Sensible advice for aches, pains & injuries

Smoking and Chronic Pain

We often underestimate the power of (tobacco) smoking to make things hurt more and longer

updated (first published 2015)
by Paul Ingraham, Vancouver, Canadabio
I am a science writer and a former Registered Massage Therapist with a decade of experience treating tough pain cases. I was the Assistant Editor of for several years. I’ve written hundreds of articles and several books, and I’m known for readable but heavily referenced analysis, with a touch of sass. I am a runner and ultimate player. • more about memore about

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.123

“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.45

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. Focussing on things like this is strong theme in the manual therapies like massage and chiropractic — but not a very good one. 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. These sorts of explanations for chronic pain leave much to be desired.6

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).7 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 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 marijuana

Smoking tobacco causes pain, and smoking marijuana probably relieves it. There are of course health risks associated with inhaling any kind of smoke, but certainly marijuana in moderation is pharmacologically safe.8 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 strong case to be made for it.

What’s new in this article?

Added example of the effect of smoking on shoulder pain/injuries.

General editing for clarity.

About Paul Ingraham

Headshot of Paul Ingraham, short hair, neat beard, suit jacket.

I am a science writer, former massage therapist, and I was the assistant editor at for several years. I have had my share of injuries and pain challenges as a runner and ultimate player. My wife and I live in downtown Vancouver, Canada. See my full bio and qualifications, or my blog, Writerly. You might run into me on Facebook or Twitter.


  1. 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.

  2. 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.”

  3. 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.” (And not just for the back pain!)

  4. For example, see “Smoking Cessation and the [American] Affordable Care Act.” BACK TO TEXT
  5. 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! BACK TO TEXT
  6. “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. BACK TO TEXT
  7. 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), a surprising vulnerability.

  8. 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.)