The Role of Anxiety Sensitivity in the Relation Between Pain Intensity with Substance Use and Anxiety and Depressive Symptoms Among Smokers with Chronic Pain



The additive effect of experiencing chronic pain in the context of nicotine addiction places smokers with chronic pain at elevated risk for experiencing physical and mental health problems. Isolating factors that explain linkages between pain and health-related outcomes among smokers with chronic pain is an important next step. Therefore, the current study examined the explanatory role of anxiety sensitivity in relations between pain intensity and current opioid misuse, severity of opioid dependence, tobacco-related problems, and anxiety/depressive symptoms.


Participants were 187 (Mage = 39.02, SD = 9.94, 74.9% female) daily smokers with chronic pain who completed a battery of self-report measures on pain experience, anxiety sensitivity, tobacco and opioid use, and anxiety/depression symptoms. Indirect effect analyses were conducted to examine anxiety sensitivity as a mediator of the relations between pain intensity and health-related outcomes.


A significant indirect effect emerged for pain intensity, through anxiety sensitivity, on opioid misuse (ab = 0.83, SE = 0.24, 95% CI [0.39, 1.34], CSE = 0.17), severity of opioid dependence (ab = 0.17, SE = 0.05, 95% CI [0.08, 0.26], CSE = 0.16), tobacco use problems (ab = 0.16, SE = 0.06, 95% CI [0.07, 0.28], CSE = 0.11), and anxiety/depressive symptoms (ab = 0.20, SE = 0.06, 95% CI [0.10, 0.31], CSE = 0.19).


The current investigation highlights the potential importance of anxiety sensitivity in terms of the experience of pain with severity of substance use and anxiety/depressive symptoms among smokers with chronic pain.

This is a preview of subscription content, log in to check access.

Fig. 1


  1. 1.

    Orhurhu VJ, Pittelkow TP, Hooten WM. Prevalence of smoking in adults with chronic pain. Tob Induc Dis. 2015;13:17.

    PubMed  PubMed Central  Google Scholar 

  2. 2.

    Zvolensky MJ, McMillan K, Gonzalez A, Asmundson GJG. Chronic pain and cigarette smoking and nicotine dependence among a representative sample of adults. Nicotine Tob Res. 2009;11:1407–14.

    CAS  PubMed  PubMed Central  Google Scholar 

  3. 3.

    Ekholm O, Grønbæk M, Peuckmann V, et al. Alcohol and smoking behavior in chronic pain patients: the role of opioids. Eur J Pain. 2009;13:606–12.

    CAS  PubMed  Google Scholar 

  4. 4.

    Fishbain DA, Lewis JE, Bruns D, Meyer LJ, Gao J, Disorbio JM. The prevalence of smokers within chronic pain patients and highest pain levels versus comparison groups. Pain Med. 2013;14:403–16.

    PubMed  Google Scholar 

  5. 5.

    Hahn EJ, Rayens MK, Kirsh KL, Passik S. Brief report: pain and readiness to quit smoking cigarettes. Nicotine Tob Res. 2006;8:473–80.

    PubMed  Google Scholar 

  6. 6.

    Oleske DM, Neelakantan J, Andersson GB, Hinrichs BG, Lavender SA, Morrissey MJ, et al. Factors affecting recovery from work-related, low back disorders in autoworkers. Arch Phys Med Rehabil. 2004;85:1362–4.

    PubMed  Google Scholar 

  7. 7.

    Riley JL III, Tomar SL, Gilbert GH. Smoking and smokeless tobacco: increased risk for oral pain. J Pain. 2004;5:218–25.

    PubMed  Google Scholar 

  8. 8.

    Scott SC, Goldberg MS, Mayo NE, Stock SR, Poîtras B. The association between cigarette smoking and back pain in adults. Spine. 1999;24:1090–8.

    CAS  PubMed  Google Scholar 

  9. 9.

    Ditre JW, Brandon TH, Zale EL, Meagher MM. Pain, nicotine, and smoking: research findings and mechanistic considerations. Psychol Bull. 2011;137:1065–93.

    PubMed  PubMed Central  Google Scholar 

  10. 10.

    Ditre JW, Zale EL, LaRowe LR. A reciprocal model of pain and substance use: transdiagnostic considerations, clinical implications, and future directions. Annu Rev Clin Psychol. 2019;15:503–28.

    PubMed  Google Scholar 

  11. 11.

    Parkerson HA, Zvolensky MJ, Asmundson GJ. Understanding the relationship between smoking and pain. Expert Rev Neurother. 2013;13:1407–14.

    CAS  PubMed  Google Scholar 

  12. 12.

    Dhingra LK, Homel P, Grossman B, Chen J, Scharaga E, Calamita S, et al. Ecological momentary assessment of smoking behavior in persistent pain patients. Clin J Pain. 2014;30:205–13.

    PubMed  Google Scholar 

  13. 13.

    Ditre JW, Brandon TH. Pain as a motivator of smoking: effects of pain induction on smoking urge and behavior. J Abnorm Psychol. 2008;117:467–72.

    PubMed  PubMed Central  Google Scholar 

  14. 14.

    Ditre JW, Heckman BW, Butts EA, Brandon TH. Effects of expectancies and coping on pain-induced motivation to smoke. J Abnorm Psychol. 2010;119:524–33.

    PubMed  PubMed Central  Google Scholar 

  15. 15.

    Nakajima M, al’Absi M. Enhanced pain perception prior to smoking cessation is associated with early relapse. Biol Psychol. 2011;88:141–6.

    PubMed  PubMed Central  Google Scholar 

  16. 16.

    Hooten WM, Vickers KS, Shi Y, Ebnet KL, Townsend CO, Patten CA, et al. Smoking cessation and chronic pain: patient and pain medicine physician attitudes. Pain Pract. 2011;11:552–63.

    PubMed  PubMed Central  Google Scholar 

  17. 17.

    Patterson AL, Gritzner S, Resnick MP, Dobscha SK, Turk DC, Morasco BJ. Smoking cigarettes as a coping strategy for chronic pain is associated with greater pain intensity and poorer pain-related function. J Pain. 2012;13:285–92.

    PubMed  PubMed Central  Google Scholar 

  18. 18.

    Waldie KE, McGee R, Reeder AI, Poulton R. Associations between frequent headaches, persistent smoking, and attempts to quit. Headache J Head Face Pain. 2008;48:545–52.

    Google Scholar 

  19. 19.

    Zale EL, Ditre JW. Associations between chronic pain status, attempts to quit smoking, and use of pharmacotherapy for smoking cessation. Psychol Addict Behav. 2014;28:294–9.

    PubMed  Google Scholar 

  20. 20.

    Barton SB, Kofoed BA, Doleys DM. Smoking and narcotics use among chronic pain patients. Psychol Rep. 1989;64:1253–4.

    CAS  PubMed  Google Scholar 

  21. 21.

    Cox BD, Prevost AT, Whichelow MJ. Associations of smoking with prescribed medications, arthritis/rheumatism and back problems in the British Health and Lifestyle Survey follow-up respondents. Eur J Pub Health. 1997;7:311–7.

    Google Scholar 

  22. 22.

    Frosch DL, Shoptaw S, Nahom D, Jarvik ME. Associations between tobacco smoking and illicit drug use among methadone-maintained opiate-dependent individuals. Exp Clin Psychopharmacol. 2000;8:97–103.

    CAS  PubMed  Google Scholar 

  23. 23.

    Patten CA, Gillin JC, Golshan S, Wolter TD, Rapaport M, Kelsoe J. Relationship of mood disturbance to cigarette smoking status among 252 patients with a current mood disorder. J Clin Psychiatry. 2001;62:319–24.

    CAS  PubMed  Google Scholar 

  24. 24.

    Baumeister H, Härter M. Prevalence of mental disorders based on general population surveys. Soc Psychiatry Psychiatr Epidemiol. 2007;42:537–46.

    PubMed  Google Scholar 

  25. 25.

    Degenhardt L, Chiu W-T, Sampson N, Kessler RC, Anthony JC, Angermeyer M, et al. Toward a global view of alcohol, tobacco, cannabis, and cocaine use: findings from the WHO World Mental Health Surveys. PLoS Med. 2008;5:e141.

    PubMed  PubMed Central  Google Scholar 

  26. 26.

    McNally RJ. Anxiety sensitivity and panic disorder. Biol Psychiatry. 2002;52:938–46.

    PubMed  Google Scholar 

  27. 27.

    LaRowe LR, Zvolensky MJ, Ditre JW. The role of anxiety-relevant transdiagnostic factors in comorbid chronic pain and tobacco cigarette smoking. Cogn Ther Res. 2019;43:102–13.

    Google Scholar 

  28. 28.

    Banks SM, Kerns RD. Explaining high rates of depression in chronic pain: a diathesis-stress framework. Psychol Bull. 1996;119:95–110.

    Google Scholar 

  29. 29.

    Gallagher RM, Verma S. Managing pain and comorbid depression: a public health challenge. Semin Clin Neuropsychiatry. 1999;4:203–20.

    CAS  PubMed  Google Scholar 

  30. 30.

    Schroeder SA, Morris CD. Confronting a neglected epidemic: tobacco cessation for persons with mental illnesses and substance abuse problems. Annu Rev Public Health. 2010;31:297–314 1p following 314.

    PubMed  Google Scholar 

  31. 31.

    Jamison RN, Link CL, Marceau LD. Do pain patients at high risk for substance misuse experience more pain? A longitudinal outcomes study. Pain Med Malden Mass. 2009;10:1084–94.

    Google Scholar 

  32. 32.

    Reddy KS, Perry CL, Stigler MH, Arora M. Differences in tobacco use among young people in urban India by sex, socioeconomic status, age, and school grade: assessment of baseline survey data. Lancet. 2006;367:589–94.

    PubMed  Google Scholar 

  33. 33.

    Weiss Wiesel TR, Nelson CJ, Tew WP, Hardt M, Mohile SG, Owusu C, et al. The relationship between age, anxiety, and depression in older adults with cancer. Psychooncology. 2015;24:712–7.

    PubMed  Google Scholar 

  34. 34.

    McLean CP, Asnaani A, Litz BT, et al. Gender differences in anxiety disorders: prevalence, course of illness, comorbidity and burden of illness. J Psychiatr Res. 2011;45:1027–35.

    PubMed  PubMed Central  Google Scholar 

  35. 35.

    Saladin ME, Gray KM, Carpenter MJ, LaRowe SD, DeSantis SM, Upadhyaya HP. Gender differences in craving and cue reactivity to smoking and negative affect/stress cues. Am J Addict. 2012;21:210–20.

    PubMed  PubMed Central  Google Scholar 

  36. 36.

    Grunberg NE, Winders SE, Wewers ME. Gender differences in tobacco use. Health Psychol. 1991;10:143–53.

    CAS  PubMed  Google Scholar 

  37. 37.

    Von Korff M, Ormel J, Keefe FJ, et al. Grading the severity of chronic pain. Pain. 1992;50:133–49.

    Google Scholar 

  38. 38.

    Taylor S, Zvolensky MJ, Cox BJ, Deacon B, Heimberg RG, Ledley DR, et al. Robust dimensions of anxiety sensitivity: development and initial validation of the Anxiety Sensitivity Index-3. Psychol Assess. 2007;19:176–88.

    PubMed  Google Scholar 

  39. 39.

    Butler SF, Budman SH, Fernandez KC, Houle B, Benoit C, Katz N, et al. Development and validation of the current opioid misuse measure. Pain. 2007;130:144–56.

    PubMed  PubMed Central  Google Scholar 

  40. 40.

    Wasan AD, Butler SF, Budman SH, Benoit C, Fernandez K, Jamison RN. Psychiatric history and psychologic adjustment as risk factors for aberrant drug-related behavior among patients with chronic pain. Clin J Pain. 2007;23:307–15.

    PubMed  Google Scholar 

  41. 41.

    Gossop M, Darke S, Griffiths P, et al. The Severity of Dependence Scale (SDS): psychometric properties of the SDS in English and Australian samples of heroin, cocaine and amphetamine users. Addiction. 1995;90:607–14.

    CAS  PubMed  Google Scholar 

  42. 42.

    Iraurgi Castillo I, González Saiz F, Lozano Rojas O, Landabaso Vázquez MA, Jiménez Lerma JM. Estimation of cutoff for the Severity of Dependence Scale (SDS) for opiate dependence by ROC analysis. Actas Esp Psiquiatr. 2010;38:270–7.

    CAS  PubMed  Google Scholar 

  43. 43.

    Rogers AH, Shepherd JM, Orr MF, Bakhshaie J, McHugh RK, Zvolensky MJ. Exploring anxiety sensitivity in the relationship between pain intensity and opioid misuse among opioid-using adults with chronic pain. J Psychiatr Res. 2019;111:154–9.

    PubMed  Google Scholar 

  44. 44.

    Kroenke K, Spitzer RL, Williams JBW. The Patient Health Questionnaire-2: validity of a two-item depression screener. Med Care. 2003;41:1284–92.

    PubMed  Google Scholar 

  45. 45.

    Löwe B, Kroenke K, Gräfe K. Detecting and monitoring depression with a two-item questionnaire (PHQ-2). J Psychosom Res. 2005;58:163–71.

    PubMed  Google Scholar 

  46. 46.

    Löwe B, Wahl I, Rose M, Spitzer C, Glaesmer H, Wingenfeld K, et al. A 4-item measure of depression and anxiety: validation and standardization of the Patient Health Questionnaire-4 (PHQ-4) in the general population. J Affect Disord. 2010;122:86–95.

    PubMed  Google Scholar 

  47. 47.

    Hayes AF. Introduction to mediation, moderation, and conditional process anlaysis: a regression-based approach. New York: Guilford Press; 2013.

    Google Scholar 

  48. 48.

    WHO ASSIST Working Group. The Alcohol, Smoking and Substance Involvement Screening Test (ASSIST): development, reliability and feasibility. Addict Abingdon Engl. 2002;97:1183–94.

    Google Scholar 

  49. 49.

    Garey L, Smit T, Mayorga NA, Peraza N, Nizio P, Otto MW, et al. Differential effects of anxiety sensitivity on E-cigarettes processes: the importance of E-cigarette quit attempt history. Am J Addict. 2019;28:390–7.

    PubMed  Google Scholar 

  50. 50.

    Krantz JH, Dalal R. Chapter 2 - Validity of Web-based psychological research. In: Birnbaum MH, editor. Psychological experiments on the Internet. San Diego: Academic Press. p. 35–60.

  51. 51.

    Mangan MA, Reips U-D. Sleep, sex, and the Web: surveying the difficult-to-reach clinical population suffering from sexsomnia. Behav Res Methods. 2007;39:233–6.

    PubMed  Google Scholar 

  52. 52.

    Zvolensky MJ, Manning K, Garey L, Mayorga NA, Peraza N. Fatigue severity and electronic cigarette beliefs and use behavior. Addict Behav. 2019;97:1–6.

    PubMed  Google Scholar 

  53. 53.

    Hayes AF. Beyond Baron and Kenny: statistical mediation analysis in the new millennium. Commun Monogr. 2009;76:408–20.

    Google Scholar 

  54. 54.

    Preacher KJ, Hayes AF. SPSS and SAS procedures for estimating indirect effects in simple mediation models. Behav Res Methods Instrum Comput. 2004;36:717–31.

    PubMed  Google Scholar 

  55. 55.

    Preacher KJ, Hayes AF. Asymptotic and resampling strategies for assessing and comparing indirect effects in multiple mediator models. Behav Res Methods. 2008;40:879–91.

    PubMed  Google Scholar 

  56. 56.

    Cheung MWL. Comparison of methods for constructing confidence intervals of standardized indirect effects. Behav Res Methods. 2009;41:425–38.

    PubMed  Google Scholar 

  57. 57.

    Edwards RR, Campbell CM, Fillingim RB. Catastrophizing and experimental pain sensitivity: only in vivo reports of catastrophic cognitions correlate with pain responses. J Pain. 2005;6:338–9.

    PubMed  Google Scholar 

  58. 58.

    Zvolensky MJ, Rogers AH, Shepherd JM, Vujanovic AA, Bakhshaie J. Anxiety sensitivity and opioid misuse and dependence among trauma-exposed adults with chronic pain. J Behav Med. 2020;43:174–84.

    PubMed  Google Scholar 

  59. 59.

    Paulus DJ, Rogers AH, Bakhshaie J, Vowles KE, Zvolensky MJ. Pain severity and prescription opioid misuse among individuals with chronic pain: the moderating role of alcohol use severity. Drug Alcohol Depend. 2019;204:107456.

    CAS  PubMed  Google Scholar 

  60. 60.

    Sullivan MJ, Thorn B, Haythornthwaite JA, et al. Theoretical perspectives on the relation between catastrophizing and pain. Clin J Pain. 2001;17:52–64.

    CAS  PubMed  Google Scholar 

  61. 61.

    Buenaver LF, Edwards RR, Haythornthwaite JA. Pain-related catastrophizing and perceived social responses: inter-relationships in the context of chronic pain. Pain. 2007;127:234–42.

    PubMed  Google Scholar 

  62. 62.

    Hser YI, McCarthy WJ, Anglin MD. Tobacco use as a distal predictor of mortality among long-term narcotics addicts. Prev Med. 1994;23:61–9.

    CAS  PubMed  Google Scholar 

  63. 63.

    Hurt RD, Offord KP, Croghan IT, Gomez-Dahl L, Kottke TE, Morse RM, et al. Mortality following inpatient addictions treatment. Role of tobacco use in a community-based cohort. JAMA. 1996;275:1097–103.

    CAS  PubMed  Google Scholar 

  64. 64.

    Kearns NT, Carl E, Stein AT, Vujanovic AA, Zvolensky MJ, Smits JAJ, et al. Posttraumatic stress disorder and cigarette smoking: a systematic review. Depress Anxiety. 2018;35:1056–72.

    PubMed  Google Scholar 

  65. 65.

    Da Silva JAP, Geenen R, Jacobs JWG. Chronic widespread pain and increased mortality: biopsychosocial interconnections. Ann Rheum Dis. 2018;77:790–2.

    PubMed  Google Scholar 

  66. 66.

    Werner MU. The relationship between chronic pain and cardiovascular disease: squaring the circle? Scand J Pain. 2016;13:134–5.

    PubMed  Google Scholar 

  67. 67.

    Vujanovic AA, Bernstein A, Berenz EC, Zvolensky MJ. Single-session anxiety sensitivity reduction program for trauma-exposed adults: a case series documenting feasibility and initial efficacy. Behav Ther. 2012;43:482–91.

    PubMed  Google Scholar 

  68. 68.

    Olthuis JV, Watt MC, Mackinnon SP, Potter SM, Stewart SH. The nature of the association between anxiety sensitivity and pain-related anxiety: evidence from correlational and intervention studies. Cogn Behav Ther. 2015;44:423–40.

    PubMed  Google Scholar 

  69. 69.

    Schmidt NB, Capron DW, Raines AM, Allan NP. Randomized clinical trial evaluating the efficacy of a brief intervention targeting anxiety sensitivity cognitive concerns. J Consult Clin Psychol. 2014;82:1023–33.

    PubMed  Google Scholar 

  70. 70.

    Schmidt NB, Norr AM, Allan NP, Raines AM, Capron DW. A randomized clinical trial targeting anxiety sensitivity for patients with suicidal ideation. J Consult Clin Psychol. 2017;85:596–610.

    PubMed  Google Scholar 

  71. 71.

    Zvolensky MJ, Garey L, Kauffman BY, et al. 6 - Integrative treatment program for anxiety sensitivity and smoking cessation. In: Smits JAJ, Otto MW, Powers MB, et al., editors. The clinician’s guide to anxiety sensitivity treatment and assessment: Academic Press. p. 101–20.

  72. 72.

    Zvolensky MJ, Rosenfield D, Garey L, Kauffman BY, Langdon KJ, Powers MB, et al. Does exercise aid smoking cessation through reductions in anxiety sensitivity and dysphoria? Health Psychol. 2018;37:647–57.

    PubMed  PubMed Central  Google Scholar 

  73. 73.

    Schmidt NB, Raines AM, Allan NP, Zvolensky MJ. Anxiety sensitivity risk reduction in smokers: a randomized control trial examining effects on panic. Behav Res Ther. 2016;77:138–46.

    PubMed  Google Scholar 

  74. 74.

    Reips U-D. Privacy and the disclosure of information on the internet: issues and measurement. Internet Psychol Res. 2011:67–100.

  75. 75.

    Rogers AH, Bakhshaie J, Mayorga NA, Ditre JW, Zvolensky MJ. Distress tolerance and pain experience among young adults. Psychol Health Med. 2018;23:1231–8.

    PubMed  Google Scholar 

  76. 76.

    LaRowe LR, Chilcott LN, Zvolensky MJ, et al. Associations between pain-related anxiety, gender, and prescription opioid misuse among tobacco smokers living with HIV/AIDS. Subst Use Misuse. 2018:1–10.

  77. 77.

    Zvolensky MJ, Goodie JL, McNeil DW, et al. Anxiety sensitivity in the prediction of pain-related fear and anxiety in a heterogeneous chronic pain population. Behav Res Ther. 2001;39:683–96.

    CAS  PubMed  Google Scholar 

Download references

Author information



Corresponding author

Correspondence to Michael J. Zvolensky.

Ethics declarations

Conflict of Interest

The authors declare that they have no conflict of interest.

Informed Consent

Informed consent was obtained from all individual participants included in the study.

Ethical Approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

This article does not contain any studies with animals performed by any of the authors.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Zvolensky, M.J., Rogers, A.H., Garey, L. et al. The Role of Anxiety Sensitivity in the Relation Between Pain Intensity with Substance Use and Anxiety and Depressive Symptoms Among Smokers with Chronic Pain. Int.J. Behav. Med. (2020).

Download citation


  • Smoking
  • Pain
  • Anxiety sensitivity
  • Opioid
  • Tobacco