In this study we examined the associations between cigarette use and chronic pain by assessing whether smoking cigarettes as a method for coping with pain is associated with pain-related variables. We analyzed 3 groups of patients with chronic pain (non-smokers, smokers who deny using cigarettes to cope with pain, and smokers who report using cigarettes to cope with pain) and found that the purposeful use of smoking cigarettes as a coping strategy for chronic pain was associated with greater pain intensity and poorer pain-related functioning. Participants who denied smoking cigarettes as a strategy to cope with pain had similar pain-related outcomes as non-smokers. Regression analyses revealed that endorsing the use of cigarettes as a coping strategy for pain was significantly and positively associated with more pain intensity, poorer pain-related function, and more fear of pain. These associations were found even after controlling for relevant demographic characteristics, pain-related variables, depressive symptoms, and prescription opioid use. Overall, our findings suggest that the use of smoking cigarettes to cope with chronic pain is associated with a constellation of pain-related problems.
suggested that increased psychological and physiological pain symptoms among persistent smokers may be caused by the experience of frequent withdrawal symptoms. Therefore, poorer pain-related outcome among individuals who smoke cigarettes to cope with pain could be a reflection of greater underlying nicotine dependence. However, in our sample there were no significant differences between the 2 smoking groups in their frequency of nicotine consumption or severity of nicotine dependence. Therefore, the differences in pain-related outcome between the 2 smoking groups were likely not related to the frequency of withdrawal symptoms. It has also been suggested that differences in pain-related outcome between smokers and non-smokers could be explained by the higher prevalence of depression among smokers.27
In our sample there were no significant differences between groups on self-report measures of depression or anxiety, or in terms of clinical diagnoses. Last, it is important to note that smokers who denied using cigarettes to cope with pain did not differ from non-smokers on measures of pain-related outcome, psychiatric symptoms, or opioid use. Therefore, among the patients in our sample, as long as the smoker was not consciously using cigarettes to cope with pain, no significant relationship existed between smoking status and pain-related variables.
Significant differences were found between the two cigarette smoking groups on measures of pain-related outcome, despite the fact that no significant differences were found in opioid use or patterns of nicotine consumption. Therefore, nicotine-induced attenuation of opioid analgesia was likely not the cause of poorer pain-related outcome in our sample, as has been suggested in prior studies.2,58
The rewarding properties of nicotine may be related to the stimulation of endogenous opioids,44
and it is possible that smoking to manage stress is more prevalent among individuals who build tolerance to this effect. Although we did not measure endogenous opioids in this study, the lack of significant differences in prescription opioid use between all three groups (both smoking and non-smoking) suggests that, in our sample, opioid-related variables may not be related to smoking status or coping with cigarettes. However, a systematic investigation controlling for opioid dose and endogenous opioid levels is needed to confirm this supposition.
The use of nicotine to cope with a distressing state has been studied and described in various terms in the scientific literature. Individuals with depression, anxiety, and particularly attention-deficit hyperactivity disorder may smoke cigarettes as a means of symptom reduction or stabilization, e.g. “self-medication.”17
A longitudinal study of 662 adolescents attempted to directly investigate self-medication of depression with cigarettes through use of a self-medication scale.6
The study found that smokers with higher self-medication scores had increased depression symptom severity, but more symptom stability, as compared to both non-smokers and smokers with low self-medication scores. The authors theorized that self-medication with cigarettes may be a trade-off between overall increased depression severity but greater long-term symptom stability. The findings of this study have similarities with the current study, and although we were not able to measure variation in pain severity over time, it is possible that smoking cigarettes may produce a similar trade-off when used to self-medicate symptoms of chronic pain.
Analyses of the different coping styles between the 3 groups provided mixed results. Although our findings suggest that smoking cigarettes to cope with pain is associated with poorer pain-related outcomes, we also found that smokers who used cigarettes to cope with pain endorsed higher scores on CPCI wellness-focused subscales assessing the use of relaxation and coping self-statements. It is possible that individuals who smoke cigarettes to help cope with chronic pain view smoking cigarettes as an active, purposeful coping mechanism that can provide relaxation and decrease pain-related anxiety. However, in the context of our study findings, this may be a misconception, or at least a fleeting phenomenon.
Individuals who are more pre-occupied with pain may have been more likely to report using cigarettes to cope with pain, and also may have scored worse on the pain measures. Therefore, the lower scores on pain-related function in the smoke-cope group may be less related to the conscious use of cigarettes to cope with pain, and more related to the mediating effect of preoccupation with pain. Although a causal relationship cannot be proven using our study design, smoking cigarettes as a mechanism to cope with pain appears to be associated with greater pain intensity and impairment. Longitudinal research is needed to clarify the interrelationships between cigarette use, coping, and pain-related function.
There are several limitations to this study. The cross-sectional design prevented us from determining causality. We used a single item self-report question to assess coping with pain with cigarettes, which has face validity, but may be only a gross proxy. To follow up on our results, studies should use more comprehensive self-report measures and biological markers of smoking status and behaviors (e.g., expired carbon monoxide). Studies that measure biological variables, such as endogenous opioid levels, may also help determine whether membership in a certain smoking group is associated with a particular chronic pain-smoking phenotype. Also, rather than relying on self-report measures of pain intensity, it may be valuable to measure this variable via quantitative sensory testing. Other limitations relate to the generalizability of our sample. All participants were veterans recruited from a single VA medical center, were predominantly male, middle to older age, and overrepresented by individuals who have the hepatitis C virus and a history of psychiatric and substance use disorders. Our sample also had average pain severity scores in the mild-to-moderate range, so the results may not generalize to those with severe pain.
Despite these limitations, the results of this study may have important clinical implications. Coping strategies for pain are a common focus of interdisciplinary pain treatment programs. However, it is doubtful if much attention is given to the use of smoking cigarettes as a coping strategy for pain and how this may be associated with pain-related function. Our results suggest that smoking cigarettes to cope with pain is associated with poorer pain-related outcome. Therefore, as part of a multidisciplinary pain treatment approach it may be important to assess if a patient is using cigarettes as a coping strategy for pain (in addition to assessing smoking status more generally). Patients who answer in the affirmative may benefit from interventions focused on reducing the use of cigarettes as a coping mechanism and increasing the use of alternative positive, effortful, self-initiated coping strategies (e.g., cognitive self-talk, exercise, relaxation).