The focus of health care is shifting paradigms away from acute conditions. Lawrence Gostin, JD, an internationally acclaimed scholar in public health ethics and law, and colleagues have said, "The United States is facing an epidemiological transition from infectious to chronic diseases … The challenge is to enable communities to facilitate physical and mental well-being."1 As providers of health care for back pain, it would seem natural for doctors of chiropractic to identify with this statement and find ways to support it.A chronic disease epidemic, back pain is cited as the most common chronic painful condition in Americans.2 Back pain is associated with reduced quality of life, human suffering, and huge financial and social burdens. Yet back pain has no cure.
As with most chronic diseases, there are many factors to consider. In chiropractic we are trained to focus on the biomechanical and neurological causes of back pain; however, we should be aware of other factors that could influence our treatment approach and patients' response to chiropractic care. Most know that smoking is both a common and harmful health behavior3 that represents the greatest modifiable risk factor for preventing many chronic diseases.4 Interestingly, back pain may also have a relationship with tobacco smoking, as has been demonstrated in a number of studies.
Smoking and Back Pain
Research conducted in several countries has shown that people who smoke have a higher prevalence of back pain.5 Tobacco use and back pain are recognized as public health priorities, being included in the Healthy People initiative6 and the Bone and Joint Decade.7
Approximately 22 million adult Americans suffer from back pain annually8 and it is estimated that the three-month prevalence for this same group is 17 percent. It is estimated that nearly 20 percent of adult Americans smoke cigarettes,3 even though the Healthy People objective is for there to be less than 12 percent of adult Americans who are smokers.3 Thus, as doctors of chiropractic we have the opportunity to assist approximately 20 percent of our patient population with two of the most common health problems.
There are a number of proposed mechanisms for the link between smoking and back pain. Some authors cite that smoking provides some pain relief through nicotinic analgesia.9 Another theory is that repeated microtrauma from chronic coughing leads to disc herniation.10 Yet another theory proposes that smoking reduces blood flow to the discs and vertebral bodies, leading to early degeneration.11
While there are other theories that attempt to explain a potential relationship between smoking and back pain,12 there are only a few studies that look at this relationship from a theoretical standpoint. Most research to date has focused simply on establishing whether or not a relationship exists between smoking and back pain.
In the military environment, many patients smoke cigarettes. I start discussing the potential link between smoking and back pain with them on day one. I know as a researcher that I need to be cautious in generalizing conclusions from studies that look at the association of back pain with smoking. However, as a clinician, it seems to me that we have adequate data to show that smoking is unhealthy for a great number of body systems.4 From that vantage point alone, I have no reservations in helping my patients to stop smoking.
And if getting patients to quit smoking, or preventing people from smoking in the first place, contributes to better spinal health, then it is beneficial to continue with education on smoking cessation and prevention. On the other hand, if at the end of the day the preponderance of research shows that smoking is not associated with back pain, then I can at least live with the fact that I helped a number of people to stop smoking for other health reasons.
Helping Patients Quit
In my practice, after I discuss smoking with them, I have found that many patients are ready to quit. For some, when they find out that their smoking behavior may be linked to the back pain that they despise so much, it is just the nudge they need to make the first steps toward smoking cessation. Once they are willing to consider cessation, I provide them with the resources needed for them to quit.
A number of free resources for smoking cessation are available to practitioners and patients. The Centers for Disease Control and Prevention offers several resources for individuals and practitioners (www.cdc.gov/tobacco). Most states have tobacco cessation programs, such as the one in California funded by the California Department of Public Health (www.nobutts.org). Chiropractors working in military and veterans hospitals and clinics may find the free educational materials specific to each military branch helpful at www.ucanquit2.org.
With back pain being one of the most common chronic diseases and smoking being a modifiable risk factor for many diseases including back pain, one can hope that if we can help people to stop smoking, then there will be less back pain in our communities. Less back pain in our population would mean more people would lead healthier and more productive lives, fewer people would suffer with pain, and a considerable amount of money would be saved in direct and indirect costs associated with back pain and tobacco use.
The Chiropractic Health Care section (CHC) of the American Public Health Association (APHA) looks at promoting health among Americans from the perspective of population health, modification of health behaviors, and prevention. If this way of thinking is something you feel "aligned" with, you might consider joining the APHA-CHC. For more information, click here.
- Gostin LO, Boufford JI, Martinez RM. The future of the public's health: vision, values, and strategies. Health Aff, 2004;23(4):96-107.
- Johannes CB, Le TK, Zhou X, Johnston JA, Dworkin RH. The prevalence of chronic pain in United States adults: results of an Internet-based survey. J Pain, 2010;11(11):1230-9.
- "Current Cigarette Smoking Prevalence Among Working Adults - United States, 2004-2010." Morb Mortal Wkly Rep, 2011;60(38):1305-9.
- Mokdad AH, Marks JS, Stroup DF, Gerberding JL. Actual causes of death in the United States, 2000. JAMA, 2004;291(10):1238-45.
- Shiri R, Karppinen J, Leino-Arjas P, Solovieva S, Viikari-Juntura E. The association between smoking and low back pain: a meta-analysis. Amer J Med, 2010;123(1):87 e7-35.
- U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. Healthy People 2020.
- Andersson G, American Academy of Orthopaedic Surgeons. The burden of musculoskeletal diseases in the United States : prevalence, societal, and economic cost. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2008.
- Martin BI, Turner JA, Mirza SK, Lee MJ, Comstock BA, Deyo RA. Trends in health care expenditures, utilization, and health status among US adults with spine problems, 1997-2006. Spine, 2009;34(19):2077-84.
- Ackerman WE III, Ahmad M. Effect of cigarette smoking on serum hydrocodone levels in chronic pain patients. J Ark Med Soc, 2007;104(1):19-21.
- Wai EK, Rodriguez S, Dagenais S, Hall H. Evidence-informed management of chronic low back pain with physical activity, smoking cessation, and weight loss. Spine J, 2008;8(1):195-202.
- Alkherayf F, Wai EK, Tsai EC, Agbi C. Daily smoking and lower back pain in adult Canadians: the Canadian Community Health Survey. J Pain Res, 2010;3:155-60.
- Leboeuf-Yde C. Smoking and low back pain. A systematic literature review of 41 journal articles reporting 47 epidemiologic studies. Spine,1999;24(14):1463-70.
Dr. Bart N. Green is a full-time corporate health chiropractor; a part-time faculty member at National University of Health Sciences; and a member of the APHA-CHC. He has extensive experience working in interdisciplinary pain management teams for patients with chronic non-cancer pain.