain with new regulations that enable them to escape the state of misery from continuing to smoke. Future policy initiatives should address an estimate of positive health benefits, rather than anticipated loss in perceived gratification,” said Dr. Pechacek.

Complex Relationship Between Chronic Pain  & Smoking

While the prevalence of cigarette smoking is at an all-time low, effective implementation of federal regulations is important to sustain this progress. One group that continues to have a high rate of smoking is the chronic pain population.3 Physicians treating chronic pain need to be aware of their patients’ smoking habits as they directly relate to pain perception, pain scores, and medication use.

Patients with pain continue to be smokers despite their awareness of its harmful effects because they feel it helps them cope or may even reduce pain. However, patients with chronic conditions who use cigarettes to alleviate pain symptoms may actually be making them worse. And, because of the effects of nicotine on the brain, they also increase their risk for opioid misuse.

The relationship between smoking and chronic pain is complex. Smoking hastens the onset and increases the intensity of pain, and pain has been shown to motivate smoking behavior.2 The vicious cycle that ensues could result in greater pain and make quitting smoking more difficult. Physicians should consider asking patients how they think smoking may be related to their pain, and vice versa.

Pain patients seeking treatment readily report that they smoke tobacco to cope with, or distract themselves from, their pain.3 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.4 However, patients may be encouraged to view their smoking in a different light if physicians note that smoking has been associated with increased pain and that quitting may help improve patients’ pain and functioning. 

Addressing Smoking in Pain Patients  

The interference of cigarette smoking in managing pain and in chronic pain treatment is well known among medical experts, said David Cosio, PhD, ABPP, a psychologist at the Pain Clinic and interdisciplinary pain program at the Jesse Brown VA Medical Center in Chicago. Illinois.

"Smoking may lead to or exacerbate painful medical conditions," Dr. Cosio said,
 "as has been reported with regard to chronic back and neck pain, it seems by contributing to osteoporosis and deterioration of spinal discs." In fact, smokers are almost three times more likely to experience lower back pain than non-smokers, and smoking has also been reported to contribute to joint pain in conditions like arthritis. 

Beyond specific pain conditions, smoking appears to increase pain sensitivity and perception. In fact, evidence suggests that smoking may cause patients to perceive pain more acutely, he told Practical Pain Management. It appears that tobacco use has some effect on the nervous system, increasing sensations and perceptions of pain as well as interfering with pain medication— larger doses may be required to reduce or manage a smoker's pain, Dr. Cosio said.

"Anecdotally, I have found that most people who suffer from pain have not considered if or how their smoking behavior may affect their pain at all.  Often, I found that having a discussion with a patient about the relationship between smoking and chronic pain may be enough reason for them to pursue smoking cessation strategies," Dr. Cosio said, "While the use of fear or scare tactics typically ineffective. providers may elicit what is behind the patient’s motivation to continue smoking and perhaps offer recommendations that may address their reason directly as a way to formulate a targeted plan to help them quit smoking.

Last updated on: January 8, 2018
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