Smoking and Persistent Pain

In this module, you will learn about:

  1. Facts about smoking.
  2. The link between smoking and persistent pain.
  3. How do I quit?
  4. Resources to help you quit smoking.

Quitting is not easy, but it is possible!


Tobacco use in Canada

Smoking is the leading cause of preventable death in Canada. Tobacco kills 1 in 5 Canadians, or from 35,000-48,000 people every year (more than deaths due to traffic accidents, suicides, homicides, drug abuse and HIV-AIDS combined). Smoking is a chronic disease that often begins in teenage years (90% of people become addicted before adulthood). 

What’s in a cigarette?

Cigarettes contain tobacco as well as about 4000 other chemicals. 

Below is a list of some of the most common chemicals found in cigarettes:




  • Nicotine

    Nicotine is a chemical that has stimulant and depressant effects on the brain. It is one of the most addictive substances in tobacco. Other plants belonging to the nightshade family (e.g. eggplants, tomatoes, potatoes, and red peppers) also contain nicotine but in much, much lower amounts than tobacco. Studies show that nicotine itself is not likely to cause diseases such as COPD or cancer. It is the 4,000 other chemicals in cigarette smoke that contributes to these diseases.

  • Carcinogens


    More than 50 known carcinogens (cancer-causing chemicals) are in cigarette smoke. Most of these carcinogens are formed during combustion (burning the tobacco), but oral tobacco use is associated with higher rates of some cancers. “Tar” is the name given to the combination of chemicals released as gasses or small particles when a cigarette is burned.

    These can include chemicals that are found in cleaning products, rocket fuel, used to preserve dead bodies, and chemicals used as insecticides.



What are the health effects of tobacco?

  • Increased pain.

  • Causes 30% of all cancer, including cancers of the mouth, throat, neck, stomach, kidneys, and bladder.

  • Causes 90% of lung cancer.

  • Higher risk of cardiovascular (heart-related) disease, such as poor circulation, heart attacks, and strokes.

  • Higher risk of respiratory (breathing-related) diseases, including asthma, chronic bronchitis and emphysema.

  • Weaker immune system and more prone to colds and flu.

  • Problems with sex and fertility.

  • Problems during and after pregnancy


Key Concepts

  1. Smoking is the leading cause of preventable death in Canada.
  2. 16% of Canadians age 15 and over are current smokers
  3. Cigarettes contain tobacco as well as about 4000 other chemicals. Tobacco is a plant that contains nicotine.
  4. More than 50 known carcinogens (cancer-causing chemicals) are in cigarette smoke.
  5. The health risks of tobacco use include: cancers, heart attack, stroke, respiratory disease, reproductive problems, weak immune system, and more pain.
  6. Tobacco dependence is a chronic disorder, but it is possible to quit.

The link between smoking and persistent pain


  • How does smoking and nicotine affect acute pain?

    • Nicotine can lower perception of pain in the short term.
      • High levels of nicotine may blunt pain perception to cold, heat, or pressure.
    • Nicotine withdrawal can enhance perception of pain.
      • When deprived of nicotine, smokers may feel cold, heat, or pressure as more painful.
      • This can lead to smoking more often to try to relieve pain, especially after nicotine blood levels fall (for example, during sleep).
  • How do smoking and nicotine affect chronic pain?

    • In the long term, smoking increases perception of pain.
      • When smokers and nonsmokers with chronic pain are compared, smokers have higher pain intensity scores and report their pain has a larger impact on daily activities.
    • Smoking can also increase someone’s risk of acute pain persisting and becoming a long term problem.
      • This can happen in many different pain disorders, including back pain and other musculoskeletal conditions.
    • Smoking can also increase risk of developing or worsening fibromyalgia. 

Many different factors can influence how smoking affects persistent pain. These factors interact with each other to impact pain experiences. The image below shows some of the ways smoking can affect pain in the brain and body.


Key concepts:

  • Nicotine can make pain seem lower in the short term but makes it worse in the long term.

  • Nicotine withdrawal can increase pain perception

  • Smokers with chronic pain report that their pain has a bigger impact on daily activities than nonsmokers.

  • Smoking increases the risk of back pain, musculoskeletal pain, and fibromyalgia.

  • Smoking can decrease the effectiveness of pain medication

  • Smoking causes changes to stress hormone production

  • Quitting tobacco use can cause a temporary increase in pain while the body withdraws from nicotine.

  • Learning healthy ways to cope with pain, stress, and anxiety can help you to quit smoking successfully.


Quitting can seem stressful, scary, or overwhelming to a lot of people. You may have tried to quit before and started smoking again. This can feel discouraging, but it is common, and many people are able to quit after a few attempts.

 Be clear about your reasons for quitting or reducing your smoking. What is important about quitting? Do you feel ready to quit now?

 Here are a few key steps for quitting using the STOP approach: (from CAMH, 2010)

  • Strategize

    • Make a plan for quitting that involves tracking your smoking habits, planning for triggers, problem solving difficult situations and obstacles, learning coping skills, identifying support people, and talking to your doctor about helpful medication.
    • Set a quit date in the next few weeks.
  • Take Action

    • Be aware of withdrawal symptoms.
    • Notice problems and come up with a few solutions for each (e.g. if motivation is low, review your reasons to quit).
    • Notice when you feel most likely to give in to the temptation to smoke.
  • Optimize your plan

    Ask family, friends, and trusted health care providers for feedback on your plan.

  • Prevent relapse

      • Relapse is not uncommon. It does not mean that trying to quit is over, and can help you learn for your next try.
      • Plan ahead: think about how you might feel if you relapse? How might you avoid it?
      • Avoid or change triggering situations (e.g. ask friends to smoke outside)
      • Find an alternative or substitute for a cigarette, such as nicotine gum, an inhaler, or a glass of water.
    • Find additional treatment, counselling, or groups to support your quitting.

Nicotine withdrawal symptoms


How long it usually lasts

Percentage of people who get it

Irritability/ aggression

4 weeks or less



4 weeks or less



4 weeks or less


Poor concentration

2 weeks or less


Increase in appetite

Over 10 weeks



48 hours or less

10 %

Waking up at night

1 week or less

25 %


Over 4 weeks

17 %

Mouth ulcers

Over 4 weeks

40 %

Urges to smoke

2 weeks or more

70 %

Not everyone has all of these symptoms. How much someone smokes can play a part in what symptoms are present. It can be helpful to think of these symptoms as positive signs that your body is healing from the chemicals that were absorbed from smoking.



 My Change Plan workbook, 8th edition

A workbook to guide you through quitting smoking.

 STOP program

A province-wide initiative that delivers smoking cessation treatment and counseling support to eligible Ontario smokers who wish to quit smoking.

 Toronto public health: Live Tobacco Free

Information on ways to support youth to remain tobacco-free, creating an environment free of second-hand smoke, and how to quit smoking.


Information for moms and moms to be about smoking.

Smokers Helpline

Information and support for quitting. Operated by the Canadian Cancer Society.

Ontario Support to Quit Smoking


My Change Plan

Can be found on App Store or Google Play Store.


Break it Off

Can be found on Google Play Store


  1. Centre for Addiction and Mental Health (CAMH). (2010). Fundamentals of Tobacco Interventions.
  2. CAMH. (2010). Tobacco.
  3. CAMH. (2006). About Tobacco.
  4. Centers for Disease Control and Prevention (CDC). (2005). State-specific prevalence of cigarette smoking and quitting among adults - United States, 2004. MMWR Morb Mortal Wkly Rep. 54, 1124–1127.
  5. Choi, C., Knutsen, R., Oda, K., Fraser, G.E., and Fonnebo Knutsen, S. (2010). The Association between Incident Self-reported Fibromyalgia and Non-psychiatric Factors: 25-years Follow-up of the Adventist Health Study. J Pain. 11(10), 994–1003. doi:10.1016/j.jpain.2010.01.267.
  6. Fiore, M.C., Bailey, W.C., Cohen, S.J., et al. (2008). Clinical Practice Guideline: Treating Tobacco Use and Dependence. US Department of Health and Human Services. Public Health Service. Available at:
  7. Freiman, A., Bird, G., et al. (2004). Cutaneous effects of smoking. J Cutan Med Surg 8(6), 415-23.
  8. Hammond, M. (2005). Healing from Smoking. Quebec: First Nations of Quebec and Labrador Health and Social Services Commission.
  9. Health Canada. (2012). Canadian Tobacco Use Monitoring Survey (CTUMS).
  10. Hecht, S. S. (2003). Tobacco carcinogens, their biomarkers and tobacco-induced cancer. Nat Rev Cancer 3(10), 733-44.
  11. Petre, B., Torbey, S., Griffith, J.W., De Oliveira, G., Herrmann, K., Mansour, A., Baria, A.T., Baliki, M.N., Schnitzer, T.J., and Apkarian, A.V. (2015). Smoking Increases Risk of Pain Chronification Through Shared Corticostriatal Circuitry. Hum Brain Mapp. 36(2), 683–694. doi:10.1002/hbm.22656.
  12. Shi, Y., Weingarten, T.N., Mantilla, C.B., Hooten, W.M., Warner, D.O. (2010). Smoking and Pain: Pathophysiology and Clinical Implications. Anesthesiology, 113 (4), 977-992.
  13. WHO. (2008). WHO Report on the Global Tobacco Epidemic. Available online at:


76 Grenville St. Toronto, ON M5S 1B2 Canada

TAPMI Hub Clinic

Phone: 416-323-6269 Office Fax: 416-323-2666 Hours: 8:00 a.m. – 4:00 p.m. Monday – Friday


Dr. Tania Di Renna, Medical Director Sandra Robinson, Administrative Director