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. Author manuscript; available in PMC: 2025 Feb 22.
Published in final edited form as: Psychiatry Res. 2016 Feb 3;237:67–71. doi: 10.1016/j.psychres.2016.01.073

Pain intensity and smoking behavior among treatment seeking smokers

Jafar Bakhshaie a,*, Joseph W Ditre b, Kirsten J Langdon c,d, Gordon JG Asmundson e, Daniel J Paulus a, Michael J Zvolensky a,f
PMCID: PMC11846046  NIHMSID: NIHMS2053932  PMID: 26921054

Abstract

Empirical evidence supporting the interplay between pain intensity and tobacco smoking has been growing. The current investigation advances this work in three important ways: (1) controlling for negative affectivity and gender; (2) examining pain intensity in smokers from a community sample, rather than specialized pain treatment centers; and, (3) studying smokers who are highly motivated to quit. Participants were adult smokers (N = 112; 35% female; Mage = 41.4, SD = 13.1) participating in a larger study examining barriers to cessation during a self-guided quit attempt. At baseline, participants completed self-report measures on pain intensity and smoking severity outcomes. As hypothesized, more intense pain was significantly associated with all four smoking severity variables: years as a daily smoker, current cigarettes per day, cigarettes per day during the heaviest lifetime smoking period, and current level of nicotine dependence. These associations remained when taking into account the variance accounted for by gender and negative affectivity. These data provide evidence that more intense pain is related to more severe smoking behavior and nicotine dependence. Pain reduction could be an important target in regard to smokers with chronic pain.

Keywords: Tobacco smoking, Nicotine dependence, Addiction, Pain intensity, Behavior, Emotion

1. Introduction

Chronic pain and tobacco addiction are both highly prevalent conditions that are theorized to interact in a bidirectional manner (Ditre et al., 2008, 2011; Parkerson et al., 2013). Tobacco addiction is a risk factor for chronic pain (Shiri et al., 2010; Sugiyama et al., 2010), and individuals who live with painful conditions are more likely to be dependent on nicotine (Cook et al., 2007; Fertig et al., 1986; Heckman et al., 2012; Jarvik et al., 1989; Pomerleau, 1986). The integrative reciprocal model of pain and smoking posits a positive feedback loop between pain and tobacco smoking that leads to worsening of both conditions (Ditre et al., 2008). Prior research has demonstrated positive associations between pain intensity and smoking behavior among persons in the general population (Hahn et al., 2006) and among those with chronically painful conditions (e.g., Andersson et al., 1998; Deyo and Bass, 1989; Kaila-Kangas et al., 2003; Melis et al., 2010; Oleske et al., 2004; Riley et al., 2004; Saag et al., 1997; Scott et al., 1999; Yunus et al., 2002).

Although promising, previous research in this emerging domain has been limited in three key ways. First, previous studies of pain intensity and smoking behavior have failed to account for the influence of negative affectivity, thus potentially obscuring the extent to which pain intensity may be uniquely related to smoking behavior above and beyond the broad-based tendency to experience negative emotional states. This information is important because elucidating the extent to which pain is associated with smoking outcomes over and above general factors, such as negative affectivity, may usefully inform whether smoking cessation interventions should target pain in addition to affective states. Moreover, although gender has been controlled for when looking at association between pain status and smoking (e.g., Zvolensky et al., 2009, 2010), previous work has not examined or adjusted for the role of gender in “pain intensity-smoking” relation. Given that gender has been shown to influence both pain ratings and smoking behavior (Jamner et al., 1998; Unrod et al., 2004), it is important to determine the unique contribution of both pain and gender when examining smoking behavior.

Second, past work has focused almost exclusively on treatment-seeking pain patients, which may have resulted in a severity range restriction governing or influencing the strength of past observed associations (i.e., a Berskon’s bias, wherein the most severe cases are studied, (Roberts et al., 1978). In a recent example of research on pain-smoking relationship among treatment seeking smokers, Bastian et al. (2015) examined the role of smoking behavior on pain intensity. In multivariate analysis, they found no association between abstinence and subsequent pain intensity. However, no study among treatment seeking smokers has evaluated the association of pain intensity with smoking behavior as a criterion variable in the context of other relevant factors. An important next step is to evaluate the role of pain severity more generally, including those with little or no pain, moderate pain, and severe pain in terms of smoking behavior. Indeed, examining relations between pain intensity and smoking in a sample experiencing a wide range of pain will likely yield valuable and novel information regarding the nature of these associations.

Third, past work has infrequently included participants endorsing high levels of motivation to quit smoking. It may be especially important to understand the association of pain intensity with severity of smoking behavior among smokers who are more willing to quit in order to better understand how pain may impact the quit experience. This knowledge could guide interventions addressing pain as a potential barrier to quit.

In sum, addressing the above-mentioned gaps in the literature will yield key insights into pain-smoking associations. To do so, the present study evaluated the association between intensity of past-month pain, (“none to mild” versus “moderate to severe”), and several indices of smoking severity, including smoking rate per day, number of years being a daily smoker, levels of smoking per day during the heaviest smoking period, and nicotine dependence among a community-based sample of daily smokers participating in a study of self-guided quit attempt. This research represents a theory-driven test of hypotheses geared toward empirically understanding the relation between “smoking behavior” and “pain intensity.” We hypothesized that “moderate to severe” past-month pain (relative to lower levels of past-month pain) would be associated with more severe smoking behavior, and that these relations would remain significant even after accounting for variance due to participant gender and negative affectivity.

2. Method

2.1. Participants

Study participants were required to: (1) be between 18 and 65 years of age; (2) report regular daily smoking for at least one year; (3) smoke at least 8 cigarettes per day (verified via expired CO); (4) endorse motivation to quit smoking of at least 5 on a 0–10 point scale; (5) report interest in making a serious quit attempt; and (6) not have decreased their daily cigarette intake by more than half in the past six months. Participants were excluded from the study based on evidence of: (1) limited mental competency (not oriented to person, place, and/or time) and the inability to give informed, voluntary, written consent to participate; (2) self-reported pregnancy or the possibility of being pregnant; (3) current use of nicotine replacement therapy and/or smoking cessation counseling; (4) current or past history of psychotic-spectrum symptoms or disorders; (5) current substance dependence (excluding nicotine dependence); (6) suicidality; and (7) any current use of psychotropic medication that was not stable for at least 3 months. Thirty eight participants were deemed ineligible based on these criteria.

2.2. Measures

Structured Clinical Interview for DSM-IV-TR Axis I Disorders, Non-Patient Version (SCID-I/NP).

Diagnostic exclusions and prevalence/incidence of current (past month) Axis I diagnoses were assessed via the SCID-NP (First et al., 2002). The non-patient version was utilized as participants enrolled in the present study were not identified as psychiatric patients. The SCID-I/NP follows the DSM-IV-TR (American Psychiatric Association, 1994) diagnosis guidelines and demonstrates good psychometric properties (Shear et al., 2000). Interviews were audio-taped and the reliability of a random selection of 10% of interviews was checked for accuracy. No dissimilarities were observed between the SCID interviewer and an outside rater regarding diagnoses.

Smoking History Questionnaire (SHQ) (Brown et al., 2002).

The SHQ is a self-report questionnaire used to assess smoking history and pattern (e.g., smoking rate, age of onset of initiation). It has been successfully used in previous studies as a measure of smoking history (Zvolensky et al., 2004). The present study utilized the following variables from the SHQ: number of years being a daily smoker, average number of cigarettes smoked per day (current), average number of cigarettes smoked per day when smoking the heaviest, and mean age of first smoking.

Fagerstrom Test for Nicotine Dependence (FTND) (Heatherton et al., 1986).

This instrument is a well-established six-item scale designed to assess gradations in tobacco dependence. This measure exhibits good internal consistency, high degrees of test–retest reliability (Pomerleau et al., 1994) and positive relations with key smoking variables (e.g., salivary cotinine; (Heatherton et al., 1986; Payne et al., 1994). The FTND demonstrated typical-range internal consistency among the present study sample (Cronbach’s alpha = .59). In the present study, the Heaviness of Smoking index(HSI) derived from the first two items of FTND was used as a criterion variable. The HSI is robustly related to quit behavior (Huang et al., 2008; Chabrol et al., 2005; Etter et al., 1999; Fagerstrom et al., 2012).

The Short-Form General Health Survey (GHS)

(Stewart et al., 1988) was used to assess current levels of bodily pain. The GHS consists of 20-items that ask respondents to indicate perceptions of their health status on a Likert-type scale. As has been done in past work (Ditre et al., 2011) the current investigation utilized question 2 on the GHS-“How much bodily pain have you had during the past four weeks” with four response options: none, very mild, mild, moderate, and severe. This item indexed non-specific pain; that is, it was not oriented on a particular pain-related medical condition. Based on the response to this question, a dichotomous variable was constructed consisting of two groups: (1) individuals who had experienced moderate to severe pain during the past month; and (2) individuals who had experienced none to mild pain during the past month (i.e. the “pain intensity dichotomy”). Specifically, moderate to severe pain intensity is typically employed as a categorical variable in research on pain-addictive behavior comorbidity and is reliably associated with personal impairment (Candiotti and Gitlin, 2010; Jaffe and Martin, 1990; Passik and Weinreb, 2000).

Positive and Negative Affect Scale (PANAS).

Negative affectivity was assessed with the negative affectivity subscale of the PANAS (Watson et al., 1988), a self-report measure that asks participants to rate the extent to which they generally experience each of 10 different feelings and emotions (e.g. nervous) using a Likert scale that ranges from 1 (Very slightly or not at all) to 5 (Extremely). The measure has strong psychometric properties (Watson et al., 1988). In the present study, the PANAS negative affectivity subscale demonstrated good internal consistency (α = .92).

2.3. Procedures

Participants were recruited from two sites—The University of Vermont, Burlington, VT, USA (86.3%) and the University of Houston, Houston, TX, USA (13.7%)—at which identical procedures were executed (April 2010 until December 2012). Participants were recruited to take part in a larger study examining barriers to smoking cessation, in which daily smokers were asked to engage in a self-guided quit attempt. Individuals who responded to advertisements for a research study on “quitting smoking” were scheduled for a baseline session to determine eligibility and collect baseline data. Participants were then instructed to refrain from smoking for 12 h prior to quit day that was scheduled for 14 days following the baseline session. At quit-day, smoking status was verified by a CO monitor. Participants then attended 5 in-person follow up visits till day 90 post-quit. At baseline session (that is the source data for current study), upon arrival at the laboratory, participants provided written informed consent and were administered the SCID-I/NP by a trained graduate student. Participants biochemically verified their smoking status via expired CO (> 48 ppm) (Society for Research on Nicotine and Tobacco Subcommittee on Biochemical Verification, 2002). The study was approved by Institutional Review Boards of both universities and participants, regardless of eligibility, were compensated $20 for participating in the baseline session. For the current study, baseline assessments of pain, smoking and other relevant psychological characteristics were utilized.

2.4. Analytic strategy

Four separate t-tests were conducted to compare the pain intensity dichotomy in relation to the smoking variables. To test the effect of pain intensity on smoking variables, we employed Generalized Linear Modeling in Proc GLM (SAS 9.4). For each t-test that evidenced between group differences on a criterion variable, we ran GLM models to examine associations between pain intensity and the criterion variable of interest. Four hierarchical regression analyses were then conducted. In the first block of each model, pain intensity dichotomy was entered. In the second block, gender and negative affectivity were entered.

3. Results

3.1. Descriptive data and between group comparisons

Participants included 112 adult smokers (35% female; Mage = 33.21, SD = 13.69; age range = 18–64) who met eligibility criteria for a larger smoking study involving a self-guided (i.e., no psychosocial or pharmacological intervention) quit attempt. The racial composition was 82.2% White, 9.3% Black or African American, 5.1% “mixed,” 2.6% Hispanic/Latino, and.8% Asian. The sample was fairly well-educated, with only 20.1% endorsing less than some college experience. Participants reported a mean age of first smoking at 14.7 (SD = 3.2) with a mean number of cigarettes smoked per day of 16.2 (SD = 9.2). On average, participants endorsed high levels of nicotine dependence as evidenced by the self-report Fagerstrom Test for Nicotine Dependence (FTND; M = 5.6; SD = 1.9) and confirmed via expired carbon monoxide (CO) reports (M = 16.9; SD = 9.9 ppm). As assessed by the Structured Clinical Interview for DSM-IV-TR Axis I Disorders-Non-Patient Version (First et al., 2002), 48.3% of the sample met criteria for current (past month) Axis I psychopathology. The most common diagnoses included Social Phobia (13.9%), Specific Phobia (11.5%), Alcohol Dependence (10.7%), and Marijuana (Cannabis) Dependence (10.7%).

See Table 1 for a summary of descriptive data and t-tests for differences in smoking-related characteristics between the two “pain intensity” categories. There were significant differences between the two groups on all four criterion variables: number of years being a daily smoker (adjusted for age), number of cigarettes smoked per day, number of cigarettes smoked during the heaviest smoking period, and severity of nicotine dependence, such that individuals with higher levels of pain intensity demonstrated worse smoking-related outcomes. (Table 2).

Table 1.

Descriptive Data (Mean and SD) and Between Group Comparisons for the smokers with past-month “moderate to severe pain” versus “less than moderate pain”.

Less than moderate pain (N=88) Moderate to severe pain (N=24) P-value
Gender(female) 27(30.68%) 11(45.83%) =.15
Age 31.20 (SD=12.75) 40.38 (SD=15.37) =.018
Negative affectivity 18.93(SD=6.01) 22.76 (SD=9.58) =.10
Years being a daily smoker* 13.21 (SD=11.24) 21.04 (SD=13.71) =.005
Cigarettes per day 15.22 (SD=8.98) 20.95 (SD=14.24) =.022
Cigarettes per day during the heaviest smoking period 24.01 (SD=12.24) 30.19 (SD=10.87) =.037
Heaviness of smoking Index (HSI) 1.32 (SD=.14) 1.41 (SD=.33) =.041
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*

Age adjusted predicted value

Note: Past-month sever to moderate pain/other=The Short-Form General Health Survey GHS; (Stewart et al., 1988), HSI=Sum of the first two items of Fagerstrom Test for Nicotine Dependence (Heatherton et al., 1986).

Table 2.

GLM models examining the effects of pain intensity on number of years being a daily smoker, number of cigarettes smoked per day, number of cigarettes smoked during the heaviest smoking period, and nicotine dependence above and beyond the covariance of gender and negative affectivity.

Parameter Beta SE t-value P-value 95% CI
Years as a daily smoker *
 Gender −.85 2.36 −.39 .70 −5.54–3.83
 Negative affectivity −.31 .16 −1.88 .06 −.64–.01
 Pain intensity 7.99 2.93 2.73 .006 2.18–13.82
Cigarettes per day
 Gender −.11 2.09 −1.13 .26 −6.50–1.78
 Negative affectivity −.12 .17 −1.24 .22 −.54–.12
 Pain Intensity .27 2.5 2.74 .007 1.93–12.05
Cigarettes per day during heaviest smoking period
 Gender −.13 2.51 −1.31 .19 −8.27–31.84
 Negative affectivity .04 .20 .39 .69 −.32–.49
 Pain intensity .22 3.05 2.16 .033 .54–12.66
Heaviness of smoking index (HSI)
 Gender −.24 0.34 −0.71 0.48 −.94–.44
 Negative affectivity −.02 0.02 −0.88 0.38 −.06–.02
 Pain intensity 0.89 0.42 2.10 0.032 .04–1.74
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*

Age adjusted predicted value

Negative Affectivity=Negative subscale of Positive and Negative Affect Scale (Watson et al., 1988), Past-month sever to moderate pain/other=The Short-Form General Health Survey GHS; (Stewart et al., 1988), HSI=Sum of the first two items of Fagerstrom Test for Nicotine Dependence (Heatherton et al., 1986).

3.2. GLM analyses

In terms of number of years being a daily smoker, the pain intensity dichotomy accounted for a significant amount of variance (β = 8.12, p =.005). After entering the covariates, the association for pain intensity remained significant over and above the other covariates (β = 7.99, p =.006; Model statistics: R2 = .11, F(3, 109) = 4.67, p =.004).

The pain intensity dichotomy also accounted for a significant amount of variance in regard to the number of cigarettes smoked per day (β = .22, p = .022). After entering the covariates, pain intensity still was significantly associated with the criterion variable (β = .27, p = .007; Model statistics: R2 = .08, F(3, 109) = 2.90, p = .035).

For the number of cigarette smoked during the heaviest smoking period, the pain intensity dichotomy accounted for a significant amount of variance (β = .20, p = .037). The association for pain intensity remained evident after adjusting for the covariates (β = .22, p = .033; Model statistics: R2 = .06, F(3, 109) = 2.07, p = .09).

Finally, the pain intensity dichotomy accounted for a significant amount of variance in Heaviness of Smoking index (HSI) (β = .75, p = .041). This association remained after adjusting for the covariates (β = .89, p = .032; Model statistics: R2 = .04, F(3, 109) = 1.62, p = .1).

4. Discussion

As expected, greater past-month pain intensity was significantly and positively associated with smoking severity and nicotine dependence. Individuals who reported more intense pain within the past month reported smoking more cigarettes per day, smoked daily for a greater number of years, smoked more cigarettes during their peak period of smoking heaviness, and endorsed higher levels of nicotine dependence. These data are consistent with integrative models of smoking-pain comorbidity (Ditre et al., 2011; Parkerson et al., 2013) and clarify that pain intensity-smoking relations remain significant even after accounting for the influence of negative affectivity and gender. These data, in conjunction with previous work (Weingarten et al., 2008; Patterson et al., 2012), suggest that gradations in pain tend to be associated with gradations in smoking behavior. Future work is needed to explore processes that underlie pain intensity-smoking severity associations, including the role of expectancies for pain and/or negative affect relief via tobacco smoking (Ditre et al., 2010).

The current findings contribute to an emerging literature that suggests there may be clinical utility in assessing and reducing pain to improve smoking cessation outcomes (Aimer et al., 2015; Ditre and Brandon, 2008; Unrod et al., 2014). Accordingly, it may be advisable to assess and possibly address pain concerns in the context of smoking cessation. For example, treatment-seeking tobacco smokers may benefit from integrated treatments that seek to enhance their ability to cope with pain in the absence of smoking.

The current study has several limitations. First, the cross-sectional design and lack of specified temporal ordering among variables of the study do not permit causal-oriented hypothesis testing. For this reason, the present study should be viewed as an initial step in empirically evaluating the pain intensity-smoking association among smokers. Future research is required to examine prospective relations between pain intensity and smoking behavior. Second, the current sample consisted of daily tobacco smokers who were ethnically/racially homogenous. Future studies would benefit from sampling ethnically/racially diverse smokers to ensure generalizability of the results to the general smoking population. Third, effects of other relevant covariates like alcohol consumption or physical illness should be considered in future work. Future work would benefit from examining the concomitant role of these covariates using larger sample sizes. Fourth, the present study relied predominately on self-report measures, although nicotine dependence was measured by self-report on the FTND with converging evidence provided via expired CO. Future research could minimize the role of method variance in the observed relations through utilization of multi-method measurement approaches; for example, experimental pain induction could be useful in testing the causal relations between pain intensity and smoking behavior (Ditre et al., 2008, 2010). Fifth, participants were excluded if they were unstable on their psychotropic medication. This exclusionary criterion may have limited the range of negative affectivity reported by this population. Future research could examine the same research questions explored herein among smokers with a wider range of psychopathology. Sixth, we did not collect data related to the individual’s duration of the current pain experienced. Thus, we were not able to analyze the observed associations in relation to pain chronicity. Seventh, we did not have data on withdrawal symptoms at the assessment point measured. Thus, we could not examine the probable effects of individual’s irritability due to these symptoms on pain experience. Future work would therefore benefit from exploring the influence of withdrawal on pain responding.

In summary, the current descriptive investigation suggests moderate to severe pain is related to more severe smoking behavior and greater nicotine dependence. Future work is needed to explore the relation of pain intensity in terms of smoking cessation, as well as the extent to which decreasing pain may be related to reductions in smoking behavior.

Footnotes

Conflicts of interest

None.

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