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Chronic pain and Cigarette Smoking

Cigarette Smoker Fiona

As a Chiropractor I deal with a a number of people who experience chronic musculoskeletal pain. I typically use Active Release Techniques, Spinal Manipulation, acupuncture and exercise as effective means for caring for this problems. But there are situations where these are not effective.  The reason being is that there are a number of factors that can influence pain.  One of these factors is cigarette smoking.  This might be surprising to many but, the research appears to show an association between chronic pain and cigarette smoking.  Though not all research shows this association the evidence appears to be leaning this way.  Based on this evidence I have begun educating my patients on the need to quite smoking to help out with their pain levels.

Instead of just telling you that there is evidence, here is some of the research on chronic pain and smoking. If you do not have the time to read all of it just read the highlights.

Michael J. Zvolensky, Katherine McMillan, Adam Gonzalez, and Gordon J. G. Asmundson

After adjusting for sociodemographic variables and the presence of a lifetime substance use disorder, individuals with a lifetime history of chronic neck or back pain were significantly more likely to be current smokers and to be diagnosed with lifetime as well as current nicotine dependence. Although there was no significant incremental relation between current chronic neck and back pain and being a current smoker, there was a significant association with lifetime and current nicotine dependence. Similar relations were evident among those with and without medically unexplained chronic pain in regard to smoking status and lifetime and current nicotine dependence.

Marcella Daniel, MD, Francis J. Keefe, PhD, Pauline Lyna, MPH, Bercedis Peterson, PhD, Jennifer Garst, MD, Mike Kelley, MD, Gerald Bepler, MD, and Lori A. Bastian, MD, MPH

The purpose of this study is to evaluate the impact of smoking status after a diagnosis of lung cancer on reported pain levels. We conducted a telephone survey of patients with lung cancer identified from four participating sites between September 2004 and July 2006. Patients were asked to rate their usual pain level over the past week on a 0-10 rating scale on which 0 was ‘no pain’ and 10 ‘pain as bad as you can imagine’. We operationally defined persistent smokers as patients who reported continuing to smoke after their lung cancer diagnosis. A logistic regression analyses was used to test the hypothesis that persistent smokers report higher usual pain levels than non-smokers. Overall, 893 patients completed the survey. The majority (76%) was found to have advanced cancer (Stages IIIb and IV). The mean age was 63 (SD=10). Seventeen percent of the patients studied were categorized as persistent smokers. The mean pain score for the study sample was 3.1 (sd=2.7) and 41% reported moderate (4-6) or severe pain (7-10). A greater proportion of persistent smokers reported moderate or severe pain than non-smokers or former smokers (p<.001). Logistic regression analysis revealed that, smoking status was associated with the usual pain even after adjusting for age, perceived health status and other lung cancer symptoms such as dyspnea, fatigue and trouble eating. In conclusion, patients who continue to smoke after a diagnosis of lung cancer report higher levels of usual pain than non-smokers or former smokers. More research is needed to understand the mechanisms that relate nicotine intake to pain and disease progression in late-stage lung cancer.

Jeanette Milgrom-Friedman, Robyn Penman,Russell Meares

1. Ischaemic pain onset and tolerance in response to a pneumatic blood pressure cuff were compared in 17 non-deprived smokers, 30 deprived smokers, 15 smokers chewing nicotine gum and 16 non-smokers.
2. Following removal of the cuff, all subjects completed the McGill pain questionnaire, rating pain in terms of its sensory, affective, evaluative and miscellaneous qualities.
3. Group differences were found in the time elapsing before reporting the first twinge of pain. Non-deprived smokers had the shortest period to onset of pain. The longer the smokers had been deprived of cigarettes, the longer before the onset of pain.
4. Non-deprived smokers also had a significantly shorter period of pain tolerance compared to deprived smokers.
5. Non-deprived smokers tended to have a faster pain onset and a shorter tolerance period compared to non-smokers.
6. Smokers’ indices of pain were significantly higher on the several sub-scales describing the qualitative pain experience compared to non-smokers and to smokers deprived of cigarettes for more than one hour.
7. Deprivation of cigarettes appears to diminish smokers’ sensitivity to pain significantly below that of non-smokers and smoking cigarettes tends to heighten sensitivity to, or beyond, the level of non-smokers.

In patients who completed evaluation in an outpatient pain clinic, current cigarette smokers reported significantly greater pain intensity and pain interference with functioning. Symptoms were more pronounced in smokers with more severe nicotine dependence.

Boshuizen, Hendriek C. PhD; Verbeek, Jos H.A.M. PhD; Broersen, J P J MSc; Weel, André N.H. MD

Recently smoking has been increasingly implicated as a possible risk factor for low-back pain. One explanation for this finding is confounding by occupation. To investigate this possibility, the relationship between smoking and self-reported back pain was studied within 13 occupations. A relationship between smoking and back pain was observed only in occupations that require physical exertion. The relationship between smoking and other musculoskeletal pain also was explored. Pain in the extremities turned out to be related more clearly to smoking than to pain in the neck or the back. This suggests confounding or a general influence of smoking on pain. It is concluded that prevention of back pain could be a beneficial side-effect of anti-smoking campaigns. However, the prime target for prevention of low-back pain would have to be other factors.


The authors examined associations between back pain prevalence and lifestyle factors (smoking and obesity) using national survey data. Back pain prevalence rose with increasing levels of smoking, with a relative risk of 1.47 for persons reporting 50 or more pack-years of smoking. This association was strongest in persons under the age of 45 years, however, for whom the corresponding relative risk was 2.33. There were similar trends toward greater prevalence with Increasing body mass index, but prevalence rose substantially only in the most obese 20% of subjects (1.7 times higher than the lowest 20%). In a logistic regression, smoking and obesity contributed independent risk, even after controlling for age, education, exercise level, and employment status. Programs for back pain prevention may wish to test interventions for these lifestyle-related factors.

K T Palmer, H Syddall, C Cooper, D Coggon

Objectives: To explore the relation between smoking habits and regional pain in the general population.
Methods: A questionnaire was mailed to 21 201 adults, aged 16–64 years, selected at random from the registers of 34 British general practices, and to 993 members of the armed services, randomly selected from pay records. Questions were asked about pain in the low back, neck, and upper and lower limbs during the past 12 months; smoking habits; physical activities at work; headaches; and tiredness or stress. Associations were examined by logistic regression and expressed as prevalence ratios (PRs).
Results: Questionnaires were completed by 12 907 (58%) subjects, including 6513 who had smoked at some time, among whom 3184 were current smokers. Smoking habits were related to age, social class, report of headaches, tiredness or stress, and manual activities at work. After adjustment for potential confounders, current and ex-smokers had higher risks than lifetime non-smokers for pain at all of the sites considered. This was especially so for pain reported as preventing normal activities (with PRs up to 1.6 in current v never smokers). Similar associations were found in both sexes, and when analysis was restricted to non-manual workers.

Conclusions: There is an association between smoking and report of regional pain, which is apparent even in ex-smokers. This could arise from a pharmacological effect of tobacco smoke (for example, on neurological processing of sensory information or nutrition of peripheral tissues); another possibility is that people with a low threshold for reporting pain and disability are more likely to take up and continue smoking.

Does smoking hurt as well as harm? (or, as if you needed another reason)

Pisinger C, Aadahl M, Toft U, Birke H, Zytphen-Adeler J, & Jørgensen T (2011). The association between active and passive smoking and frequent pain in a general population. European journal of pain (London, England), 15 (1), 77-83 PMID: 20627783

We found significant association, dose-response and reversibility between active smoking and frequent pain in all six locations. Furthermore, we found that increasing intensity of ETS increased the probability of frequent pain in non-smokers, which has not been shown before. In conclusion, several findings in this study indicate a causal link between tobacco smoke and pain, which is supported by recent prospective studies.

I hope this research has been eye opening to you.  If you are a smoker, I advise you to pursue methods of quitting.

Dr Notley
The only dual credentialed Chiropractor / Athletic Therapist in Winnipeg


Originally posted on May 17, 2022 @ 4:40 pm