Smoking and Chronic Pain
We often underestimate the power of (tobacco) smoking to make things hurt more and longer
Smokers are two to three times more likely to suffer from chronic pain than non-smokers1 — an alarming statistic for smokers.
Pain is so complex and weird that the role of smoking often gets lost in the mess of possibilities — two chaotic phenomena interacting, like storm fronts colliding. And that’s exactly why smoking is relevant to pain: smoking tobacco affects practically everything, and practically everything affects chronic pain, and so there’s bound to be overlap. And there is. Smoking is a major risk factor for chronic pain of many kinds.2345
Ironically, nicotine is also a pain-killer — but that short term effect is swamped by the long term impact on pain.6
“Smoking was established long ago as a strong predictor of failure of pain treatment,” writes Dr. Tim Taylor, a chronic pain specialist. “Smokers are so difficult to treat that I will not accept smokers as patients.”
Smokers often assume that they’re mostly just hurting their lungs and risking cancer, but that is just the tip of the iceberg. Smoking compromises so many aspects of health — nearly all of them, really — that quitting is a vital pre-requisite for beating pain.
Doctors and smoking advice
Doctors are often maligned for not caring about “prevention”, and yet discovering the health risks of smoking is one of the clearest triumphs of scientific medicine, among so many others in the last two hundred years. In fact, probably nowhere else in medicine is it more obvious that doctors do care about prevention. Certainly my doctor cares.89
Ironically, it is often the accusers who ignore the clinical importance of factors like smoking in chronic pain, because they are preoccupied with their own pet theories about what causes pain …
Missing the smoking forest in the biomechanical trees
Many therapists (and patients too) often miss the forest for the trees. This forest represents an extremely important clinical consideration: smoking. The trees are the biomechanical explanations for pain that so many people get obsessed with: specific, “exciting,” and therapizable biomechanical causes of pain like crooked, asymmetrical, and degenerated anatomy. Focusing on things like this is strong theme in the manual therapies like massage and chiropractic — but not a very good one. These sorts of explanations for chronic pain leave much to be desired.10
And they may be an unfortunate distraction from more basic and powerful explanations for pain. Like smoking.
Smoking is one of those big picture medical factors in pain — like insomnia, stress, or nutritional deficiencies — that can be the main reason an otherwise minor pain problem is so stubborn. It might be the reason a little biomechanical glitch hurts in the first place, instead of being painless like it is in other people.
One excellent example: smoking is clearly associated with shoulder pain and injuries (like rotator cuff tears).11 Think about that: smoking makes people tear their shoulder muscles more. That’s hardly the kind of vulnerability people expect from smoking. It’s also very likely that it’s a risk factor for frozen shoulder.
Smoking and breathing
Biomechanics may often be overemphasized, while smoking is neglected as a consideration, but there is one scenario in which they may both be involved:
In addition to the many harmful effects on physiology, wheezing smokers may also painfully exhaust accessory breathing muscles in the neck, like the scalenes … which might cause more upper body pain than you’d ever guess (via the mechanism of “referred pain,” which the scalenes are unusually “good” at). This is just my own pet biomechanical theory of pain, but it’s reasonable: I explain it in much more detail in The Respiration Connection: How dysfunctional breathing might be a root cause of a variety of common upper body pain problems and injuries.
Smoking tobacco causes pain, and cannabis might relieve it: the evidence is mixed and a lot less impressive that proponents make it out to be, but it’s certainly worth experimenting with.12 There are of course health risks associated with inhaling any kind of smoke, but certainly marijuana in moderation is pharmacologically safe.13 And, where legal, there are other good delivery mechanisms: edibles and vapourizing, most notably. The efficacy of marijuana for pain is controversial — what about marijuana isn’t controversial? — but clearly there is a case to be made for giving it a try. For a full review and user’s guide, see Marijuana for Pain: The hype versus the science! What does the evidence actually show about cannabis and chronic pain?
- 17 Ways To Quit Smoking In Honor Of The Great American Smokeout
- Evidence base and strategies for successful smoking cessation (academic paper)
- Smoking Cessation and the Affordable Care Act — Includes a good science-based overview of quitting methods.
- Chronic, Subtle, Systemic Inflammation — One possible sneaky cause of puzzling chronic pain
- 35 Surprising Causes of Pain — Trying to understand pain when there is no obvious explanation. Smoking is just one of many sources of biological vulnerability to pain.
- Insomnia Until it Hurts — The role of sleep deprivation in chronic pain, especially muscle pain.
- The Trouble with Chairs — The science of being sedentary and how much it does (or doesn’t) affect your health and back pain. Gets into detail on the risks of smoking versus sedentariness.
What’s new in this article?
Four updates have been logged for this article since publication (2015). All PainScience.com updates are logged to show a long term commitment to quality, accuracy, and currency. more
Like good footnotes, update logging sets PainScience.com apart from most other health websites and blogs. It’s fine print, but important fine print, in the same spirit of transparency as the editing history available for Wikipedia pages.
I log any change to articles that might be of interest to a keen reader. Complete update logging started in 2016. Prior to that, I only logged major updates for the most popular and controversial articles.
See the What’s New? page for updates to all recent site updates.
2020 — Science update. Added a good fresh citation to Smuck et al about the link between smoking and pain.
2016 — Added a related reading section with links to help with quitting. Added a minor item with citation about smoking being (ironically) a short term pain-killer.
2016 — Added example of the effect of smoking on shoulder pain/injuries.
2016 — General editing for clarity.
2015 — Publication.
About Paul Ingraham
I am a science writer in Vancouver, Canada. I was a Registered Massage Therapist for a decade and the assistant editor of ScienceBasedMedicine.org for several years. I’ve had many injuries as a runner and ultimate player, and I’ve been a chronic pain patient myself since 2015. Full bio. See you on Facebook or Twitter., or subscribe:
- Smuck M, Schneider BJ, Ehsanian R, Martin E, Kao MC. Smoking Is Associated with Pain in All Body Regions, with Greatest Influence on Spinal Pain. Pain Med. 2020 Sep;21(9):1759–1768. PubMed 31578562 ❐
This 2020 study analyzed survey data for 2300 Americans from 2004, looking for the relationship between smoking and pain and finding strong links. Smokers had close to a three times greater risk of spinal pain than non-smokers, with headache almost as bad. Most other kinds of pain were around twice as likely to occur in smokers.
- Choi CJ, Knutsen R, Oda K, Fraser GE, Knutsen SF. The association between incident self-reported fibromyalgia and nonpsychiatric factors: 25-years follow-up of the Adventist Health Study. J Pain. 2010 Oct;11(10):994–1003. PubMed 20400378 ❐
Over 3000 women who took comprehensive lifestyle and medical history questionnaires in 1976. A quarter century later, 136 of them reported a diagnosis of fibromyalgia. Their medical history was examined in more detail to look for correlations between fibromyalgia and diseases, lifestyle factors, and health behaviors. “Smoking as well as prevalent allergies, and a history of hyperemesis gravidarum [morning sickness, but much worse], seem to predict development of FM in women during 25 years of follow-up.” No correlation was found with the number of surgeries, ulcers, or medication usage.
More smokers have fibromyalgia than non-smokers.
- Behrend C, Prasarn M, Coyne E, et al. Smoking Cessation Related to Improved Patient-Reported Pain Scores Following Spinal Care. J Bone Joint Surg Am. 2012 Dec 5;94(23):2161–6. PubMed 23095839 ❐
This study added to the pile of evidence that smoking is “associated with low back pain, intervertebral disc disease” along with many other medical complications. Their conclusion, after studying the records of more than 5000 patients with “axial or radicular pain from a spinal disorder,” was that there is a “need for smoking cessation programs for patients with a painful spinal disorder.” Very likely both neck and back, of course.
- Petre B, Torbey S, Griffith JW, et al. Smoking increases risk of pain chronification through shared corticostriatal circuitry. Human brain mapping. 2014 Oct. PubMed 25307796 ❐
The science here is a bit more complex than I usually deal with, but the punchline is simple enough: “We conclude that smoking increases risk of transitioning to chronic back pain.”
- Shiri R, Viikari-Juntura E, Varonen H, Heliövaara M. Prevalence and determinants of lateral and medial epicondylitis: a population study. Am J Epidemiol. 2006 Dec;164(11):1065–74. PubMed 16968862 ❐ Smokers are at least twice as likely to get tennis elbow.
- Shi Y, Weingarten TN, Mantilla CB, Hooten WM, Warner DO. Smoking and pain: pathophysiology and clinical implications. Anesthesiology. 2010 Oct;113(4):977–92. PubMed 20864835 ❐ “Experimental studies suggest that nicotine has analgesic properties. However, epidemiologic evidence shows that smoking is a risk factor for chronic pain. The complex relationship between smoking and pain not only is of scientific interest, but also has clinical relevance in the practice of anesthesiology and pain medicine.”
- Vallance JK, Gardiner PA, Lynch BM, et al. Evaluating the Evidence on Sitting, Smoking, and Health: Is Sitting Really the New Smoking? Am J Public Health. 2018 Nov;108(11):1478–1482. PubMed 30252516 ❐ PainSci Bibliography 53105 ❐
- For example, see Smoking Cessation and the [American] Affordable Care Act. Dr. Harriet Hall: “‘Doctors don’t do prevention’ is a lie. This is a common complaint we hear from alternative medicine advocates, especially from naturopaths. It is so wrong it hardly deserves an answer. Doctors are the ones who invented prevention, who have always known it’s better to prevent disease than to treat it, who actually have evidence-based ways to prevent disease.”
- My own family doctor is so diligent about diet, exercise, sleep, stress, etc that he’s downright annoying about it. In a good way, of course! I saw an ENT specialist for my weird sore throat who was so preoccupied with lifestyle factors that he actually was annoying: it was hard to get him to discuss anything else!
- “Structuralism” is the excessive focus on causes of pain like crookedness and biomechanical problems. It’s an old and inadequate view of how pain works, but it persists because it offers comforting, marketable simplicity that is the mainstay of entire styles of therapy. For more information, see Your Back Is Not Out of Alignment: Debunking the obsession with alignment, posture, and other biomechanical bogeymen as major causes of pain.
- Bishop JY, Santiago-Torres JE, Rimmke N, Flanigan DC. Smoking Predisposes to Rotator Cuff Pathology and Shoulder Dysfunction: A Systematic Review. Arthroscopy. 2015 Aug;31(8):1598–605. PubMed 25801046 ❐
Smoking is strongly linked to more shoulder pain and injuries (like rotator cuff tears, and probably frozen shoulder as well), which is weird. This seems to be excellent evidence of two principles:
- There doesn’t seem to be anything that smoking will not make worse.
- Musculoskeletal pain/injury that seems “mechanical” is often more about subtle biological vulnerability.
This review considered thirteen studies of shoulder trouble in about 6000 smokers out of 16,000 patients. The studies showed clear links between smoking and rotator cuff tears: more tears and worse tears, with more degenerative signs later on. That is, the “cuff” of muscles around the shoulder joint is apparently more fragile in smokers. They also found a link with unexplained chronic shoulder pain and dysfunction. One experimental study showed that nicotine made rat shoulder tendons stiffer.
Smoking is bad for your shoulders! Who knew.
- Ingraham. Marijuana for Pain: The hype versus the science! What does the evidence actually show about cannabis and chronic pain? ❐ PainScience.com. 6789 words.
- Ware MA, Wang T, Shapiro S, Collet JP; COMPASS study team. Cannabis for the Management of Pain: Assessment of Safety Study (COMPASS). J Pain. 2015 Dec;16(12):1233–42. PubMed 26385201 ❐
Although we already have many reasons to suspect that cannabis usage is very safe, the more data the better on this topic, and particularly in the context of treating non-cancer pain. The results are good news, and completely consistent with other evidence. Ars Technica:
Almost every news story one reads about the use of cannabis as a medical therapy contains some variation of disclaimer saying ‘more research is needed’ into the longterm safety of medical cannabis use. Now a tiny bit of that ‘more research’ has been published in the Journal of Pain. The headline result was that there was NO INCREASE IN THE NUMBER OF SERIOUS ADVERSE EVENTS in a group that used cannabis for chronic pain when compared to a group that did not.
It’s hard to overstate how significant that kind of safety level is for any medication that helps with pain. Even the mildest over-the-counter analgesics come with serious risks (see How risky are NSAIDS?). Cannabis is not risk free — this study did find evidence of non-serious adverse events — but the total absence of serious adverse events is a big deal.
(By the way, this science comes from Canada, which is where I come from. You’re welcome.)