The Role of Pain Avoidance in the Relation Between Pain Intensity and Smoking Cessation Processes

Abstract

Scientific evidence suggests that smokers who experience varying levels of pain are more likely to maintain their addiction to tobacco. The relationship between pain intensity and cognitive-based smoking processes within a mechanistic framework has received relatively little attention. Pain avoidance may influence the association between pain intensity and smoking, as it is a construct that is related to adverse pain and smoking processes. Thus, the current cross-sectional study examined the indirect effect of pain intensity on three clinically significant smoking processes (i.e., prior quit problems, perceived barriers for cessation, and negative affect reduction smoking expectancies) through pain avoidance among 95 treatment-seeking adult smokers. Regression analyses were conducted using bootstrapping techniques through PROCESS, a conditional modeling program that utilizes an ordinary least squares-based path analytical framework to test for both direct and indirect associations. Results indicated that pain intensity had a statistically significant indirect association on quit problems and perceived barriers for cessation, through pain avoidance. Pain intensity did not have a statistically significant indirect association on the negative affect reduction smoking expectancies through pain avoidance. The current findings provide evidence for the role of pain avoidance as a potential transdiagnostic mechanism that contributes to maladaptive smoking outcomes within the larger context of the reciprocal model of pain and substance use.

INTRODUCTION

In the United States, cigarette smoking remains the leading preventable cause of death ¹ and cigarette smokers are at increased risk for numerous health conditions (e.g., stroke, coronary, cardiovascular, and respiratory illnesses).¹ Despite the risk of negative effects, approximately 30.8 million Americans continue to smoke cigarettes,¹ and specific subgroups may be more at risk for continued smoking. Although smoking has decreased over time among the general population, smoking rates have remained high among the chronic pain population.²

A large body of work has documented the reciprocal association between pain and smoking.^3,4 Cigarette smoking is related to the development and exacerbation of pain⁵ and individuals experiencing pain may be more motivated to smoke cigarettes to cope with pain.^6,7 Experimental paradigms (e.g., the cold pressor test) have suggested that individuals who are more sensitive to pain may be at greater risk of smoking relapse.⁸ Acute, experimentally induced pain (i.e., heat-pain induction) contributes to smoking urges more so among individuals who expect that smoking cigarettes will alleviate pain compared to individuals who do not hold pain alleviation smoking expectancies, suggesting that the experience of pain may contribute to increased motivation to smoke to relieve pain.⁹ Further, individuals who experience pain tend to exhibit more severe tobacco use behavior, as evidenced by higher levels of nicotine dependence¹⁰ and higher rates of dual tobacco use; (i.e., using electronic cigarettes in addition to using combustible cigarettes)¹¹ relative to smokers without co-occurring pain. Additionally, individuals who report smoking cigarettes to cope with pain tend to endorse higher pain intensity and interference, and greater fear of pain.¹² Moreover, experiencing pain has an impact on pre-cessation smoking processes, including perceived difficulty of quitting smoking and subjective quality of quit attempts and quit success, and smokers who experience pain frequently identify pain as an experience that impedes quit success.^4,7

Importantly, pain-smoking relations have been observed even in the absence of chronic pain.^13–16 Smokers with both chronic and non-chronic pain report greater difficulty quitting during cessation efforts and lower confidence in their ability to stop smoking, indicating that experiencing pain, whether acute or chronic, may hinder their capacity to successfully quit.^16–19 However, there is a need for exploration of pain-related transdiagnostic constructs that may impact the relation between pain and smoking outcomes.

Pain avoidance, defined as an engagement in behaviors that reduce, prevent, or escape the experience of pain,²⁰ is one specific pain-related construct that may be relevant to smoking behavior. Consistent with the fear-avoidance model of pain,²¹ smoking may provide a means of acutely avoiding or escaping both the sensory and affective components of pain experience.²² Importantly, pain-related fear, which may present as pain avoidance behavior, likely exacerbates both nicotine dependence and pain.²³ Regarding sensory pain experience, nicotine may provide acute analgesia, and thus, may help to decrease the intensity of pain short term.²⁴ Smoking may also be used as a coping mechanism for pain-related negative affect.^6,9 Among individuals who smoke and have co-occurring pain, reporting motivation to smoke in response to pain is associated with increased pain interference, and perceiving pain as a barrier to quitting smoking may be related to lower self-efficacy for quitting smoking.²⁵

Utilization of pain-coping strategies, including maladaptive strategies such as pain avoidance, are hypothesized to underlie the pain-smoking association.²² Theoretically, smokers who experience greater pain intensity may be more likely to engage in pain avoidance behavior,^5,21 which can reinforce expectations that smoking helps relieve pain.⁹ In turn, this process may contribute to the continued use of cigarettes as a pain-coping mechanism and greater difficulty quitting smoking.⁷ Thus, avoidance behavior may be indirectly associated with problems experienced during smoking quit attempts¹⁷ and maladaptive beliefs about smoking, including perceiving greater barriers to smoking cessation²⁶ and expectancies that smoking will alleviate negative internal states.^6,27

Despite the links between perceived pain and cessation-related difficulties, little work has examined the relationship between pain avoidance and cessation-related smoking outcomes. To address these gaps in the literature, the current study examined the role of pain avoidance in associations between pain intensity and clinically significant smoking variables, including severity of prior quit problems,²⁸ perceived barriers for smoking cessation,²⁹ and negative reinforcement smoking expectancies.³⁰ Specifically, we hypothesized that higher pain intensity would be indirectly associated with greater quit problems, greater perceived barriers for cessation, and greater negative affect reduction smoking expectancies via pain avoidance, above and beyond the theoretically relevant covariates of age³¹ and sex.¹⁵

METHODS

Procedure

Adult daily smokers were recruited from the Houston community through a variety of methods (e.g., flyers, newspaper ads, online posts) to participate in smoking cessation treatment. Interested participants were scheduled for an in-person baseline assessment to determine study eligibility. Following written informed consent, participants completed a self-report battery of questionnaires. Participants were compensated $20 for their time. The current study sample consists of baseline data from participants who provided responses for all variables used in the current study and endorsed experiencing chronic pain in the last 6 months. The study protocol was approved by the Institutional Review Board at the sponsoring institution.

Participants

A total of 200 individuals completed the baseline appointment for the parent randomized controlled trial, wherein eligibility was assessed. Participants who met the following inclusion criteria at the initial screening survey administered via telephone were invited to participate in the baseline appointment: (1) (1) being between 18 and 65 years of age; (2) reporting daily smoking; (3) being motivated to quit smoking (i.e., rating their motivation to quit smoking at least a 5 out of 10). Exclusion criteria were (1) self-reported pregnancy, (2) current use of nicotine replacement therapy and/or smoking cessation counseling not provided by the research staff; (4) reported illicit substance use in the last 6 months; or (5) an inability to provide informed, voluntary, written consent to participate.

The current analysis represents a subset of individuals (N = 95) from the baseline data of the parent trial who met the following criteria: (1) reported smoking at least 1 cigarette daily; (2) reported experiencing chronic pain in the last 6 months; (3) provided complete data for the variables of interest. Specifically, 59 participants were excluded because they did not smoke at least 1 cigarette daily, 16 were excluded because they did not report experiencing pain, and 30 were excluded because they had missing data for one or more variables of interest. The final sample for the current analyses included 95 adults (M_age = 44.99, SD = 10.52; n=32 female). Mean difference tests indicated that the current sample (N = 95) did not significantly differ from individuals who were part of the larger study but did not meet the eligibility criteria for the current analyses (N = 105) in terms of smoking characteristics (i.e., average cigarettes per day, nicotine dependence), pain outcomes, or smoking outcomes (i.e., barriers to cessation, prior quit problems, and negative reinforcement abstinence expectancies).

Measures

Demographics Questionnaire.

The demographics questionnaire collected sociodemographic information, including sex, race, and age. Fagerström Test for Cigarette Dependence (FTND)³² was used to assess cigarette dependence. Demographic information was used to describe the sample, and sex and age were included as a priori covariates in all study models.

Perceived Barriers for Cessation Scale (BCS).

The BCS²⁹ is a 19-item self-report assessment of perceived barriers to or stressors resulting from smoking cessation (e.g., “Feeling less in control of your moods”). Responses are provided on a 4-point Likert scale ranging from 0 (not a barrier) to 3 (large barrier). The BCS has three subscales as originally developed: Addictive Barriers, External Barriers, and Internal Barriers. The BCS has demonstrated strong psychometric properties in a sample of treatment-seeking smokers.^10,33 The BCS total score, which is the sum of all items, was utilized in the present study in order to capture the severity of perceiving barriers to quitting smoking across addictive barriers, external barriers, and internal barriers (Cronbach’s α = .88).

Smoking History Questionnaire.

The Smoking History Questionnaire (SHQ)²⁸ is a self-report questionnaire used to assess smoking history (e.g., the onset of regular daily smoking), pattern (e.g., number of cigarettes consumed per day), and problematic symptoms experienced during prior quit attempts (e.g., weight gain, nausea, irritability, and anxiety). As in past work,³⁴ a mean composite score of severity of problematic psychosomatic experienced during prior quit attempts was derived from this measure. Items were rated on a 1 (not at all) to 5 (extremely) Likert scale. The severity of these items was summed and divided by 17 to compute the mean composite score and served as an outcome in the present study. This scale demonstrated excellent internal consistency (Cronbach’s α = .93). The SHQ was also employed to describe the sample smoking history.

Smoking Consequences Questionnaire (SCQ).

The SCQ contains 50 self-report items assessing subjective positive and negative expectancies of the smoking.³⁰ Responses are provided on a 10-point Likert scale ranging from completely unlikely (0) to completely likely (9). The SCQ consists of four subscales: Negative Consequences (18 items that describe negative consequences of smoking, e.g., “My throat burns after smoking”), Negative Reinforcement/Negative Affect Reduction (12 items that assess expectancies that smoking will reduce negative affect, e.g., “Cigarettes help me deal with anger”), Positive Reinforcement/Sensory Satisfaction (15 items that evaluate expectancies for smoking to provide sensory satisfaction and promote positive consequences, e.g., “Cigarettes are good for dealing with boredom), and Appetite–Weight Control (5 items that assess beliefs for smoking to suppress one’s appetite, e.g., “Smoking helps me control my weight”). The Negative Reinforcement/Negative Affect Reduction subscale was utilized as a measure of negative affect reduction of smoking expectancies in the present study as a criterion variable (Cronbach’s α = .94).

Psychological Inflexibility in Pain Scale (PIPS)

The PIPS contains 16 self-report items assessing psychological inflexibility (i.e. avoidance, acceptance, fusion, values orientation, dirty discomfort) in people with chronic pain.²⁰ Responses are provided on a 7-point Likert scale ranging from (1) never true to (7) always true. The current study utilized the avoidance subscale of PIPS (e.g., “When I am in pain, I stay away from other people”) as a cross-sectional mediating variable. It demonstrated good internal reliability in the current sample (Cronbach’s α = .86).

Graded Chronic Pain Scale (GCPS)

The GCPS consists of 7 self-report items which serve to assess the severity of chronic pain (i.e. pain intensity, disability, persistence, and recency of onset) in the general population.³⁵ Responses are provided on a 10-point Likert scale ranging from (1) no pain to (10) pain as bad as it could be. The current study employed the 3-item pain intensity subscale (e.g., “In the past 6 months, how intense was your worst pain rated on a 0–10 scale where 0 is ‘no pain’ and 10 is ‘pain as bad as could be’”) as the predictor variable in all models (Cronbach’s α = .85).

Analytic Strategy

Sample descriptive statistics and zero-order correlations among study variables were examined. Cross-sectional regression analyses were conducted using bootstrapping techniques through the ‘mediation’ function in PROCESS, a conditional modeling program that utilizes an ordinary least squares-based path analytical framework to test for both direct and indirect associations.³⁶ Bootstrapping is the recommended approach when the data distribution is non-normal or unknown.^37,38 In PROCESS, path a refers to the relation between the predictor (X) and the ‘mediator’ (M), path b refers to the relation between the ‘mediator’ (M) and the outcome (Y), and path c refers to the relation between the predictor (X) and the outcome (Y; see Figure 1). An indirect association is the product of path a and path b and is assumed to be significant if the confidence intervals (CIs) around their product do not include zero.^39,40 Effect size in cross-sectional ‘mediation’ analysis was assessed with the completely standardized indirect effect size (ES), represented as the indirect effect of a one-unit change in the standardized predictor (1 unit=1 standard deviation) on the standardized outcome. ES is interpreted as small (0.01), medium (0.09), and large (0.25).⁴¹

Figure 1.

Conceptual model of the indirect association (ab) of pain intensity on quit problems, barriers to cessation, and negative reinforcement smoking consequences through pain avoidance.

Note: N = 95; * p < .05. a path = Effect of X on M; b paths = Effect of M on Y_i; c paths = Total effect of X on Y_i; c’ paths = Direct effect of X on Y_i controlling for M. Three separate paths were conducted (Y_1–3) with the predictor (X). Covariates included in the establishment of paths included: Age and Sex.

Three models were conducted with (1) perceived barriers for cessation (as measured by the BCS), (2) quit problems (as measured by the SHQ), and (3) negative reinforcement smoking consequences (as measured by the SCQ-NR) as criterion variables. Pain avoidance (as measured by PIPS avoidance) served as the hypothesized mediator and pain intensity (as measured by GCPS) served as a predictor variable in all models. Covariates, determined a priori based on theoretical relevance, included sex (0 = male, 1 = female) and age, as past work indicated these variables contribute to smoking and chronic pain. ^15,31 Models were subjected to 10,000 bootstrap re-samplings and 95 percent CIs were estimated.^39,42,43

RESULTS

Descriptive Analyses

The racial/ethnic distribution of the current sample was 58.9% (n = 56) Non-Hispanic/Latino Black, 31.6% (n = 30) Non-Hispanic/Latino White/Caucasian, 4.2% (n = 4) Hispanic White, 3.2% (n = 3) Non-Hispanic/Latino ‘Other’, 1.1% (n = 1) Hispanic/Latino Black, and 1.1% (n = 1) Non-Hispanic/Latino Asian. Participants reported smoking 18.09 (SD = 17.05) cigarettes per day and reporting they have been smoking daily for an average of 24.76 (SD = 12.54) years. The average level of nicotine dependence of the sample (as measured by the FTND)³² was 5.44 (SD = 1.87), which is in the moderate range. On average, participants reported experiencing chronic pain on 59.14 days of the past 180 days (SD = 69.69) with an average pain intensity score of 13.53 (SD = 7.62); and a disability score of 11.79 (SD = 10.96), as measured by the GCPS.³⁷ All participants underwent a mental health assessment via the SCID-I, and most participants (81.1%) met diagnostic criteria for at least one psychological disorder within the past year. Major depressive disorder (24.3%, n = 24) was the most endorsed disorder, followed by alcohol abuse (10.5%, n = 10), substance abuse (8.5%, n = 8), bipolar disorder (7.4%, n = 7), posttraumatic stress disorder (7.4%, n = 7), social anxiety (7.4%, n = 7), generalized anxiety disorder (7.4%, n = 7), and specific phobia (1.1%, n = 1). See Table 1 for additional sample sociodemographic information.

Table 1.

Sociodemographic Characteristics of Participants.

		M	SD
Age		44.9	10.52
		n	%
Gender	Female	31	32.6%
	Male	64	67.4%
Ethnicity	Hispanic	5	5.3%
	Non-Hispanic	90	94.7%
Race	White	34	35.8%
	Black/African American	57	60.0%
	Asian	1	1.1%
	Native Hawaiian or Other Pacific Islander	0	0.0%
	Native American/Alaska Native	0	0.0%
	Other	3	3.2%
Highest Level of Education	Graduate school	9	9.5%
	College graduate	7	7.4%
	Partial college	40	42.1%
	High school graduate	31	32.6%
	Partial high school	6	6.3%
	Junior high school	2	2.1%
Annual Income	Not given	18	18.9%
	$0 to $4,999	35	36.8%
	$5,000 to $9,999	11	11.6%
	$10,000 to $14,999	10	10.5%
	$15,000 to $24,999	7	7.4%
	$25,000 to $34,999	7	7.4%
	$35,000 to $49,999	4	4.2%
	$50,000 to $74,999	3	3.2%
	> $75,000	0	0.0%
Employment (past 3 years)	Full-time employment	14	14.7%
	Part-time employment	23	24.2%
	Dependent on spouse or is a student	6	6.3%
	Recipient of public or private assistance	25	26.3%
	Not given	27	28.4%
		M	SD
Smoking characteristics	Average cigarettes per day	18.09	17.05
	Average years smoked	24.76	12.54
	Average nicotine dependence (FTND)	5.44	1.87

Note: N = 95.

Zero-order correlations among all study variables are presented in Table 2. Pain intensity was positively correlated with pain avoidance (r = .44; p < .001) and prior quit problems (r = .27, p = .01), but not barriers for cessation (r = .14, p = .18) or negative affect reduction expectancies (r = .16, p = .12). Pain avoidance was positively correlated with perceived barriers for cessation (r = .32, p = .001) and prior quit problems (r = .39, p < .001). All criterion variables were statistically significantly and positively correlated with one another (r’s range = .39 - .61, p < .01).

Table 2.

Descriptive Statistics and Correlations among Variables

	Mean/[n]	SD / [%]	1.	2.	3.	4.	5.	6.	7.	8.	9.
1. Age	44.98	10.51	--
2. Sex (female)	[31]	[32.60]	−.27**	--
3. SF-36	2.94	1.12	.14	−.02	--
4. FTCD	5.44	1.86	−.01	.09	.16	--
5. GCPS-CPI	13.52	7.62	−.05	−.08	.35**	.11	--
6. PIPS-avoid	23.89	10.64	.03	.03	.40**	.15	.44**	--
7. Prior quit problems	2.29	.89	−.19	.30**	.33**	.28**	.27**	.39**	--
8. BCS	27.88	11.62	−.20	.23*	.20	.35**	.14	.32**	.58**	--
9. SCQ-NR	5.67	2.27	−.25*	.18	.16	.25*	.16	.19	.52**	.61**	--

Note. N = 95

^***p < .001

^**p < .01

^*p < .05.

Sex: 0 = Male, 1 = Female; SF-36= 36-Item Short Form Health Survey ⁵⁷; FTCD= Fagerström Test for Cigarette Dependence ³³; GCPS-CPI= Graded Chronic Pain Scale-Chronic Pain Intensity ³⁷; PIPS-avoid= Psychological Inflexibility in Pain Scale- Avoidance of Pain ; Prior quit problems= Smoking History Questionnaire ²⁹; BCS = Barriers to Cessation Scale ³⁰; SCQ-NR = Smoking Consequences Questionnaire-Negative Reinforcement/Negative Affect Reduction.³¹

Indirect association Analyses

Severity of prior quit problems.

For severity of quit problems, including covariates and pain intensity in the regression model accounted for statistically significant variance (R²= .18, F[3, 91] = 6.85, p < .001). The addition of pain avoidance accounted for greater variance in prior quit problems (R² =.27, F[4, 90] = 8.30, p < .001). The independent indirect association of pain intensity on perceived prior quit problems through pain avoidance was statistically significant (ab =.02, SE =.01 CI_95%[.01, .04]), such that higher pain intensity was related to higher pain avoidance (a path: b = .63, SE = .13, p < .001), which was associated with more prior quit attempts for cessation (b path: b = .03, SE =.01, p = .002; see Figure 1). The effect size (ES) for the statistically significant indirect association was medium (ES= .15, CI_95%[.04, .32]).

Perceived barriers for smoking cessation

For perceived barriers for smoking cessation, including covariates and pain intensity in the regression model accounted for statistically significant variance (R² .09, F[3, 91] = 3.14, p = .03). The addition of pain avoidance accounted for greater variance in perceived barriers for cessation (R² = .18, F[4, 90] = 4.83, p =.001). The independent indirect association of pain intensity on perceived barriers for cessation through pain avoidance was statistically significant (ab = .22, SE =.11, CI_95% [.05, .48), such that higher pain intensity was related to higher pain avoidance (a path: b = .63, SE = .13, p < .001), which was associated with greater perceived barriers for cessation (b path: b = .35, SE = .12, p = .003; see Figure 1). The effect size for this pathway was in the medium range (ES = .15, CI_95% [.03, .33]).

Negative affect reduction expectancies

For negative affect reduction smoking expectancies, including covariates and pain intensity in a regression model accounted for statistically significant variance (R² = .10, F[3, 91] = 3.40, p = .02). The addition of pain avoidance to the regression model did not account for a significant variance in negative affect reduction expectancies beyond the effect of pain intensity and covariates (R² = .12, F[4, 90] = 3.05, p < .02). Higher pain intensity was related to higher pain avoidance (a path: b = .63, SE = .13, p < .001), however, pain avoidance was not significantly related to negative reinforcement smoking expectancies (b = .03, SE = .02, p = .17). The indirect association between pain intensity and negative affect reduction expectancies via pain avoidance was not statistically significant (ab = .02, SE = .02, CI_95% [−.01, .06]; see Figure 1).

Specificity Analyses

To further strengthen the interpretation of results, pain intensity and pain avoidance variables were reversed for the two statistically significant models;⁴³ specifically, for prior quit problems and barriers for cessation, PIPS-Avoidance was entered as the predictor, GCPS was the explanatory variable. Tests of the indirect associations in these models were estimated based on 10,000 bootstrap re-samples. All results of the reversed models were non-significant (BCS: ab = 0.00, SE = 0.07, CI_95% [−0.14, 0.13]; SCQ-NR: ab = 0.01, SE = 0.01, CI_95% [−0.02, 0.03]), which supports the conceptual ordering of the models.

DISCUSSION

The current study examined the indirect association of pain intensity, through pain- avoidance, in relation to smoking cessation-related processes, including prior quit problems, perceived barriers for smoking cessation, and negative affect reduction expectancies. Results indicated that pain intensity was significantly indirectly associated with both problems experienced during prior quit attempts and perceived barriers for smoking cessation through pain avoidance. However, there was no discernible indirect association of pain intensity on negative affect reduction smoking expectancies.

Further, specificity analyses were conducted by reversing pain intensity and pain avoidance (i.e., entering pain avoidance as the predictor variable and pain intensity as the mediating variable) for each of the statistically significant models, and indirect associations were no longer significant. This finding suggests that greater pain intensity may be associated with greater pain avoidance, which in turn, may be associated with more severe prior cessation problems and greater perceived barriers for cessation. Effect sizes for the indirect associations were medium. These findings are consistent with prior research documenting the relation between pain intensity and pain avoidance.^5,21 In the context of smoking, individuals may be motivated to use smoking as a means to alleviate or modulate pain as well as the negative emotional experience associated with pain. Indeed, nicotine acts as an acute analgesic²⁴ and individuals often report using smoking as a coping mechanism for negative affect,^6,9 which may reinforce smoking behavior.⁹ Theoretically, if individuals rely on smoking as a mechanism for avoiding pain, they may experience increased difficulties related to quitting smoking,⁷ including endorsing stronger beliefs that there are barriers that stand in the way of them successfully quitting smoking (i.e., barrier for smoking cessation) and experiencing more difficulties when attempting to quit smoking (i.e., quit problems). The current study adds to the extant literature by identifying pain avoidance as an underlying cognitive factor that may contribute to smoking cessation-related difficulties among individuals who smoke cigarettes and are experiencing pain.

Contrary to our hypothesis, negative affect reduction smoking expectancies were not significantly associated with either pain intensity or pain avoidance. It is important to mention that the questionnaire used to measure negative affect reduction expectancies for smoking specifically captured beliefs that smoking would alleviate negative affect (e.g., anger, sadness, worry) and not necessarily pain. It is possible that there are other key variables, such as anxiety sensitivity^44,45 or distress tolerance,^46,47 that are more centrally relevant to negative affect reduction expectancies for smoking. Although a different pattern of findings might emerge when examining the impact of pain intensity and pain avoidance on pain alleviation expectancies, future work is needed to explore this possibility.

Clinically, the results provide support for targeting pain avoidance tendencies as a transdiagnostic risk factor in smoking cessation programs for smokers who experience pain. Although some work has focused on developing integrated cessation treatments for smokers with pain,⁴⁸ research in this area is limited,⁴⁹ despite a multitude of past work documenting bidirectional pain-smoking relations.^{3,5,7,16,22,50} In future smoking cessation treatments for smokers with pain, it may be beneficial to employ techniques, such as interoceptive exposure of pain sensations⁵¹ and teaching mindfulness and acceptance,⁵² to reduce pain avoidance.

There are several limitations to the current study that should be noted. First, the study employed a cross-sectional design, which limits assumptions that can be made regarding causality. While the current study offers initial relevance on how pain avoidance may attribute to cessation-related difficulties, future studies should replicate the findings using a longitudinal study design to better understand how pain avoidance may impact smoking behaviors. Second, the generalizability of the current study to the general population of smokers is limited due to multiple factors. For example, the current sample consisted of treatment-seeking smokers who were motivated to quit smoking (i.e., they rated their motivation to quit at least a 5 on a 10-point scale). Given that motivation to quit smoking and treatment-seeking behavior are directly relevant to smoking cessation processes and likelihood of engaging in future smoking quit attempts,^53,54 additional work is needed to explore how pain, pain avoidance, and smoking processes relate among non-treatment-seeking smokers. Additionally, the current sample was predominantly male (n=68). Therefore, future studies should aim to explore these relations in a sample with a more equal sex distribution. Further, the current sample was predominantly (n=56) Non-Hispanic Black. Non-Hispanic Black individuals who smoke are a subgroup of smokers that may be more vulnerable to experiencing greater difficulty quitting smoking.⁵⁵ For example, Non-Hispanic Black smokers have higher rates of relapse following a quit attempt compared to the general population.⁵⁶ Additional research would benefit from determining whether the current findings extend to smokers of various races and ethnicities. It is also important to mention that the currentl sample was predominantly low-income and approximately one quarter of the sample (26.3%) reported receiving public or private assistance. Large scale population-based studies have found that low-income individuals, and particularly individuals below the poverty line, are more likely to smoke and evince greater challenges with quitting smoking than individuals with income above the poverty line.^57–59 It is important to replicate the observed findings in a sample of higher-income smokers to see if these findings would generalize. Lastly, we only explored a few smoking-related processes. Future work would benefit from further exploring smoking constructs, such as subfacets of barriers to cessation (i.e., addictive barriers, external barriers, and internal barriers), in the context of pain and pain avoidance behaviors to further parse apart the observed relations and to provide a more nuanced understanding of how pain and pain avoidance contribute to smoking-cessation-related processes.

CONCLUSIONS

Overall, the current findings offer a novel perspective on the role of pain avoidance in the relationship between pain severity and cessation-related smoking outcomes. This study adds to the extant literature by providing evidence for the role of pain avoidance as a potential transdiagnostic mechanism that contributes to maladaptive smoking outcomes within the larger context of the reciprocal model of pain and substance use.⁴ Continued study of pain avoidance in the context of smoking behavior could provide valuable insights for modifying and developing smoking cessation interventions for smokers who experience pain.

Data Availability:

Data will be made available upon request.