Nicotine, Tobacco Smoking, and Pain in Orthopedic Trauma Settings: A Conceptual Framework for Practice and Research

Abstract

Orthopedic injuries are associated with significant pain and are a major factor in long-term disability rates. Nicotine and tobacco use has received increasing empirical and clinical attention in the context of orthopedic trauma, given observed links to poorer recovery outcomes and elevated healthcare costs. Although an established reciprocal model of pain and substance use posits that pain and nicotine/tobacco use interact in a bidirectional manner leading to greater pain, functional impairment, and the maintenance of addiction, no prior work has extended this model to the orthopedic trauma context. In this review, we first discuss pain as a key aspect of orthopedic injury and recovery, alongside the clinical implications of nicotine/tobacco use, which is highly prevalent among orthopedic trauma inpatients. Next, we propose a conceptual framework to consider pain and nicotine/tobacco use in the context of orthopedic trauma research and practice. Greater understanding of how tobacco smoking and nicotine use can independently influence recovery may be leveraged to inform the development and delivery of customized programs that consider psychosocial, medical, and transdiagnostic factors underlying both conditions. We also consider barriers and facilitators to managing co-occurring pain and nicotine/tobacco use within orthopedic trauma settings, offering practical advice for clinical practice. Employing a multidisciplinary strategy to address the complexities of nicotine and tobacco use, as well as their relationship with pain, may significantly enhance the efficacy of clinical interventions, leading to improved nicotine/tobacco cessation approaches and enhanced orthopedic recovery outcomes.

Introduction

Orthopedic traumas (i.e., acute musculoskeletal injuries, such as fractures and dislocations) constitute the primary reason for adult hospital admissions²⁰ and account for over one million emergency room visits annually in the United States (US).²¹ Moreover, orthopedic injuries contribute to nearly 20% of overall long-term disability rates,^20,22–23 with associated annual healthcare costs (e.g., multiple surgeries and medical appointments, pain and physical impairment, loss of productivity) exceeding $200 billion.²⁴ Pain is nearly ubiquitous among orthopedic trauma patients²², due to a variety of factors including tissue damage, inflammation, nerve injury, and trauma/surgery complications.³⁰ Pain in the context of orthopedic trauma has been shown to interfere with daily activities, social participation, sleep, and fatigue, and thus represents a significant source of distress and impairment.³¹ Moreover, despite adequate biomedical recovery related to bones and soft tissues, approximately 50% of all patients with orthopedic trauma go on to develop chronic pain.^128–131

One factor that has received increasing clinical and empirical attention in the areas of orthopedic trauma and pain is tobacco cigarette smoking and use of other nicotine products (e.g., electronic cigarettes).^32–79 Tobacco cigarette smoking remains the primary contributor to preventable diseases, disabilities, and fatalities in the United States,¹⁴⁴ and the estimated prevalence of current tobacco smoking among orthopedic trauma patients (25–50%)^1–5,27–8 is more than double the rate (~12%) observed in the general population.²⁶ In the context of orthopedic trauma, nicotine/tobacco use has been related to poorer health outcomes, greater post-surgical functional impairment, and higher healthcare costs.^10–19

Although an established reciprocal model posits that pain and nicotine/tobacco use interact in the manner of a positive feedback loop, resulting in the perpetuation of nicotine/tobacco addiction and the exacerbation of pain over time, ^32–3,79 no prior work has extended this model to the context of orthopedic trauma. Adapting the reciprocal model of pain and nicotine/tobacco use for the context of orthopedic trauma may inform future research and practice by providing a more nuanced conceptualization of how tobacco smoking and nicotine use can independently and bidirectionally impact pain and recovery among orthopedic trauma patients. These efforts may also help guide the development and integration of nicotine/tobacco interventions that are optimized for this unique medical population.

Reciprocal Model of Pain and Nicotine/Tobacco Use

The reciprocal model of pain and substance use posits that pain and self-administration of nicotine/tobacco interact in a bidirectional manner, leading to greater pain/impairment and the maintenance of addiction.^32–33,79 This interaction is supported by experimental evidence showing that the experience of pain can significantly motivate nicotine use among individuals with and without chronic pain.⁴⁷ Pain patients often report using smoking as a primary method of coping with their pain,^146–147 and pain has been identified as a barrier to quitting smoking and has been associated with increased risk of lapse and relapse.^148–150 Moreover, although nicotine can produce acute analgesic effects,¹³⁶ smoking is a known risk factor in onset and exacerbation of chronic pain.^151–155 Further, while early stages of smoking abstinence have been shown to result in a state of hyperalgesia (i.e., increased sensitivity to pain) among nicotine-deprived smokers,¹³⁷ there is also evidence that smoking cessation may improve pain in long term.^156–159 In the following sections, we will discuss these pathways, in turn, with specific deference to the context of orthopedic trauma.

Effects of Nicotine and Tobacco Use on Orthopedic Trauma Pain

A growing body of research indicates that nicotine and tobacco use increases risk for a variety of deleterious and impactful orthopedic trauma/surgery complications that are implicated in the development and persistence of pain (e.g., infection¹⁰, non-union¹⁹, wound/flap necrosis^11–12, and delayed tissue healing^13–19). For example, an investigation among 906 patients with ankle fractures found that current cigarette smokers (vs. non-smokers) had a 30% higher rate of postoperative complications and were 6 times more likely to develop deep wound infections.^34–5 Systemic inflammation caused by smoking tobacco can aggravate pain at the site of injury, and impaired healing process can prolong the duration of pain.¹⁶⁰ Results of a systematic review further indicated that tobacco smoking was related to elevated risk of non-union in all types of fractures.³⁶ This finding is concerning, given that non-union is associated with poorer pain trajectories.¹⁶¹

There is also reason to believe that nicotine itself (even when separated from other components of tobacco smoke)¹³³ can negatively impact pain-related outcomes in the context of orthopedic trauma. For example, a recent case series described a cluster of delayed unions of bone fractures in adolescents using electronic cigarettes.¹³³ Although the authors concluded that the effect of electronic cigarettes on the musculoskeletal system remains poorly understood, they found evidence that nicotine consumption causes vasoconstriction,¹⁶² which may contribute to poorer orthopedic- and pain-related outcomes. Other studies have similarly revealed that nicotine consumption can restrict blood flow crucial for healing and may extend duration of pain experienced after an injury.^163–166 Nicotine may also affect bone metabolism, leading to decreased bone mass and increased vulnerability to osteoporosis and fractures.^167–170 Moreover, in accordance with an allostatic load model, repeated episodes of nicotine use and disuse may modify pain perception contributing to escalation of pain intensity and the development of chronic pain conditions over time.⁷⁹ Indeed, chronic nicotine use has been associated with increased sensitivity to pain, posing a significant challenge in effectively managing pain in the context of orthopedic trauma.³³ These isolated effects of nicotine highlight the importance of considering its unique role in orthopedic trauma recovery and cessation approaches (e.g., nicotine replacement therapy) that may be employed among orthopedic trauma patients. Although we are not aware of any studies to date that directly examined the effects of electronic nicotine delivery system (ENDs) use on pain in the context of orthopedic trauma, these products are anticipated to have similar clinical relevance to orthopedic recovery outcomes.^132–135

In addition to increasing risk for painful complications, prolonged use of nicotine via tobacco smoking or other nicotine products can disrupt neural reward circuitry, contribute to an imbalance in neurological functioning, and impose frequent demands on the physiological system leading to increased allostatic load.^191–192 This heightened load is characterized by a sustained state of physiological imbalance, resulting in exacerbated pain sensitization and increased pain-related suffering (Simons et al. 2014). Thus, through its detrimental effects on recovery and allostatic load, continued use of nicotine and tobacco may exacerbate pain intensity and increase risk for developing and maintaining chronic pain and disability following orthopedic trauma. This possibility underscores the need for novel nicotine and tobacco cessation interventions that are tailored for the context of orthopedic trauma.

Finally, given evidence that nicotine deprivation may increase pain through both central (e.g., enhanced excitability of spinal dorsal horn neurons, release of pain-related neurotransmitters, and nAChR availability) and peripheral (e.g., vasodilation caused by neuropeptide release from peripheral C-fiber activation) processes,^{32, 137,139} medically recommended abstinence for orthopedic trauma patients who use nicotine/tobacco could result in withdrawal-induced hyperalgesia and further undermine cessation attempts.^137–138

Effects of Orthopedic Trauma Pain on Nicotine/Tobacco Use

Acute orthopedic trauma pain and related distress are likely potent factors in the maintenance of nicotine/tobacco use behavior. Converging evidence indicates that pain can motivate nicotine/tobacco use^47–80, and that individuals often report smoking cigarettes to cope with pain.¹⁴⁰ Consistent with this evidence, initial work conducted among 819 orthopedic trauma patients (22% current smokers) revealed that pain-related distress was associated with higher odds of reporting current nicotine/tobacco use.²⁹ Given the acute analgesic effects of nicotine¹³⁶, patients may attempt to self-medicate orthopedic trauma pain using nicotine/tobacco products. In turn, nicotine-induced reductions in pain and related distress may negatively reinforce nicotine/tobacco use,¹⁹⁰ perpetuating nicotine consumption and addiction. Therefore, in the context of acute orthopedic trauma, attempts to avoid pain and related distress could motivate continued nicotine/tobacco use or intensify existing patterns of use.

Orthopedic trauma patients also face numerous barriers to nicotine/tobacco cessation, including low levels of motivation and self-efficacy for quitting.²⁸ Notably, one recent study revealed that only about one-fourth of orthopedic trauma patients who use nicotine/tobacco express motivation to quit, even following post-admission physician advice.⁵ Other studies have revealed similarly low levels of motivation to quit among orthopedic trauma patients.^{49, 28} It is possible that patients are unaware of the deleterious effects of continued nicotine/tobacco use on orthopedic trauma recovery and orthopedic surgery complications. In accordance with the Health Belief Model, individuals are more likely to change unhealthy behaviors if they see themselves at risk for severe health consequences and believe that behavior change can avert such risks.⁶⁵ Thus, an inadequate threat appraisal of nicotine/tobacco use outcomes may contribute to low motivation to quit in the context of orthopedic trauma.

Moreover, a web-based survey of orthopedic trauma patients from two public hospitals revealed that nearly 50% of nicotine/tobacco users reported low self-efficacy for quitting.²⁸ Indeed, orthopedic trauma patients may experience low self-efficacy for coping with orthopedic trauma/recovery, pain, and associated distress in the absence of nicotine/tobacco use, given that they may not yet possess more adaptive pain coping strategies.^66,67 The self-reinforcing cascade of acute orthopedic trauma pain and related distress, negative reinforcement processes, low smoking threat appraisal and low self-efficacy for coping with orthopedic trauma/recovery in the absence of nicotine/tobacco use likely contributes to a downward spiral perpetuating low motivation to quit and contributing to continued use of nicotine/tobacco.

Although no prior work has investigated orthopedic trauma-related pain as a predictor of lapse/relapse following nicotine/tobacco cessation, there is reason to believe that patients may be less successful with quitting in the context of an orthopedic injury. Indeed, smokers who report recent pain are less likely to initiate a quit attempt and maintain smoking abstinence than smokers without recent pain.¹⁹³

Adapted Reciprocal Model of Pain and Nicotine/Tobacco Use for Orthopedic Trauma

We propose that pain and nicotine/tobacco use interact in a complex reciprocal model in the context of orthopedic trauma. Initially, nicotine may offer short-term pain relief¹³⁶, but over time, it leads to increased pain intensity, disability, and distress.^6–8,37,46 Similar to the non-trauma context, this reciprocal relationship in orthopedic trauma patients is perpetuated by negative reinforcement processes,²⁰¹ expectancies regarding the relationships between pain and nicotine/tobacco use,¹⁴⁹ allostatic load, and nicotine/tobacco-induced complications. In the adapted reciprocal model below, we highlight psychosocial, medical, and transdiagnostic factors underlying the proposed bidirectional relationship between pain and nicotine/tobacco use specific to orthopedic trauma, as well as clinical practice considerations in the orthopedic trauma setting.

Factors Underlying Reciprocal Pain and Nicotine/Tobacco Use in Orthopedic Trauma

Psychosocial Factors

Orthopedic trauma patients exhibit a complex psychosocial profile. First, rates of anxiety, depression, and PTSD symptoms are notably high among these patients^186–187, especially those who smoke.¹⁸⁵ Both orthopedic trauma pain and nicotine/tobacco use contribute to the development and maintenance of these symptoms.¹⁸⁶ Furthermore, rates of non-nicotine/tobacco substance use (e.g., alcohol, opioids) are higher among patients with orthopedic trauma pain, with each condition potentially exacerbating the other.^188–189 Second, compared to the general population, orthopedic trauma patients tend to face greater challenges related to social/contextual determinants of health. These challenges include lower socioeconomic status, education levels, and health literacy, as well as past traumatic experiences or repeated exposure to life-time stressors, and a lack of social support systems. These contextual factors can modulate the reciprocal impact of orthopedic trauma pain and nicotine/tobacco use. For example, limited access to adequate insurance or care services can directly influence the recovery trajectory²⁰³, affecting both orthopedic pain and the use of nicotine/tobacco as a coping mechanism. Similarly, limited knowledge about the detrimental impact of nicotine/tobacco use on recovery could diminish the motivation to quit. Age is another important contextual factor, given the rapidly expanding population of older adults experiencing orthopedic trauma.¹⁷¹ Notably, nicotine/tobacco use is associated with a greater risk of delirium, which has impactful consequences for both orthopedic pain and nicotine/tobacco use among older adults with orthopedic trauma.¹⁷². Finally, there is evidence that men derive greater analgesic benefits from smoking¹⁹⁸, and thus may be more likely to turn to nicotine/tobacco use for pain coping in the context of orthopedic trauma.¹⁹⁸ This, in turn, may expose them to a higher risk of smoking maintenance and cessation problems, as well as poorer pain-outcomes over time.

Medical Factors

In patients with orthopedic trauma injuries, medical comorbidities such as cardiovascular disease, diabetes mellitus, obesity, osteoporosis, chronic respiratory disease, and malnutrition are more prevalent compared to the general population.^173–175 These comorbidities are associated with an increased risk of orthopedic surgery complications, longer hospital stays, and morbidity. Moreover, they are related to orthopedic surgery complications and may exacerbate the impact of bidirectional orthopedic pain and nicotine/tobacco effects, further compounding this vicious cycle. For example, higher levels of pain intensity associated with cardiovascular disease and post-surgery infections linked to diabetes could diminish motivation to quit among orthopedic trauma patients. In addition, orthopedic trauma patients have complex pain management needs that often require pharmacological intervention. Such injuries are often treated with prescription opioid analgesics.¹⁹⁹ Nicotine/tobacco is a significant predictor of prolonged opioid use following orthopedic trauma/surgery²⁰⁰, which may contribute to “weathering” or allostatic load. Moreover, prescription opioid misuse (i.e., using medication in a manner or dose other than prescribed) may further amplify bidirectional relations between pain and nicotine/tobacco use via the effects of cross-tolerance.³²

Transdiagnostic Factors

Transdiagnostic factors are core psychological constructs that exhibit commonalities across a range of disorders (e.g., emotional disorders, substance use disorders, pain conditions).¹⁷⁶ They provide a framework for understanding shared characteristics and mechanisms among various medical and mental health conditions. Several transdiagnostic factors should be considered in the context of orthopedic trauma pain and nicotine/tobacco use.

Pain catastrophizing (i.e., a cognitive-affective response characterized by exaggerated negative thoughts and feelings towards actual or anticipated pain) is associated with heightened pain intensity/disability, a greater likelihood of heavy nicotine/tobacco use to alleviate pain/negative emotions, and an elevated risk of relapse following cessation.¹⁹⁵ This exaggerated focus on pain can lead to more intense pain experiences and may drive individuals toward tobacco use as a coping mechanism, amplifying both the experience of pain and the challenges associated with tobacco cessation efforts. Pain catastrophizing is a unique predictor of orthopedic trauma recovery trajectory and outcomes.¹⁹⁴ Accumulating evidence supports pain catastrophizing as one of the most important psychosocial factors implicated in pain chronicity and substance use outcomes following orthopedic trauma/surgery.²⁰⁴ Related to the interplay of orthopedic trauma pain and nicotine/tobacco use, pain catastrophizing could create a vicious cycle of avoidance (of pain, related emotional distress, and activities which are required for successful rehabilitation) and overreliance on maladaptive sources of relief such as nicotine/tobacco use, complicating both conditions.

Pain-related anxiety (i.e., worry about painful sensations and activities that might worsen pain) has been associated with the use of nicotine/tobacco products, including cigarettes and ENDs. Pain-related anxiety can lead to the use of tobacco as a form of self-medication for pain, and high levels of pain-related fear among current smokers may increase the likelihood of using tobacco for pain coping, potentially impacting smoking cessation efforts. Similar to pain catastrophizing, pain-related anxiety is implicated in the transition from acute to chronic pain in the context of orthopedic trauma and contributes to worsening pain intensity and interference.²⁰⁵ Related to the reciprocal model, pain-related anxiety could create a vicious cycle of pain-related emotional distress and overreliance on nicotine/tobacco which could complicate both outcomes for orthopedic trauma patients who smoke.¹⁹⁶

Distress tolerance (i.e., the ability to withstand aversive emotional and physical experiences) is significantly associated with both pain experiences and nicotine/tobacco use. Individuals with lower distress tolerance may experience more severe pain and find it more challenging to quit smoking, as they might use tobacco as a coping mechanism for their difficulty tolerating distressing physical and emotional states. Thus, patients with low distress tolerance could be at greater risk of lapse and relapse following quit attempts which can further complicate their recovery trajectory.

Finally, anxiety sensitivity (i.e., the degree to which the experience of anxiety is expected to have deleterious consequences) has been linked to both pain and nicotine/tobacco use.²⁰⁶ Individuals with high anxiety sensitivity may experience amplified pain-related fears and avoidance behaviors, contributing to greater pain severity.²⁰⁶ Additionally, individuals high in anxiety sensitivity may be more likely to use nicotine or tobacco to cope with or alleviate symptoms of pain and anxiety. Anxiety sensitivity is a risk factor for the maintenance of smoking and pain intensity/interference among orthopedic trauma patients who smoke.²⁰⁷ Anxiety sensitivity is also linked to higher levels of pain-related emotional distress, which in turn poses significant demand and deplete the psychological resources needed for adaptive coping with acute orthopedic trauma pain and nicotine/tobacco withdrawal-induced hyperalgesia.

Clinical Practice Considerations in the Orthopedic Trauma Setting

Interventions to Address Nicotine/Tobacco Use among Orthopedic Trauma Inpatients

The period following trauma presents an underutilized ‘teachable moment’ for nicotine/tobacco cessation interventions, as even short-term abstinence can improve outcomes related to orthopedic trauma and surgery. Currently, only two interventions have been developed to address nicotine/tobacco use among orthopedic trauma patients. First, the Let’s STOP (Smoking in Trauma Orthopaedic Patients) Now trial, employed a randomized controlled trial (RCT) design at a Level I trauma center.¹⁴² This trial compared no counseling vs. brief in-person counseling vs. extended counseling groups among 266 orthopedic trauma patients. At 3- and 6-months post-intervention, smoking cessation rates were 17% and 15% for the no counseling group, 11% and 10% for brief counseling, and 10% and 5% for extended counseling, respectively. Although patients who received extended counseling and brief counseling were 3- and 2-times as likely, respectively, to accept quit line services, these interventions did not significantly increase quit rates compared to no counseling control.

Second, a pilot trial of the Smoke-Free Recovery (SFR) program employed a multi-module web-based approach with a focus on smoking cessation and cessation motivation among 31 orthopedic trauma patients.¹⁴³ Although changes in smoking behaviors were noted, program retention was low, with high engagement during hospital admission but low post-discharge adherence rates. Patients reported issues such as lack of time, need for additional support, and technological barriers, thus highlighting the complexities in maintaining cessation efforts following hospital discharge. These studies emphasize the need for comprehensive and ongoing support in smoking cessation interventions for orthopedic trauma patients. Notably, neither intervention addressed the negative impacts of pain on nicotine and tobacco use, nor did they inform smokers about how continued nicotine/tobacco use may hinder achievement of pain management goals.

Barriers to Addressing Nicotine/Tobacco Use in the Orthopedic Trauma Setting

Despite evidence that continued nicotine/tobacco use can worsen outcomes following orthopedic trauma/surgery¹⁹⁷, a recent study found that only 4% of patients undergoing fracture management procedures who reported current smoking were assessed for motivation to quit.⁵⁶ Moreover, the standard peri-operative smoking screening and cessation advice is rarely adhered to⁵⁷, and only about 5% of surgical patients recommended to a quit-smoking program pursue a referral. Further, conventional smoking cessation approaches often involve nicotine replacement therapies (NRTs) like patches and e-cigarettes. While these methods effectively mitigate tobacco withdrawal and are suggested to pose less harm to recovery compared to tobacco smoking,²⁰² they do not eliminate the adverse effects of nicotine itself on the healing process. Although this paradox may be construed as a dilemma in clinical practice, NRT remains an important harm reduction tool.

Orthopedic trauma settings present specific barriers to the effective implementation of nicotine/tobacco cessation interventions. For example, according to the results of a focus group of 79 orthopedic providers conducted by our team across three Level I trauma centers, the higher medical priority of addressing urgent issues related to multiple trauma injuries may prevent the timely addressal of nicotine/tobacco use.^181,182 Other barriers include prioritization of clinic efficiency over innovations, limited understanding of psychosocial recovery factors among providers, stigma and bias surrounding mental health, varied comfort levels among providers in discussing mental health, concerns about disrupting clinical workflow, perceived lack of support resources, and difficulties related to multidisciplinary communication.^181,182 Additionally, challenges arise from skepticism about the relevance of psychosocial interventions¹⁸³, concerns about the suitability of interventions for low literacy patients or patients from diverse cultures, limited insurance coverage, and perceived high costs.¹⁸⁴ The barriers impeding the successful implementation of cessation interventions could intensify the vicious cycle of pain/disability and continued nicotine/tobacco use among orthopedic trauma patients.

Implications and Applications

In the context of orthopedic trauma settings, the currently adapted reciprocal model of pain and nicotine/tobacco use highlights unique challenges that require clinical attention. Patients who smoke in this setting represent a vulnerable subgroup with a complex biopsychosocial profile. Medically recommended smoking abstinence and associated withdrawal-induced hyperalgesia could further exacerbate acute pain and complicate the recovery trajectory of these patients. A major implication is that routine and repeated assessments of nicotine/substance use and orthopedic trauma pain, along with their related outcomes, should be integral to comprehensive orthopedic trauma care for patients who use nicotine/tobacco. These simultaneous assessments necessitate staff acknowledgment of the bidirectional impact of nicotine/tobacco use on orthopedic trauma pain. Importantly, these individualized risk assessments should include evaluation of the patient’s psychosocial/contextual profile, such as gender, age, mental health, health literacy, and socioeconomic status. Modifiable psychosocial factors such as mental illness, other substance use, and limited health literacy should be addressed through specialized psychological interventions. Contextual factors can be managed through referrals to social work and related support services. Additionally, medical comorbidities and the use of opioid medications should be addressed as part of the orthopedic trauma pain-nicotine/tobacco use interventions. Addressing medical comorbidities and efforts to reduce over-reliance on opioid medications for pain management, as well as preventing prolonged use of prescription opioids should be a priority in these patients, perhaps as part of a multidisciplinary collaboration aimed at reducing barriers to cessation and pain reduction. Finally, similar to all patients with orthopedic trauma, routine evaluation and addressing of transdiagnostic determinants of recovery trajectory such as pain catastrophizing and pain-related anxiety via available psychological services is of potentially critical importance.

Nicotine/tobacco cessation strategies should not only focus on eliminating the harmful effects of tobacco smoke and the independent impact of nicotine on healing but also on how these factors interact with pain. For example, non-nicotine-based pharmacotherapies such as bupropion or varenicline may be preferred, as they do not promote nicotine-induced alteration in pain perception.²⁰⁸ It may also be advisable to implement comprehensive pain management plans, integrating pharmacological and non-pharmacological interventions (e.g., cognitive behavior therapies, mind-body interventions), that are personalized for orthopedic trauma patients who smoke.

For instance, nicotine/tobacco use cessation interventions delivered in the orthopedic trauma setting may be coupled with strategies that enhance self-efficacy in pain management, as insufficiently addressed orthopedic trauma pain could promote the continuation or intensification of nicotine/tobacco use patterns. In line with our adapted reciprocal model of pain and nicotine/tobacco use, brief interventions targeting nicotine/tobacco use, combined with the teaching of pain coping skills (such as ‘pain wave surfing’), may improve self-efficacy for coping with orthopedic trauma/recovery without smoking.

Standard smoking cessation advice is often not heeded by patients who lack the motivation to quit, particularly in the context of orthopedic trauma recovery, pain, and related distress. Drawing on the Transtheoretical Model (TTM), which emphasizes the stages of change and the balance between the positive and negative effects of tobacco smoking, patients may become increasingly motivated to quit as they recognize that continued smoking can worsen orthopedic complications and impede recovery goals. Prior work has demonstrated that providing patients with psychoeducation about associations between pain and nicotine/tobacco use (e.g., informing patients that smoking may worsen pain) has been shown to increase motivation to quit smoking.⁵⁴ Moreover, Personalized Feedback Interventions (PFIs) offer another approach to increasing motivation for cessation. PFIs can provide normative feedback on a patient’s nicotine/tobacco use relative to their demographic peers and other orthopedic trauma patients, while also educating them about the reciprocal impact of nicotine/tobacco use on orthopedic trauma pain. Given that successful healing and pain management are significant concerns for orthopedic trauma patients, pairing such interventions with training in pain coping self-efficacy skills could boost their motivation to quit.

Barriers to addressing comorbid nicotine/tobacco use and pain in context of orthopedic trauma organizational cultures that typically prioritize heavy medical workflow, could be addressed in several ways. Leadership emphasis on comprehensive patient care and fostering acceptance of psychosocial care through a multidisciplinary approach could enhance staff buy-in and effectively implement such interventions. These efforts involve incentivizing integrated models of care that incorporate embedded psychosocial services, along with ongoing staff training focused on enhancing knowledge and comfort in discussing the interrelation of nicotine/substance use and pain with patients. Additionally, training should cover engaging with other disciplines, using destigmatizing language, and referring patients for nicotine/tobacco use services. Leveraging the existing perceived need for immediate psychosocial interventions in orthopedic trauma settings, along with the existing centralized screening for psychosocial factors (i.e., patient reported outcome measures and anxiety/depression screening), could significantly enhance the effectiveness of such efforts. Provision of low-cost, technology-enhanced, brief, culturally adapted interventions could facilitate the integration and dissemination of nicotine/tobacco use-pain interventions in orthopedic trauma settings. Importantly, future implementation research is needed to systematically study which methods best support the delivery of integrated pain and nicotine/tobacco interventions in the context of orthopedic trauma settings.

Major Literature Gaps

This review highlights several notable gaps in the literature. First, despite the established bidirectional impact of pain and nicotine/tobacco use, there is currently no work focused on assessing and addressing pain-nicotine/tobacco use comorbidity in orthopedic trauma settings. We are not aware of any basic science or experimental design studies specifically focused on integrated programs in this domain. Additionally, existing research on non-integrated programs for tobacco smoking cessation following orthopedic trauma suffers from a lack of statistical power, undermining the reliability and generalizability of these findings. Another key limitation of the extant literature is the insufficient assessment of feasibility barriers for addressing orthopedic trauma pain-nicotine/tobacco use comorbidity, particularly in non-U.S. settings, which restricts the comprehensive understanding of challenges faced in implementing effective interventions. Finally, despite increasing rates of e-cigarette use among adults (4.5%)¹⁴¹ and its observed impact on pain and related outcomes, specific data on e-cigarette use in the context of orthopedic trauma is lacking. Similarly, while NRTs are proposed to reduce the harm of tobacco smoking on post-surgery recovery, the evidence supporting their effectiveness is still emerging, and further research into their safety is needed.^177–180 These gaps in research hinder a complete understanding of the reciprocal relationship of e-cigarette use/NRTs and orthopedic trauma pain, representing a significant oversight in current research. These limitations collectively highlight the need for more rigorous and nuanced study designs to advance the understanding of the pain-nicotine/tobacco use comorbidity in orthopedic trauma settings.

Future Directions

First, there is an immediate need for research focused on testing the utility of brief integrated motivational enhancement and pain coping interventions for addressing co-occurring pain and nicotine/tobacco use in orthopedic trauma care. Developed through rigorous feasibility and efficacy RCT designs, such integrated models could be crucial in encouraging nicotine/tobacco cessation and effective pain management, thereby breaking the bidirectional impact of orthopedic trauma pain and nicotine/tobacco use. For example, future research should test integrated models that combine PFIs for nicotine/tobacco use with orthopedic trauma pain-coping skills.

Next, there is a need to develop and evaluate brief, technology-enhanced interventions that can be seamlessly integrated into the fast-paced and high-pressure environment of orthopedic trauma care settings. These interventions should be designed as flexible and user-friendly tools that minimize the dependence on specialty providers for their administration, thereby aligning with the current care paradigms without disrupting clinical workflows. For instance, provision of integrated care via web-based platforms or mobile applications could enable orthopedic trauma patients to independently track their recovery progress, receive personalized advice on nicotine/tobacco use and pain management, and access support resources, all without requiring extensive involvement from medical providers. This approach could streamline the integrated nicotine/tobacco use-orthopedic trauma pain care model, making it more feasible and effective.

Future intervention development should employ Human-Centered Design principles to ensure that integrated nicotine/tobacco-pain interventions are tailored to the unique contexts of orthopedic trauma settings (i.e., intervention-context fit). This approach would involve stakeholders (patients, healthcare providers, administrators) in the design process to create interventions that are more likely to be effective, well-received, and sustainable. This approach could address the diverse needs of patients and the complexities of healthcare systems and ensure adaptive implementation of such interventions.

Given the crucial role of leadership, research should also focus on strategies for garnering support from department heads, orthopedic trauma leaders, and policymakers. This involves developing evidence-based arguments for the implementation of integrated nicotine/tobacco use-pain care into orthopedic trauma settings, demonstrating how such comprehensive care can improve patient outcomes and potentially reduce healthcare costs. The goal is to emphasize the importance of accessible integrated nicotine/tobacco use-pain interventions, specifically tailored and embedded in orthopedic trauma settings. In addition, efforts should be directed towards clearly articulating to medical providers the significance of integrated nicotine/tobacco use and pain interventions in the recovery of orthopedic trauma patients. This includes designing educational programs targeting medical providers, highlighting the interconnectedness of orthopedic trauma pain and nicotine/tobacco use, and outlining the benefits of addressing both aspects in recovery. Research could also explore effective methods of reducing nicotine/tobacco use and overall mental health stigma among medical providers and patients, such as educational campaigns, stigma-reduction training, and the incorporation of peer support and advocacy.

Finally, future intervention development efforts in orthopedic trauma care should be sensitive to and inclusive of diverse cultural backgrounds. This extends beyond merely translating materials into different languages; it also entails adapting content to align with various cultural values, beliefs, and practices that pertain to health, pain management, and nicotine/tobacco use. Considering the complex psychosocial profiles of orthopedic trauma patients, it is critical to address factors such as limited health literacy, mental health challenges, and social disadvantages. These considerations should be central to the design and implementation of novel integrated nicotine/tobacco use-pain interventions in orthopedic trauma settings, ensuring they are accessible, relevant, and effective for a wide range of patient demographics.

Figure 1.

Adapted reciprocal model of pain and nicotine/tobacco use in orthopedic truam settings.