Original Report| Volume 13, ISSUE 11, P1058-1067, November 2012

Distinguishing Features of Cancer Patients Who Smoke: Pain, Symptom Burden, and Risk for Opioid Misuse

Published:September 25, 2012DOI:


      Although many cancer patients who have pain are smokers, the extent of their symptom burden and risk for opioid misuse are not well understood. In this study we analyzed records of patients being treated for cancer pain, 94 of whom were smokers and 392 of whom were nonsmokers, to determine smoking status group differences. Smokers had significantly higher pain intensity, fatigue, depression, and anxiety than nonsmokers (independent samples t-tests P < .002). Smokers were at higher risk for opioid misuse based on the short form of the Screener and Opioid Assessment for Patients with Pain (SOAPP). Specifically, smokers had more frequent problems with mood swings, taking medications other than how they are prescribed, a history of illegal drug use, and a history of legal problems (chi-square tests P ≤ .002). Changes in pain and opioid use were examined in a subset of patients (146 nonsmokers and 46 smokers) who were receiving opioid therapy on at least 2 of the 3 data time points (consult, follow-up 1 month after consult, follow-up 6 to 9 months after consult). Results based on multilevel linear modeling showed that over a period of approximately 6 months, smokers continued to report significantly higher pain than nonsmokers. Both smokers and nonsmokers reported a significant decline in pain across the 6-month period; the rate of decline did not differ across smokers and nonsmokers. No significant difference over time was found in opioid use between smokers and nonsmokers. These findings will guide subsequent studies and inform clinical practice, particularly the relevancy of smoking cessation.


      This article describes pain, symptom burden, and risk for opioid misuse among cancer patients with pain across smoking status. Smoking appears to be a potential mechanism for having an increased pain and symptom burden and risk for opioid misuse. This improved understanding of cancer pain will inform clinical practice.

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        • Albano S.A.
        • Santana-Sahagun E.
        • Weisman M.H.
        Cigarette smoking and rheumatoid arthritis.
        Sem Arthritis Rheumatism. 2001; 31: 146-159
        • American Cancer Society
        Cancer Facts and Figures 2009.
        American Cancer Society, Atlanta, GA2009
        • Baker T.B.
        • Brandon T.H.
        • Chassin L.
        Motivational influences on cigarette smoking.
        Annu Rev Psychology. 2004; 55: 463-491
        • Barrera R.
        • Shi W.
        • Amar D.
        • Thaler H.T.
        • Gabovich N.
        • Bains M.S.
        • White D.A.
        Smoking and timing of cessation: Impact on pulmonary complications after thoracotomy.
        Chest. 2005; 127: 1977-1983
        • Browman G.P.
        • Wong G.
        • Hodson I.
        • Sathya J.
        • Russell R.
        • McAlpine L.
        • Skingley P.
        • Levine M.N.
        Influence of cigarette smoking on the efficacy of radiation therapy in head and neck cancer.
        N Engl J Med. 1993; 328: 159-163
        • Bruera E.
        • Macdonald S.
        Audit methods: The Edmonton Symptom Assessment System.
        in: Higginson I. Clinical audit in palliative care. Radcliffe Medical Press, Oxford1993: 61-77
        • Butler S.F.
        • Budman S.H.
        • Fernandez K.
        • Jamison R.N.
        Validation of a screener and opioid assessment measure for patients with chronic pain.
        Pain. 2004; 112: 65-75
        • Chang V.T.
        • Hwang S.S.
        • Feuerman M.
        Validation of the Edmonton Symptom Assessment Scale.
        Cancer. 2000; 88: 2164-2171
        • Cleeland C.S.
        • Ryan K.M.
        Pain assessment: Global use of the Brief Pain Inventory.
        Ann Acad Med Singapore. 1994; 23: 129-138
        • Cox L.S.
        • Africano N.L.
        • Tercyak K.P.
        • Taylor K.L.
        Nicotine dependence treatment for patients with cancer.
        Cancer. 2003; 98: 632-644
        • Daniel M.
        • Keefe F.J.
        • Lyna P.
        • Peterson D.
        • Garst J.
        • Kelley M.
        • Bepler G.
        • Bastian L.A.
        Persistent smoking after a diagnosis of lung cancer is associated with higher reported pain levels.
        J Pain. 2009; 10: 323-328
        • Dasgupta P.
        • Rizwani W.
        • Pillai S.
        • Kinkade R.
        • Kovacs M.
        • Rastogi S.
        • Banerjee S.
        • Carless M.
        • Kim E.
        • Coppola D.
        Nicotine induces cell proliferation, invasion and epithelial-mesenchymal transition in a variety of human cancer cell lines.
        Intl J Can. 2009; 124: 36-45
        • Ditre J.W.
        • Brandon T.H.
        Pain as a motivator of smoking: Effects of pain induction on smoking and urge behavior.
        J Abn Psychol. 2008; 117: 467-472
        • Ditre J.W.
        • Brandon T.H.
        • Zale E.L.
        • Meagher M.M.
        Pain, nicotine, and smoking: Research findings and mechanistic considerations.
        Psych Bulletin. 2011; 137: 1065-1093
        • Ditre J.W.
        • Gonzalez B.D.
        • Simmons V.N.
        • Faul L.A.
        • Brandon T.H.
        • Jacobsen P.B.
        Associations between pain and current smoking status among cancer patients.
        Pain. 2011; 152: 60-65
        • Ditre J.W.
        • Heckman B.W.
        • Butts E.A.
        • Brandon T.H.
        Effects of expectancies and coping on pain-induced motivation to smoke.
        J Abnorm Psychol. 2010; 119: 524-533
        • Ekholm O.
        • Gronbaek M.
        • Peuckmann V.
        • Sjogren P.
        Alcohol and smoking behavior in chronic pain patients: The role of opioids.
        Eur J Pain. 2009; 13: 606-612
        • Eriksen W.B.
        • Brage S.
        • Bruusgaard D.
        Does smoking aggravate musculoskeletal pain?.
        Scand J Rheumatol. 1997; 26: 49-54
        • Goldberg M.S.
        • Scott S.C.
        • Mayo N.E.
        A review of the association between cigarette smoking and the development of nonspecific back pain and related outcomes.
        Spine. 2000; 25: 995-1014
        • Gritz E.R.
        • Lam C.Y.
        • Vidrine D.J.
        • Fingeret M.C.
        Cancer prevention: Tobacco Dependence and its Treatment.
        in: DeVita V. Lawrence T. Rosenberg S. Cancer: Principles and Practice of Oncology. 2, Part 3, Chapter 51. 9th edition. Lippincott Williams & Wilkins, Philadelphia, PA2011: 529-542
        • Hahn E.J.
        • Rayens M.K.
        • Kirsh K.L.
        • Passik S.D.
        Brief report: Pain and readiness to quit smoking cigarettes.
        Nicotine Tob Res. 1999; 1: S143-S147
        • Hooten W.M.
        • Shi Y.
        • Gazelka H.M.
        • Warner D.O.
        The effects of depression and smoking on pain severity and opioid use in patients with chronic pain.
        Pain. 2011; 152: 223-229
        • IARC
        Tobacco smoke and involuntary smoking (IARC Monographs on the Evaluation of Carcinogenic Risks to Humans Rep. No. 83).
        World Health Organization, Lyon France2002
      1. International Agency for Research on Cancer Working Group on the Evaluation on Carcinogenic Risks to Humans, Volume 83: Tobacco smoke and involuntary smoking. IARC, Lyon (France)2004
        • Jamison R.N.
        • Stetson B.A.
        • Parris W.C.V.
        The relationship between cigarette smoking and chronic low back pain.
        Addict Behav. 1991; 16: 103-110
        • Kawahara M.
        • Ushijima S.
        • Kamimori T.
        • Kodama N.
        • Ogawara M.
        • Matsui K.
        • Masuda N.
        • Takada M.
        • Sobue T.
        • Furuse K.
        Second primary tumors in more than 2-year disease-free survivors of small-cell lung cancer in Japan: The role of smoking cessation.
        Br J Cancer. 1998; 78: 409-412
        • Krebs E.E.
        • Lurie J.D.
        • Fanciullo G.
        • Tosteson T.D.
        • Blood E.A.
        • Carey T.S.
        • Weinstein J.N.
        Predictors of long-term opioid use among patients with painful lumbar spine conditions.
        J Pain. 2010; 11: 44-52
        • Littell R.C.
        • Milliken G.A.
        • Stroup W.W.
        • Wolfinger R.D.
        • Schabenberfer O.
        SAS for mixed models.
        SAS Institute Inc, Cary, NC2006
        • Logan H.L.
        • Fillingim R.B.
        • Bartoshuk L.M.
        • Sandow P.
        • Tomar S.L.
        • Werning J.W.
        • Mendenhall W.M.
        Smoking status and pain level among head and neck cancer patients.
        J Pain. 2010; 11: 528-534
        • Michna E.
        • Ross E.L.
        • Hynes W.L.
        • Nedeljkovic S.S.
        • Soumekh S.
        • Janfaza D.
        • Palombi D.
        • Jamison R.N.
        Predicting aberrant drug behavior in patients treated for chronic pain: Importance of abuse history.
        J Pain Symptom Manage. 2004; 28: 250-258
        • Moller A.M.
        • Villebro N.
        • Pedersen T.
        • Tonnesen H.
        Effect of preoperative smoking intervention on postoperative complications: A randomized clinical trial.
        Lancet. 2002; 359: 114-117
        • Morasco B.J.
        • Duckart J.P.
        • Carr T.P.
        • Deyo R.A.
        • Dobscha S.K.
        Clinical characteristics of veterans prescribed high doses of opioid medications for chronic non-cancer pain.
        Pain. 2010; 151: 625-632
        • Moryl N.
        • Coyle N.
        • Essandoh S.
        • Glare P.
        Chronic pain management in cancer survivors.
        J Natl Compr Canc Netw. 2010; 8: 1104-1110
        • Pamuk O.N.
        • Donmez S.
        • Carkir N.
        The frequency of smoking in fibromyalgia patients and its association with symptoms.
        Rheumatol Int. 2009; 29: 1311-1314
        • Patterson A.L.
        • Gritzner S.
        • Resnick M.P.
        • Dobscha S.K.
        • Turk D.C.
        • Morasco B.J.
        Smoking cigarettes as a coping strategy for chronic pain is associated with greater pain intensity and poorer pain-related function.
        J Pain. 2012; 13: 285-292
        • Shi Y.
        • Weingarten T.N.
        • Mantilla C.B.
        • Hooten W.M.
        • Warner D.O.
        Smoking and pain: Pathophysiology and clinical implications.
        Anesthesiology. 2010; 113: 977-992
        • Stevens M.H.
        • Gardner J.W.
        • Parkin J.L.
        • Johnson L.P.
        Head and neck cancer survival and life-style change.
        Arch Otolaryngology. 1983; 109: 746-749
        • Sturgis E.M.
        • Ciniripini P.M.
        Trends in head and neck cancer incidence in relation to smoking prevalence: An emerging epidemic of human papillomavirus-associated cancers?.
        Cancer. 2007; 110: 1429-1435
        • Theadom A.
        • Cropley M.
        Effects of preoperative smoking cessation on the incidence and risk of intraoperative and postoperative complications in adult smokers: A systematic review.
        Tobacco Control. 2006; 15: 352-358
        • Van den Beuken-van Everdingen M.H.J.
        • de Riijke J.M.
        • Kessels A.G.
        • Schouten H.C.
        • van Kleef M.
        • Patijn J.
        Prevalence of pain in patients with cancer: A systematic review of the past 40 years.
        Ann Oncol. 2007; 18: 1437-1449
        • Weingarten T.N.
        • Moeschler S.M.
        • Ptaszynski A.E.
        • Hooten W.M.
        • Beebe T.J.
        • Warner D.O.
        An assessment of the association between smoking status, pain intensity, and functional interference in patients with chronic pain.
        Pain Physician. 2008; 11: 643-653
        • Zarrindast M.R.
        • Khoshayand M.R.
        • Shafaghi B.
        The development of cross-tolerance between morphine and nicotine in mice.
        Eur Neuropsychopharmacol. 1999; 9: 227-233
        • Zevin S.
        • Benowitz N.L.
        Drug interactions with tobacco smoking. An update.
        Clin Pharmacokinet. 1999; 36: 425-438
        • Zvolensky M.J.
        • McMillan K.
        • Gonzalez A.
        • Asmundson G.J.
        Chronic pain and cigarette smoking and nicotine dependence among a representative sample of adults.
        Nicotine Tob Res. 2009; 11: 1407-1414