ABSTRACT
Background
There is a complex relationship between tobacco use and pain. Nicotine provides temporary pain relief but increases the risk of chronic pain. This study aimed to investigate use of tobacco for pain relief and its association with demographic and medical characteristics in Japan.
Methods
We used a web‐based survey to recruit 2000 individuals aged 20–69 who had experienced pain in the previous month. They answered questions on demographics, smoking status, lifestyle, socioeconomic status, and medical information. Smokers were asked if they smoked tobacco to relieve pain. Those who responded “strongly agree” or “agree” were labeled as using tobacco for pain relief. We used analysis of covariance to test the associations among smokers' background characteristics by whether they used tobacco for pain relief.
Results
Overall, 6.6% of smokers with pain (3.5% with acute or subacute pain and 8.8% with chronic pain) used tobacco for pain relief. These individuals were generally younger, more likely to be treated for schizophrenia and use analgesics, with higher pain severity, more catastrophic thinking about pain, and a centralized symptom. However, they were less likely to engage in regular exercise.
Conclusions
Overall, 6.6% of smokers (3.5% with acute or subacute pain and 8.8% with chronic pain) used tobacco to relieve their pain, even though most of them also received medical treatment and used pain medication. Healthcare providers and policy makers should account for this population of smokers in their planning.
Keywords: cohort studies, chronic pain, epidemiology, nicotine, smoking, pain
This research reports the results of a preliminary cross‐sectional study on tobacco use for pain relief in Japan. The survey found that 6.6% of smokers experiencing pain (8.8% in cases of chronic pain) used tobacco for pain relief. Those who used tobacco for pain relief tended to be younger, more likely to be receiving treatment for schizophrenia and pain, had higher rates of analgesic use, and reported greater pain intensity and catastrophic thinking about pain.
1. Introduction
Previous research suggests that tobacco, and particularly nicotine, may have analgesic effects, with potentially increasing pain tolerance and threshold [1]. Both animal studies and human studies have shown that nicotine activates nicotinic acetylcholine receptors, which are distributed throughout the central and peripheral nervous systems, producing an acute analgesic effect [2, 3]. However, the analgesic properties of nicotine are complex and can vary depending on factors such as duration of exposure and dose. While nicotine has a short‐term effect of raising the pain threshold and increasing pain tolerance [1], chronic smoking has been identified as a potential risk factor for the development of chronic pain [4]. Additionally, increased pain perception has been reported during nicotine withdrawal [5].
The mechanisms underlying the analgesic effects of tobacco are thought to involve multiple pathways, including the activation of the endogenous opioid system and the regulation of the hypothalamic–pituitary–adrenal axis [6]. These findings suggest that the relationship between tobacco use and pain is not simple, but rather involves a complex interplay of biological, psychological, and social factors.
However, the association between tobacco use and pain is complex, with chronic nicotine exposure being a risk factor for chronic pain [7]. The higher prevalence of smoking among individuals with chronic pain highlights the bidirectional association between smoking and pain [8]. People using smoking as a coping strategy for chronic pain have worse pain‐related outcomes [9], and nicotine withdrawal can increase pain intensity [10]. Individuals who use tobacco for pain relief may therefore be an important group for application of tobacco control strategies. Despite this, little epidemiological research exists on tobacco use for pain relief, and it remains unclear whether individuals rely on smoking instead of pain medications. The aim of this preliminary study was to investigate the prevalence of use of tobacco for pain relief in a general population, and to explore demographic and medical information related to pain using data from a web‐based survey in Japan.
2. Methods
From October to November 2020, 2000 people aged 20–69 years who reported pain in the past month were recruited via email invitation from the approximately 2.2 million panelists registered with a Japanese Internet survey agency (Rakuten Insight Inc., Tokyo, Japan). The selection was designed to be representative of the Japanese population in terms of age, gender, and geographic distribution. We designed this Internet survey to examine the association between smoking and pain. Of the 2000 respondents, we eliminated responses from 399 former smokers and 1129 people who had never smoked. This left responses from 472 smokers (23.6% of total respondents) who had experienced pain in the past month for analysis. We collected information on smoking status across four categories: daily smoker, occasional smoker, former smoker, or never smoked. We also collected the number of cigarettes smoked per day.
Two original questions were used: “Do you smoke tobacco to relieve pain?” and “Does smoking relieve your pain?” Each had five response options: strongly agree, agree, neither, disagree, and strongly disagree. Respondents who “strongly agreed” or “agreed” with the first question were defined as “individuals who use tobacco for pain relief” and with the second question as “individuals who felt pain relief from smoking.”
We collected information on age, gender (men, women, or other), body mass index (BMI), educational attainment, number of family members living together, and household income. Overweight was defined as BMI of ≥ 25. Equivalized income was calculated by dividing the annual household income by the square root of the number of family members. Poverty was defined by the 2018 Japanese poverty line as an equivalized income < 1.27 million yen [11]. For lifestyle, we collected information on regular exercise (exercise causing light sweating for 30 min or more at a time, for 2 days or more per week, and for 1 year or more; yes or no), and sleep duration (hours). We also collected data for treatment for depression, schizophrenia, other mental health problems, and pain. Sleep < 5 h per night was defined as short.
We collected information on medication use related to pain: over‐the‐counter (OTC) analgesics, prescribed analgesics (prescribed non‐steroidal anti‐inflammatory drugs, pregabalin, and narcotics), hypnotics (OTC or prescribed), anxiolytics, and antidepressants, or none. Pain intensity (average over 4 weeks) was measured using a numerical rating scale (NRS) on an 11‐point scale (0; no pain; 10, maximum imaginable pain). Pain interference was measured using the Japanese version of the five‐item Pain Disability Index (PDI‐5) [12], with scores ranging from 0 to 50 points. Central sensitization symptoms resulting in amplified pain signals was measured by Part A of the Japanese version of the Central Sensitization Inventory (CSI) [13], with scores ranging from 0 to 100 points. Central sensitization symptoms are associated with central sensitization, a phenomenon where sensory input experiences heighten stimulation within the central nervous system [2]. Anxiety and depression were assessed using the Japanese version of the Hospital Anxiety and Depression Scale (HADS) [14], with a total score of 0–21 calculated by summing seven items each for anxiety and depression. Catastrophic thinking about pain, an exaggerated negative attitude toward pain, was assessed using the Japanese version of the Pain Catastrophizing Scale (PCS) [15], with the score ranging from 0 to 52.
Participants were examined using analysis of covariance with Bonferroni correction to test the associations between their background characteristics and whether the purpose of their smoking behavior was to relieve pain. With 26 tests performed, the significance level was adjusted to 0.002 (0.05/25) to mitigate the risk of false positives. SAS 9.4 was used for analysis, and p < 0.002 (two‐tailed tests) were considered statistically significant.
All procedures were in accordance with the ethical standards of the Helsinki Declaration of 1975, as revised in 2013, and the Ethical Guidelines for Epidemiological Research, and the Ethical Guidelines for Clinical Studies in Japan. Respondents were incentivized with Rakuten‐points that could be used for Internet shopping.
3. Results
Table 1 shows the results. A total of 6.6% of smokers with pain (3.5% of smokers with acute or subacute pain and 8.8% of smokers with chronic pain; not shown in the table) used tobacco to relieve pain. Among participants experiencing pain who reported that their primary reason for using tobacco was not to relieve pain, 5.2% experienced pain relief while smoking.
TABLE 1.
Characteristics of smokers by smoking purpose related to pain relief.
| Smoking but NOT for pain relief | Using tobacco for pain relief | p | |||
|---|---|---|---|---|---|
| n = 441 (93.4%) | n = 31 (6.6%) | ||||
| Mean | SD | Mean | SD | ||
| Age, years | 46.5 | 12.3 | 38.1 | 0.2 | < 0.001 |
| n | % | n | % | ||
|---|---|---|---|---|---|
| Women | 103 | 23.4 | 6 | 19.4 | 0.73 |
| Overweight | 127 | 28.8 | 5 | 16.1 | 0.24 |
| High school graduate and under | 122 | 27.7 | 8 | 25.8 | 0.72 |
| Living alone | 113 | 25.6 | 7 | 22.6 | 0.59 |
| Living in poverty | 11 | 2.5 | 3 | 9.7 | 0.01 |
| Lack of regular exercise | 304 | 68.9 | 6 | 19.4 | < 0.001 |
| Short sleep | 59 | 13.4 | 7 | 22.6 | 0.08 |
| Under treatment for depression | 30 | 6.8 | 6 | 19.4 | 0.01 |
| Under treatment for schizophrenia | 3 | 0.7 | 3 | 9.7 | < 0.001 |
| Under treatment for other mental health problems | 18 | 4.1 | 5 | 16.1 | 0.007 |
| Under medical treatment for pain | 101 | 22.9 | 22 | 71.0 | < 0.001 |
| Chronic pain | 248 | 56.2 | 24 | 77.4 | 0.01 |
| Medication use (multiple answers possible) | |||||
| OTC analgesic | 111 | 25.2 | 21 | 67.7 | < 0.001 |
| Prescribed analgesic | 94 | 21.3 | 16 | 51.6 | < 0.001 |
| Prescribed NSAIDs | 56 | 12.7 | 5 | 16.1 | |
| Pregabalin | 3 | 0.7 | 0 | 0.0 | |
| Narcotic | 33 | 7.5 | 12 | 38.7 | |
| Hypnotic (OTC or prescribed) | 45 | 10.2 | 7 | 22.6 | 0.07 |
| Anxiolytic | 32 | 7.3 | 3 | 9.7 | 0.49 |
| Antidepressant | 34 | 7.7 | 6 | 19.4 | 0.04 |
| No pain medication | 214 | 48.5 | 2 | 6.5 | < 0.001 |
| Number of cigarettes | |||||
| 1–9 cigarettes | 116 | 26.3 | 9 | 29.0 | |
| 10–19 cigarettes | 136 | 30.8 | 8 | 25.8 | |
| ≥ 20 cigarettes | 189 | 42.9 | 14 | 45.2 | |
| Mean | SE | Mean | SE | ||
|---|---|---|---|---|---|
| NRS (0–10) | 5.1 | 0.1 | 6.5 | 0.4 | 0.001 |
| PDI (0–50) | 14.3 | 0.6 | 20.5 | 2.2 | 0.006 |
| HADS anxiety (0–21) | 9.9 | 0.1 | 11.0 | 0.4 | 0.003 |
| HADS depression (0–21) | 5.2 | 0.1 | 5.8 | 0.4 | 0.14 |
| PCS (0–52) | 19.9 | 0.6 | 27.2 | 2.2 | 0.001 |
| CSI (0–100) | 27.5 | 0.8 | 41.0 | 3.0 | < 0.001 |
| n | % | n | % | ||
|---|---|---|---|---|---|
| Felt pain relief during smoking | 23 | 5.2 | 28 | 90.3 |
Note: Variables other than age were adjusted for age. Overweight was defined as body mass index ≥ 25 kg/m2. Poverty was defined as an equivalized income < 1.22 million Japanese yen. Chronic pain was defined as pain duration ≥ 3 months. Short sleep was defined as sleep duration < 5 hours per night. Participants were examined using analysis of covariance with Bonferroni correction to test the associations between their background characteristics and whether the purpose of their smoking was to relieve pain. p < 0.002 (0.05/25) was considered statistically significant, and values meeting this criterion are highlighted in bold. n = 472.
Abbreviations: CSI, Central Sensitization Inventory; HADS, Hospital Anxiety and Depression Scale; NRS, numerical rating scale; NSAIDs, non‐steroidal anti‐inflammatory drugs; OTC, over‐the‐counter; PCS, Pain Catastrophizing Scale; PDI, Pain Disability Index; SD, standard deviation; SE, standard error.
Compared with smokers not using tobacco for pain relief, those smoking for pain relief were likely to be younger, under treatment for schizophrenia and pain, use OTC/prescribed analgesic, and have a high NRS score, PCS score, and CSI score. They were less likely to take regular exercise and use no pain medication. Although not statistically significant, those who smoked to relieve pain were more likely to live in poverty, be under treatment for depression and other mental health problems, have chronic pain, use narcotics and antidepressants, and have high PDI and HADS anxiety scores. These variables had p > 0.002 but < 0.05 (two‐tailed tests).
4. Discussion
We found that 6.6% of smokers with pain (8.8% chronic pain) used tobacco to relieve pain. Even among participants who did not primarily use tobacco for pain relief, 5.2% felt less pain when smoking. Smokers using tobacco for pain relief generally tended to be younger, and were often being treated for schizophrenia and pain, with higher use of analgesics, and greater pain intensity and catastrophic thinking about pain. They were less likely to exercise regularly but more prone to using pain medication. They also tended toward poverty, being treated for mental health problems, chronic pain, and higher use of narcotics and antidepressants, along with greater pain interference and anxiety and depression symptoms, compared with those not smoking to relieve pain.
This is the first study of which we are aware to determine the prevalence of tobacco use for pain relief in Japan. The proportion of smokers using tobacco for chronic pain relief may seem relatively low at 24/[248 + 24] = 8.8%. However, when this proportion is translated into actual numbers, the impact becomes more significant. Japan had a population of approximately 126 million in 2024. An estimated 20% of the population experience chronic pain, about 25 million people. An estimated 20% of the population experience chronic pain, approximately 25 million people. Estimates suggest that 42%–68% of people with chronic pain are smokers [2], or 10.5–17 million smokers. Our findings suggest approximately 0.9–1.5 million of these may smoke to relieve chronic pain.
Interestingly, compared with smokers not using tobacco for pain relief, more of those who used tobacco for pain relief were receiving medical care and using analgesics. In other words, they were not using tobacco as a substitute for medical care for pain. This suggests that conventional medical care is not controlling their pain effectively, and they are supplementing with tobacco, using it as additional pain relief when medical interventions are inadequate. The behavior of smoking to relieve pain may have led to nicotine dependence (i.e., substance dependence). This is a very important and new finding from both a pain medicine perspective and a tobacco control perspective. Populations using tobacco for analgesic purposes may have difficulty quitting smoking or treating pain, and further research on this population is needed.
Compared with smokers not using tobacco for pain relief, those who did use it had higher psychological risks and poorer socioeconomic status. While our study did not measure nicotine dependence directly, the literature supports the idea that substance‐dependent individuals face higher psychosocial risks [12]. The higher prevalence of regular exercise habits among those using tobacco for pain relief than other smokers is interesting, but the reason is unclear. Since this is a univariate study, there may be some confounding.
This study had some limitations. First, the cross‐sectional and preliminary design, with a small sample from Japan, limits the generalizability and prevents causal inference. Second, we did not use direct measures to distinguish between smoking for nicotine dependence and smoking for pain relief. Although some participants reported using tobacco for pain relief, we lacked standardized instruments or detailed questions to separate these behaviors. Future studies should include validated scales and focused questions. Third, we did not collect data on participants' smoking history in relation to pain, including whether they started or increased smoking because of pain, or how long they had been smoking. This limits our understanding of the long‐term relationship between pain and smoking behavior. Future research should include questions about smoking initiation, duration, and changes in use related to pain experiences. Finally, we did not assess nicotine dependence with standardized measures that would have provided insight into its association with smoking for pain relief. Future studies should include such assessments to better understand the relationship between nicotine dependence, pain, and smoking.
In conclusion, 6.6% of smokers with pain reported using tobacco for pain relief, mostly for chronic pain. These tobacco users have increased psychosocial risks, and are more likely to seek medical care and use analgesics.
Author Contributions
Keiko Yamada: Acquisition of data, study design, analysis/interpretation of data, and drafting the article. Satoko Chiba, Masako Iseki: Acquisition of data, interpretation of data, and revised the manuscript critically for important intellectual content. Takahiro Tabuchi: Interpretation of data, and revised the manuscript critically for important intellectual content. All authors approved the final version and agreed to be accountable for all aspects of the work thereby ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
Ethics Statement
This cross‐sectional observational study was approved by the Research Ethics Committee, Faculty of Medicine, Juntendo University (approval number: 2020173).
Consent
All participants provided web‐based informed consent before responding to the online self‐report questionnaire.
Conflicts of Interest
T.T. has declared the following potential conflicts of interest. T.T. is received grant support from Japan Society for the Promotion of Science (JSPS) KAKENHI Grant Number JP 21H04856. K.Y., S.C., and M.I. have no competing interests to declare.
Acknowledgments
The authors are grateful to participants of this research. We also thank Melissa Leffler, MBA, from Edanz (https://jp.edanz.com/ac) for editing a draft of this manuscript. We acknowledge the use of ChatGPT‐4 to assist in improving the readability and language of this manuscript.
Funding: This study was supported by Health Labor Sciences Research Grants (22FG2001 for Keiko Yamada and Masako Iseki; 23FA1004 for Takahiro Tabuchi and Keiko Yamada). The findings and conclusions of this article are the sole responsibility of the authors and do not represent the official views of the research funders.
Data Availability Statement
The data used in this study are not available in a public repository because they contain personally identifiable or potentially sensitive personal information. Even when anonymized, it can be difficult to ensure that the data are completely unidentifiable, especially when multiple low‐frequency responses are combined, which could risk identifying participants. Therefore, the Research Ethics Committee, Faculty of Medicine, Juntendo University, approved the research on the condition that the data would not be redistributed. While secondary use of the data requires approval from an ethics committee, the original research plan was approved with the specific condition that the data would not be used for secondary purposes. However, de‐identified data may be shared after consultation with the ethics committee to ensure compliance with ethical guidelines. Researchers interested in accessing the data should contact the data manager, Dr. Keiko Yamada, at keiko-yamada@umin.org. Requests will be considered on an individual basis based on ethical considerations and study requirements.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The data used in this study are not available in a public repository because they contain personally identifiable or potentially sensitive personal information. Even when anonymized, it can be difficult to ensure that the data are completely unidentifiable, especially when multiple low‐frequency responses are combined, which could risk identifying participants. Therefore, the Research Ethics Committee, Faculty of Medicine, Juntendo University, approved the research on the condition that the data would not be redistributed. While secondary use of the data requires approval from an ethics committee, the original research plan was approved with the specific condition that the data would not be used for secondary purposes. However, de‐identified data may be shared after consultation with the ethics committee to ensure compliance with ethical guidelines. Researchers interested in accessing the data should contact the data manager, Dr. Keiko Yamada, at keiko-yamada@umin.org. Requests will be considered on an individual basis based on ethical considerations and study requirements.