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Published in final edited form as: AIDS Care. 2019 Mar 7;31(11):1348–1352. doi: 10.1080/09540121.2019.1587355

Characteristics associated with perceived interrelations of pain and smoking among people living with HIV.

Hannah Esan 1, Josh Agress 2, Elizabeth K Seng 1,3,4, Jonathan Shuter 5,6, Andrea H Weinberger 1,5
PMCID: PMC6732051  NIHMSID: NIHMS1523261  PMID: 30843727

Abstract

Persons living with HIV/AIDS (PLWH) have very high prevalences of both cigarette smoking and pain, yet little is known about the relationship between smoking and pain for PLWH. The current study examines the perceived interrelations between pain and smoking and participant characteristics (i.e., demographics, heavier versus lighter smoking, current pain severity, depression, anxiety symptoms) in a sample of 101 current cigarette smoking adult PLWH in the Bronx, New York. Participants completed assessments of demographics, smoking behaviors, psychiatric symptoms, and pain severity. Interrelations of pain and smoking were measured using the 9-item Pain and Smoking Inventory (PSI) total score and three domain scores (pain as a motivator for smoking, smoking to cope with pain, and pain as a barrier for smoking cessation). Significant associations were found between greater current pain severity and greater endorsement of overall perceived interrelations between pain and smoking, pain as a motivator for smoking, and smoking to cope with pain. Greater anxiety symptoms were significantly associated with greater endorsement of overall perceived interrelations between pain and smoking, pain as a motivator for smoking, and smoking to cope with pain. Understanding the perceived relations between smoking and pain, as well as associated factors such as anxiety and pain severity, may help to guide interventions for PLWH who smoke in order to reduce the high prevalence of smoking and significant smoking-related health consequences.

Keywords: Smoking, Cigarettes, HIV, Pain, Anxiety

Introduction

Cigarette smoking is the leading preventable cause of mortality and morbidity in the United States (US; USDHHS, 2014). Persons living with HIV/AIDS (PLWH) smoke cigarettes at high prevalences (CDC, 2009, 2015; Mdodo et al., 2015; Park, Hernandez-Ramirez, Silverberg, Crothers, & Dubrow, 2016; USDHHS, 2014) and smoking can increase HIV symptom severity and the progression of HIV (CDC, 2015).

PLWH report high prevalences of chronic pain (Merlin, Bulls, Vucovich, Edelman, & Starrels, 2016; Merlin et al., 2012; Parker, Stein, & Jelsma, 2014) as do smokers (Ditre, Kosiba, Zale, Zvolensky, & Maisto, 2016; Ditre, Zale, Heckman, & Hendricks, 2017; Orhurhu, Pittelkow, & Hooten, 2015). Furthermore, those who report chronic pain report higher prevalences of smoking than those without pain (Orhurhu, Pittelkow, & Hooten, 2015; Patterson et al., 2012).

Despite the co-report of smoking and pain, little is known about association between smoking and pain among PLWH. This study examined the perceived interrelations between pain and smoking and participant characteristics (e.g., demographics) in a sample of current cigarette smoking adult PLWH.

Materials and Methods

Participants

Participants were PLWH receiving care at the Montefiore Medical Center’s Center for Positive Living (CPL) in the Bronx, New York. Inclusion criteria were: (1) a reported diagnosis of HIV and/or AIDS (2) capacity to give informed consent, (3) age 18 years or older, (4) English-speaking, and (5) current cigarette smoking (i.e., one or more cigarettes self-reported in the past day).

Procedure

All aspects of the study were approved by the Albert Einstein College of Medicine IRB. Following oral consent procedures, participants completed a paper survey (see measures below) and received a Target gift card. See (Weinberger, Seng, Ditre, Willoughby, & Shuter, 2018) for additional details about the study methodology.

Measures/Assessments

Demographics

Gender, race, ethnicity, sexual orientation, and education were assessed as categorical variables; age and years since HIV diagnosis were assessed as continuous variables.

Smoking

Participants were asked to report cigarette smoking frequency (days per week), number of cigarettes smoked per day (CPD), and use of non-cigarette tobacco products. Participants smoking 11 or more CPD were categorized as heavy smokers while those smoking 1-10 CPD were categorized as light smokers based on previous literature (e.g., Schane, Ling, & Glantz, 2010; Warner, 2015; Yi, Mayorga, Hassmiller Lich, & Pearson, 2017).

Anxiety

Anxiety symptoms were assessed using the Patient-Reported Outcomes Measurement Information System (PROMIS) for Anxiety Short Form-8A which is an 8-item questionnaire that is scored using a 5-point Likert scale (1=never to 5=always). Raw scores ranged from 8-40 and were converted into T-scores (i.e., a standardized score with a mean of 50 and a SD of 10; Levin et al., 2015). The PROMIS has demonstrated good internal consistency reliability (αs=0.93-0.96; Cella et al, 2010; Pilkonis et al., 2011).

Depression

The PROMIS for Depression-short form-8A was administered to assess depression symptoms. It is an 8-item questionnaire that is scored using a 5-point Likert scale (1=never to 5=always; Cella et al., 2010; Pilkonis et al., 2011). The raw scores (i.e., sum of all items; range 8-40) were converted into T-score using the PROMIS online system. Given the high correlation between the short form and the full-item bank (r=0.95, p<0.01), the short form was utilized in our analyses. Cronbach’s α for each measure ranged from 0.77 to 0.90 (Levin et al., 2015).

Pain

The Numeric Pain Rating Scale (NPRS) assessed past-seven day pain severity on an 11-point Likert scale (0=no pain, 10=most severe pain). The NPRS has excellent test–retest reliability (r=0.95-0.96) and high construct validity with other measure of pain (rs=0.86-0.95; Ferraz et al., 1990; Hawker, Mian, Kendzerska, & French, 2011).

Pain and Smoking Inventory

The Pain and Smoking Inventory (PSI) is a 9-item questionnaire measuring perceived interrelations of pain and smoking using a seven-point Likert scale (0=not true at all, 6=extremely true). The PSI includes a total score and three domains with three items each: (1) pain as a motivator of smoking, (2) smoking to cope with pain, and (3) pain as a barrier to smoking. Higher scores indicate greater endorsement of each domain. The PSI has demonstrated excellent internal consistency reliability for the total score and the three domains in a community sample (αs = 0.84-0.95; Ditre, Zale, Heckman, & Hendricks, 2017) and in the current study (αs = 0.92-0.95; Weinberger, Seng, Ditre, Willoughby, & Shuter, 2018). With regard to missing data, if one question was missing, the researchers averaged the other two questions from that domain. If there was more than one missing item, the data from that participant were excluded from the analyses (Ditre, personal communication, May 9, 2017).

Statistical Analysis

All statistics were performed using the Statistical Package for the Social Sciences (SPSS)-22.0. Heavy and light smokers were compared on participant characteristics using t-tests for continuous variable and chi-squares for categorical variables. In a test of multi-collinearity for anxiety and pain level, all tolerance values were <0.1 and VIF values were >10, within acceptable cutoffs. A multivariate linear regression was utilized to analyze the association between the PSI total score and three domains and the predictor variables of demographics, smoking status, anxiety, depression, and pain severity. All variables were entered in a backwards entry procedure, entering smoking status in Block 1, demographics in Block 2, psychiatric symptoms in Bock 3, and pain severity in Block 4. A multivariate linear regression was also run with all variables entered in together (see Supplemental Tables). Analyses were run without and then with a Holm-Bonferroni adjustment.

Results

Sample Characteristics

Over two hundred participants were approached over the four-month recruitment period. The major reason for exclusion was no current smoking. One hundred fourteen participants completed oral consent procedures. Thirteen participants did not meet the inclusion criteria resulting in an analytic sample of n=101. See Table 1 for demographic and smoking characteristics for the full sample and by smoking status.

Table 1:

Demographic and smoking characteristics of the full sample of persons living with HIV who smoke cigarettes and for heavy versus light smokers.




Characteristics		 Total Sample
(n=101)
M (SD) or %(N)		 Light Smokersa
(n=76)
M (SD) or %(N)		 Heavy Smokersa
(n=25)
M (SD) or %(N)

p-valueb
Age (years) 49.55 (8.81) 49.13 (9.08) 50.84 (7.95) 0.403
Gender (male) 50.5% (51) 48.7% (37) 56.0% (14) 0.526
Ethnicity (Latino/a) 54.4% (49) 51.5% (35) 63.6% (14) 0.319
Race (African American) 47.9% (45) 53.5% (38) 30.4% (7) 0.200
Sexual Orientation
  Heterosexual 72.4% (71) 69.9% (51) 80.0% (20)
  Homosexual 18.4% (18) 17.8% (13) 20.0% (5) 0.335
  Bisexual 8.20% (8) 11.0% (8) 0.0% (0)
  Education
  1st-8th Grade 7.2% (7) 4.2% (4) 16.0% (4)
  9th-11th Grade 27.8% (27) 31.9% (23) 16.0% (4) 0.002
  High School or GED 37.1% (36) 31.9% (23) 52.0% (13)
  Some College or College or Junior College 27.8% (27) 31.9% (23) 16.0% (4)
Years since HIV diagnosis 18.20 (7.20) 18.17 (7.11) 18.28 (7.60) 0.948
Smoking Behaviors
Smoking days per week 6.52 (2.48) 6.37 (2.84) 7.00 (0.00) 0.290
Using other tobacco products 11.0% (11) 12.0% (9) 8.0% (2) 0.580
Smoked ≥100 cigarettes in lifetime 92.9% (91) 91.9% (68) 95.8% (23) 0.515
Cigarettes per day (CPD) 9.55 (7.62) 6.08 (3.18) 20.10 (7.51) <0.001
Motivation to Quit (range=1-10)c 7.23 (2.75) 7.53 (2.62) 6.32 (2.97) 0.055
Confidence to Quit (range=1-10)c 5.92 (2.96) 6.04 (2.87) 5.56 (3.24) 0.485
Numeric Rating Scale for Pain (NRS; range=0-10) 4.60 (3.66) 4.50 (3.68) 4.88 (3.67) 0.656
Pain and Smoking Inventory total score (PSI; range=0-6) 2.01 (1.87) 1.90 (1.78) 2.32 (2.14) 0.343
Pain as a Motivator to Smoke 1.92 (2.09) 1.77 (2.02) 2.37 (2.25) 0.805
Smoking to Cope with Pain 2.16 (1.93) 2.13 (1.86) 2.24 (2.16) 0.343
Pain as Barrier to Quitting Smoking 1.94 (2.05) 1.81 (1.96) 2.33 (2.30) 0.272
PROMIS Depression Scale 53.08 (11.94) 52.14 (12.30) 56.38 (10.16) 0.152
PROMIS Anxiety Scale 56.99 (12.83) 57.05 (13.71) 56.82 (9.89) 0.940
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Key: PROMIS, Patient-Reported Outcomes Measurement Information System

Notes: The total number of individuals reporting data for each characteristic differs from the N=101. Total response for each characteristic are as follows: Age, N= 101; Gender; N= 101; Ethnicity, N=90, Race, N=94; Sexual Orientation, N= 98; Education, N=97; Years of HIV diagnosis, N=96;Smoking Days per a week, N=95; Use of other Tobacco products, N=100; Smoking more 100 cigarettes, N=98; CPD, N=101; NRS, N=99; Pain and Smoking Inventory, N=101; Pain as a Motivator to Smoke, N=101; Smoking to Cope with Pain, N=101; Pain as Barrier to Quitting Smoking, N=101 PROMIS Depression Scale, N= 95; PROMIS Anxiety scale, N=98; Feels about Quitting, N=100; Confident about Quitting, N=100.

a

Light smokers were defined as those reporting smoking 1 to 10 cigarettes per day and heavy smokers were defined as those reporting smoking 11 or more cigarettes per a day.

b

Light smokers versus heavy smokers

c

Higher scores indicated greater motivation or confidence to quit smoking

Association of demographic and smoking variables to the PSI (Supplemental Tables 1-4)

Greater anxiety symptoms (β =0.056, SE=0.015 p<0.001) and greater current pain severity (β =0.226, SE=0.050, p<0.001) were significantly associated with a higher total PSI score after controlling for smoking status, demographics, and depression symptoms. Smoking status, demographics, and depression symptoms were not significantly associated with the total PSI score.

With regard to the PSI domains, greater anxiety symptoms (β=0.063, SE=0.018, p=<0.001) and greater current pain severity level (β=0.221, SE=0.060, p<0.001) were significantly associated with greater endorsement of pain as a motivator for smoking. Greater anxiety symptoms (β=0.059, SE=0.016, p<0.001) and greater current pain severity level (β=0.239, SE=0.053, p<0.001) were also significantly associated with higher endorsement of smoking to cope with pain. Finally, greater anxiety symptoms (β=0.048, SE=0.018, p=0.008), greater current pain severity level (β=−0.075, SE=0.033, p=0.010), and the length of time since the HIV diagnosis (β=0.166, SE=0.062, p=0.028) were associated with greater endorsement of pain being a barrier to stopping smoking. When the Holm-Bonferroni adjustment was run, the significant relationships remained the same except that the results for the pain as barrier to quitting smoking domain were no longer significant.

Discussion

The current study was the first to examine factors associated with perceived interactions of pain and smoking among PLWH who smoke cigarettes. Pain severity, anxiety symptoms, and length of time since HIV diagnosis were each related to aspects of the perceived interrelations of pain and smoking. First, greater current pain severity was related to greater endorsement of overall perceived interrelations between pain and smoking, pain as a motivator for smoking, and smoking to cope with pain. Second, greater anxiety symptoms were associated with greater endorsement of overall perceived interrelations between pain and smoking, pain as a motivator for smoking, and smoking to cope with pain. While pain severity, anxiety, and HIV diagnosis length were originally associated with pain as a barrier for smoking cessation, these associations were no longer significant after a correction for multiple comparisons.

People who smoke and report pain also report less confidence in their ability to quit smoking and have greater expectations that quitting smoking will be difficult (Ditre, Kosiba, Zale, Zvolensky, & Maisto, 2016; Zale, Ditre, Dorfman, Heckman, & Brandon, 2014). Futhremore, pain is a predictor for relapse in smoking cessations program (Aigner, Gritz, Tami-Maury, Baum, Arduino, & Vidrine, 2017). Being able to identify barriers to smoking cessation are vital for creating more effective interventions. Ditre and collegues (2018) found that indiviudals who received a personalized intervention targeting pain had better smoking cessation outcomes than those who did not receive pain and smoking information. Future research can target these factors (e.g., pain severity, pain anxiety, the use of smoking to help manage pain) to improve quit outcomes for PLWH.

This study had a number of limitations. First, participants may have not been honest with their self-report or been impacted by recall biases. Second, the study had a relatively small sample. Third, results may not generalize to other PLWH due to the demographics of the sample.

Conclusions

Understanding the beliefs about the relationship between smoking and pain, as well as associated factors such as anxiety and pain severity, may help to guide interventions for PLWH who smoke.

Supplementary Material

Supp 1

Acknowledgments

The authors thank Alyssa Burns, Brittlyn Katz Pearlman, Christine Lee, and Kate Segal for their help with data collection.

Grant funding

This work was funded by the National Institutes of Health (NIH) under grants R01-DA036445, R01-CA192954, R34-DA037042, and K23-NS096107 and the Einstein-Rockefeller-CUNY Center for AIDS Research; which is supported by the following NIH co-funding and participating institutes and centers: NIAID, NCI, NICHD, NHBL, NIDA, NIMH, NIA, FIC and OAR; under grant P30-AI124414.

Footnotes

Conflicts of interest

The authors have no conflicts of interest to report

Contributor Information

Hannah Esan, Email: Hannah.esan@gmail.com.

Josh Agress, Email: agressj0@rowan.edu.

Elizabeth K. Seng, Email: Elizabeth.Seng@einstein.yu.edu.

Jonathan Shuter, Email: jshuter@montefiore.org.

Andrea H. Weinberger, Email: andrea.weinberger@einstein.yu.edu.

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