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Health Services Research & Development

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HSR&D In Progress

September 2021

In This Issue: Helping Veterans Cope with and Conquer Pain
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Pain-Related Anxiety Intervention for Veterans who Smoke and have Chronic Pain

Feature Article

Takeaway: Pain is frequently reported by Veterans, and research suggests smoking is associated with concurrent pain intensity. Veterans with chronic pain represent an important population in which to focus smoking cessation efforts, and this study is expected to provide more options for Veterans with chronic pain who want to quit smoking.

Military service is a risk factor for smoking, and approximately 20% of US Veterans currently smoke cigarettes. Further, smoking cessation among patients with chronic medical illnesses substantially decreases morbidity and mortality, yet many patients (>50%) with chronic pain continue to smoke. Concomitant efforts to address smoking cessation and pain-related anxiety via established cognitive behavioral interventions (CBIs) have the potential to provide patients who smoke and have chronic pain the skills to navigate the smoking cessation process and manage the associated anxiety-related cues that interfere with efforts to quit. Given the widespread prevalence of smoking and its staggering impact on Veterans’ health, VA has highlighted the critical need to improve the reach of smoking cessation efforts, while simultaneously removing barriers that limit access to and participation in effective interventions.

The ongoing (February 2017 – January 2022) Pain and Smoking Study (PASS) aims to compare the effectiveness of a telephone-based smoking cessation intervention, including CBI for pain, to a standard telephone-based smoking cessation intervention among Veterans who smoke and have moderate to severe chronic pain. More specifically, study investigators will:

  • Evaluate the impact of smoking cessation plus CBI (SMK-CBI) on cigarette abstinence rates among Veterans with chronic pain at 6 and 12-months compared to standard smoking cessation counseling (SMK-STD);
  • Examine the impact of SMK-CBI on pain intensity and pain interference among Veterans at 6- and 12-months compared to SMK-STD; and
  • Assess whether changes in self-efficacy and pain-related anxiety mediate the impact of SMK-CBI on smoking cessation in Veterans with pain at 6- and 12-months compared to SMK-STD.


This randomized comparative effectiveness trial includes a two-group design in which 371 Veterans who smoke and have chronic pain were randomized to either:

  • SMK-CBI—an intervention that includes a proactive tele-health intervention combining evidence-based smoking cessation counseling augmented with behavioral approaches for coping with pain; or
  • SMK-STD—a contact-equivalent intervention that provides standard smoking cessation telephone counseling.

Recruitment started in December 2017 and concluded in July 2020. Investigators sent introductory letters to 3,478 patients who were identified by an automated data pull, and then underwent electronic health record review to confirm that they were currently smoking, had a pain score >4 for more than 3 months, and were receiving VA healthcare. Among 2,758 Veterans who were contacted, 371 Veterans were subsequently enrolled into the study and randomized into the SMK-CBI (n=186) or SMK-STD arm (n=185). Investigators have now completed the six-month post-intervention assessments and will have completed the remaining 12-month post-intervention assessments by October 2021.


Thus far, findings at baseline show that participants were 88% male, were a median age of 60 years old (range 24-82), and smoked a median of 15 cigarettes per day. Veterans in this study are mainly white (61%), unemployed (70%), and reported their overall health as “Fair” (40%) to “Poor” (11%). Overall, pain was moderately high (mean pain intensity in past week = 5.2 (Standard Deviation (SD) =1.6) and mean pain interference = 5.5 (SD=2.2). With regards to mental health, 59% passed the clinical threshold for major depressive symptoms, and 11% of Veterans experienced suicidal ideation. Moreover, almost one-third (32%) screened positive for potential alcohol problems. These baseline characteristics reflect a socioeconomically vulnerable population with a high burden of mental health comorbidities and multiple barriers to smoking cessation.

Anticipated Impact

Pain is frequently reported by Veterans and research suggests smoking is associated with concurrent pain intensity. Veterans with chronic pain represent an important population in which to focus smoking cessation efforts.

Principal Investigators

Lori Bastian, MD, MPH, is Director of HSR&D’s Pain Research, Informatics, Multi-morbidities, and Education (PRIME) Center in West Haven, CT, and William Becker, MD, is a senior investigator at PRIME and co-lead of the VA HSR&D Pain and Opioid CORE.


Charokopos A, Card M, Gunderson C, Steffens C, and Bastian L. The association of obstructive sleep apnea and pain outcomes in adults: A systematic review. Pain Medicine. September 1, 2018; 19(suppl1):S69-S75.

View study abstract

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