Two recent papers look at the subtle and surprising links between smoking and pain in different parts of the body.
The association between smoking cigarettes and the risk of developing serious and potentially fatal health problems (most notably cardiovascular diseases, pulmonary diseases, and cancer), has long been accepted fact. However, an additional health problem that may also be associated with smoking has often been overlooked: pain.
Two recent papers indicate a strong association between smoking and pain.
The first is a literature review of the current research on the subject.1 Among the review’s important findings is that those who suffer from chronic pain are substantially more likely to smoke than are those who do not suffer from chronic pain. Although smoking rates continue to decline in the latter group, this does not appear to be occurring in those with pain.
Cigarette smoking has been cited as a risk factor for a wide variety of painful conditions, including back pain, headache, and diabetic peripheral neuropathy. Smoking appears to be associated with both the development and severity of pain.
The second paper specifically studied the most likely locations of pain among individuals who smoke. The study examined data from a 2003-2004 National Health and Nutrition Examination Survey which contained data from comprehensive bodily pain questionnaires in addition to questions on other health issues, including tobacco use.2 The study compared 1054 participants in the survey who smoked tobacco to 1316 who did not.
Those who smoked were found to be more likely to suffer chronic pain. Although the likelihood of pain was increased throughout the body, the study found that spine pain, and especially low back pain, had the strongest association with smoking. The second strongest association was between headaches and smoking. Smoking was also associated with both trunk pain, which included the chest and abdomen, and limb pain. (All statistical associations drawn from Smuck et al.2)
This is an interesting and perhaps an unexpected finding. Because of the association between smoking and cardiovascular and cerebrovascular problems, it is easy to see why headaches would be fairly common among individuals who smoke. However, it might be reasonably expected that pain in the trunk and limbs would be more common than pain in the spine. The authors suggest that vascular factors may play a greater role in back pain than is often thought.
Whether e-cigarettes, which are becoming more popular, are any less associated with pain than traditional cigarettes remains an unanswered question.
From personal experience treating patients with chronic pain who also smoke, I know that helping them with smoking cessation attempts can be challenging. Although most patients are often well aware of the risks associated with smoking, their pain and its impact on their lives may make it more difficult for them to quit. Their pain may make them feel restricted, and their ability to participate in previously enjoyable activities is limited. Smoking is one of the few such activities in which they can still indulge. They may also feel that smoking helps them cope with the pain.
There is evidence indicating that nicotine may have some analgesic effects, but abstaining from smoking may cause individuals to suffer hyperalgesia, a lowering of the pain threshold.3,4 Thus, those who smoke may receive temporary relief from tobacco use, and their pain may get worse when they try to stop.
Additionally, depression and anxiety are frequent comorbidities among those with chronic pain, and their presence can also contribute to the challenge of getting patients to stop smoking.5
Ultimately, all evidence points to the importance of convincing patients with chronic pain who also smoke that tobacco is not helpful. Indeed, tobacco may be significantly exacerbating their pain and adding to their misery.
The multitude of challenges can understandably make it difficult to convince patients with chronic pain to stop using tobacco. Unfortunately, there are only a limited number of studies that have sought to investigate the best treatments for attaining this goal.6
Although no single optimal treatment has yet been identified, it appears that while nicotine replacement therapy can be useful, the interventions that are most successful are those that address both the pain and the smoking using psychotherapeutic interventions.7 In this way, treating tobacco use disorder and comorbid chronic pain is similar to the treatment of pain and iatrogenic opioid use disorder, where there must be management of both problems together in order to be successful in treating either.
Of course, this raises the important issue of who treats pain and how it is treated. (For more information on psychiatry and pain, see the November Special Report.)
For the most part, the management of chronic pain has been under the aegis of anesthesiology, followed by physiatry and neurology, with psychiatry far down the list. However, the order of these specialties would be reversed if we asked which is best able to aid in smoking cessation. One doubts that there are many anesthesiologists, physiatrists, or neurologists who have expertise in treating patients with nicotine addiction.
As a result, it is difficult for patients with chronic pain who smoke to find health care professionals qualified to treat both issues. If it appears to patients that smoking and pain are 2 separate problems that require different medical specialties to treat them, it may make it more difficult to convince them that the issues are actually entangled. Nonetheless, the evidence suggests that managing 1 issue may aid in managing the other.
Dr King is in private practice in Philadelphia.
1. LaRowe LR, Ditre JW. Pain, nicotine, and tobacco smoking: current state of the science. Pain. 2020;161(8):1688-1693.
2. Smuck M, Schneider BJ, Ehsanian R, et al. Smoking is associated with pain in all body regions, with greatest influence on spinal pain. Pain Medicine. 2020;21:1759-1768.
3. Ditre JW, Zale EL, LaRowe LR, et al. Nicotine deprivation increases pain intensity, neurogenic inflammation, and mechanical hyperalgesia among daily tobacco smokers. J Abnorm Psychol. 2018;127(6):578-589.
4. Nakajima M, Al'Absi M. Nicotine withdrawal and stress-induced changes in pain sensitivity: a cross-sectional investigation between abstinent smokers and nonsmokers. Psychophysiology. 2014;51(10):1015-22.
5. Zale EL, Maisto SA, Ditre JW. Anxiety and depression in bidirectional relations between pain and smoking: implications for smoking cessation. Behav Modif. 2016;40(1-2):7-28.
6. Ditre JW, Zale EL, LaRowe LR. A reciprocal model of pain and substance use: transdiagnostic considerations, clinical implications, and future directions. Annu Rev Clin Psychol. 2019;15:503-528.
7. Hooten WM, LaRowe LR, Ditre JW, et al. Effects of a brief pain and smoking cessation intervention in adults with chronic pain: a randomized controlled trial. Addict Behav. 2018:92:173-179.