Aims: To evaluate the impact of smoking on pain severity, psychosocial impairment, depression, anxiety, and sleep disturbances in a large sample of patients with temporomandibular disorders (TMD). Methods: A retrospective database review was performed on data from 3,251 patients with TMD, diagnosed according to the Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD). Pain severity ratings and psychometric data regarding impairment, sleep disturbance, depression, and anxiety were obtained. Differences between smokers and nonsmokers were evaluated by means of chi-square tests and independent samples t tests. Logistic regression models were used to study the impact of smoking, pain severity, and psychometric variables. Results: Of the total population, 42.5% comprised RDC/TMD group I (muscle pain), 25.3% comprised RDC/TMD group III (joint pain), and 32.2% comprised a mixed RDC/TMD group consisting of patients with both a group I and a group III diagnosis. Of the entire population, 26.9% admitted they were smokers. Even after controlling for relevant covariates, smokers reported significantly higher pain severity, impairment, anxiety, depression, and sleep disturbances than nonsmokers. Conclusion: Smokers with TMD reported higher pain severity than nonsmokers with TMD. These patients are at higher risk for factors that may adversely affect treatment outcomes. J OROFAC PAIN 2013;27:32-41.

anxiety; depression; nicotine; sleep disturbance; temporomandibular disorders

1. Fishbain DA, Lewis JE, Cole B, et al. Variables associated with current smoking status in chronic pain patients. Pain Med 2007;8:301–311.

2. Jamison RN, Stetson BA, Parris WC. The relationship between cigarette smoking and chronic low back pain. Addict Behav 1991;16:103–110.

3. Ackerman WE 3rd, Ahmad M. Effect of cigarette smoking on serum hydrocodone levels in chronic pain patients. J Ark Med Soc 2007;104:19–21.

4. Bjorckvan Dijken C, Fjellman-Wiklund A, Hildingsson C. Low back pain, lifestyle factors and physical activity: A population based-study. J Rehabil Med 2008;40:864–869.

5. Yunus MB, Arslan S, Aldag JC. Relationship between fibromyalgia features and smoking. Scand J Rheumatol 2002;31:301–305.

6. Weingarten TN, Podduturu VR, Hooten WM, et al. Impact of tobacco use in patients presenting to a multidisciplinary outpatient treatment program for fibromyalgia. Clin J Pain 2009;25:39–43.

7. Pamuk ON, Donmez S, Cakir N. The frequency of smoking in fibromyalgia patients and its association with symptoms. Rheumatol Int 2009;29:1311–1314.

8. Logan HL, Fillingim RB, Bartoshuk LM, et al. Smoking status and pain level among head and neck cancer patients. J Pain 2010;11:528–534.

9. Weingarten TN, Moeschler SM, Ptaszynski AE, et al. An assessment of the association between smoking status, pain intensity, and functional interference in patients with chronic pain. Pain Physician 2008;11:643–653.

10. Melis M, Lobo SL, Ceneviz C, et al. Effect of cigarette smoking on pain intensity of TMD patients: A pilot study. Cranio 2010;28:187–192.

11. Weingarten TN Iverson BC, Shi Y, et al. Impact of tobacco use on the symptoms of painful temporomandibular joint disorders. Pain 2009;147:67–71.

12. Wanman A. Temporomandibular disorders among smokers and nonsmokers: A longitudinal cohort study. J Orofac Pain 2005;19:209–217.

13. Dworkin SF, LeResche L. Research diagnostic criteria for temporomandibular disorders: Review, criteria, examinations and specifications, critique. J Craniomandib Disord 1992;6:301–355.

14. Schane RE, Ling PM, Glantz SA. Health effects of light and intermittent smoking: A review. Circulation 2010;121:1518–1522.

15. Husten CG. How should we define light or intermittent smoking? Does it matter? Nicotine Tob Res 2009;11: 111–121.

16. Derogatis L. Symptom checklist-90-R. Minneapolis, MN: National Computer Systems, 1979.

17. Kerns RD, Turk DC, Rudy TE. The West Haven-Yale Multidimensional Pain Inventory (WHYMPI). Pain 1985;23:345–356.

18. Buysse DJ, Reynolds CF 3rd, Monk TH, Berman SR, Kupfer DJ. The Pittsburgh Sleep Quality Index: A new instrument for psychiatric practice and research. Psychiatry Res 1989;28:193–213.

19. Carpenter JS, Andrykowski MA. Psychometric evaluation of the Pittsburgh Sleep Quality Index. J Psychosom Res 1998;45:5–13.

20. Asmundson GJ, Katz J. Understanding the cooccurrence of anxiety disorders and chronic pain: State-of-the-art. Depress Anxiety 2009;26:888–901.

21. Grotle M, Brox JI, Veierød MB, et al. Clinical course and prognostic factors in acute low back pain: Patients consult-ing primary care for the first time. Spine (Phila Pa 1976) 2005;30:976–982.

22. Shaw WS, Pransky G, Winters T. The Back Disability Risk Questionnaire for work-related, acute back pain: Prediction of unresolved problems at 3-month follow-up. J Occup Environ Med 2009;51:185–194.

23. Iversen LL, Iversen SD, Bloom FE, Roth RH. Introduction to neuropsychopharmacology. New York: Oxford University Press; 2009.

24. Kryger MH. Atlas of Clinical Sleep Medicine. Philadelphia, PA: Saunders Elsevier, 2010.

25. Zhang L, Samet J, Caffo B, Punjabi NM. Cigarette smoking and nocturnal sleep architecture. Am J Epidemiol 2006;164:529–537.

26. Sleep disorders and sleep deprivation: An unmet public health problem. Washington, DC: National Academies Press, 2006.

27. Scharf DM, Dunbar MS, Shiffman S. Smoking during the night: Prevalence and smoker characteristics. Nicotine Tob Res 2008;10:167–178.

28. Breslau N, Novak SP, Kessler RC. Daily smoking and the subsequent onset of psychiatric disorders. Psychol Med 2004;34:323–333.

29. Collins BN, Lepore SJ. Association between anxiety and smoking in a sample of urban black men. J Immigr Minor Health 2009;11:29–34.

30. McKenzie M, Olsson CA, Jorm AF, Romaniuk H, Patton GC. Association of adolescent symptoms of depression and anxiety with daily smoking and nicotine dependence in young adulthood: Findings from a 10-year longitudinal study. Addiction 2010;105:1652–1659.

31. Mykletun A, Overland S, Aaro LE, Liabo HM, Stewart R. Smoking in relation to anxiety and depression: Evidence from a large population survey: The HUNT study. Eur Psychiatry 2008;23(2):77–84.

32. Breslau N. Psychiatric comorbidity of smoking and nicotine dependence. Behav Genet 1995;25:95–101.

33. Breslau N, Kilbey MM, Andreski P. DSM-III-R nicotine dependence in young adults: Prevalence, correlates and associated psychiatric disorders. Addiction 1994;89:743–754.

34. Brook JS, Cohen P, Brook DW. Longitudinal study of co- occurring psychiatric disorders and substance use. J Am Acad Child Adolesc Psychiatry 1998;37:322–330.

35. Dierker LC, Avenevoli S, Merikangas KR, Flaherty BP, Stolar M. Association between psychiatric disorders and the progression of tobacco use behaviors. J Am Acad Child Adolesc Psychiatry 2001;40:1159–1167.

36. Goodman E, Capitman J. Depressive symptoms and cigarette smoking among teens. Pediatrics 2000;106:748–755.

37. Johnson JG, Cohen P, Pine DS, et al. Association between cigarette smoking and anxiety disorders during adolescence and early adulthood. JAMA 2000;284:2348–2351.

38. Breslau N, Klein DF. Smoking and panic attacks: An epidemiologic investigation. Arch Gen Psychiatry 1999;56: 1141–1147.

39. Goodwin RD, Lewinsohn PM, Seeley JR. Respiratory symptoms and mental disorders among youth: Results from a prospective, longitudinal study. Psychosom Med 2004;66:943–949.

40. Isensee B, Wittchen HU, Stein MB, Hofler M, Lieb R. Smoking increases the risk of panic: Findings from a prospective community study. Arch Gen Psychiatry 2003;60:692–700.

41. McLeish AC, Zvolensky MJ, Bucossi MM. Interaction between smoking rate and anxiety sensitivity: Relation to anticipatory anxiety and panic-relevant avoidance among daily smokers. J Anxiety Disord 2007;21:849–859.

42. Zvolensky MJ, Schmidt NB, McCreary BT. The impact of smoking on panic disorder: An initial investigation of a pathoplastic relationship. J Anxiety Disord 2003;17: 447–460.

43. Zvolensky MJ, Bernstein A. Cigarette smoking and panic psychopathology. Current Directions Psychological Sci 2005;14:301–305.

44. Breslau N, Kilbey M, Andreski P. Nicotine dependence, major depression, and anxiety in young adults. Arch Gen Psychiatry 1991;48:1069–1074.

45. Boden JM, Fergusson DM, Horwood LJ. Cigarette smoking and depression: Tests of causal linkages using a longitudinal birth cohort. Br J Psychiatry 2010;196:440–446.

46. Haustein KO, Haffner S, Woodcock BG. A review of the pharmacological and psychopharmacological aspects of smoking and smoking cessation in psychiatric patients. Int J Clin Pharmacol Ther 2002;40:404–418.

47. Morissette SB, Tull MT, Gulliver SB, Kamholz BW, Zimer-ing RT. Anxiety, anxiety disorders, tobacco use, and nicotine: A critical review of interrelationships. Psychol Bull 2007;133:245–272.

48. Hooten WM, Townsend CO, Bruce BK, et al. Effects of smoking status on immediate treatment outcomes of multi-disciplinary pain rehabilitation. Pain Med 2009;10:347–355.

49. Hooten WM, Townsend CO, Bruce BK, Shi Y, Warner DO. Sex differences in characteristics of smokers with chronic pain undergoing multidisciplinary pain rehabilitation. Pain Med 2009;10:1416–1425.

50. Shi Y, Weingarten TN, Mantilla CB, Hooten WM, Warner DO. Smoking and pain: Pathophysiology and clinical implications. Anesthesiology 2010;113:977–992.

51. Taly A, Corringer PJ, Guedin D, Lestage P, Changeux JP. Nicotinic receptors: Allosteric transitions and therapeutic targets in the nervous system. Nat Rev Drug Discov 2009; 8:733–750.

52. Richards JM, Stipelman BA, Bornovalova MA, et al. Biological mechanisms underlying the relationship between stress and smoking: State of the science and directions for future work. Biol Psychol 2011;88:1–12.

53. Robinson MJ, Edwards SE, Iyengar S, et al. Depression and pain. Front Biosci 2009;14:5031–5051.

54. Perkins KA, Gerlach D, Broge M, et al. Quitting cigarette smoking produces minimal loss of chronic tolerance to nicotine. Psychopharmacology (Berl) 2001;158:7–17.

55. Girdler SS, Maixner W, Naftel HA, et al. Cigarette smoking, stress-induced analgesia and pain perception in men and women. Pain 2005;114:372–385.

56. Jamner LD, Girdler SS, Shapiro D, Jarvik ME. Pain inhibition, nicotine, and gender. Exp Clin Psychopharmacol 1998;6:96–106.

57. Benwell ME, Balfour DJ, Anderson JM. Evidence that tobacco smoking increases the density of (-)-[3H]nicotine binding sites in human brain. J Neurochem 1988;50:1243–1247.

58. Mukhin AG, Kimes AS, Chefer SI, et al. Greater nicotinic acetylcholine receptor density in smokers than in non-smokers: A PET study with 2-18F-FA-85380. J Nucl Med 2008;49:1628–1635.

59. Sallette J, Pons S, Devillers-Thiery A, et al. Nicotine up-regulates its own receptors through enhanced intracellular maturation. Neuron 2005;46:595–607.

60. Armstrong SC, Cozza KL. Pharmacokinetic drug interactions of morphine, codeine, and their derivatives: Theory and clinical reality, Part II. Psychosomatics 2003; 44:515–520.

61. Coffman BL, Rios GR, King CD, Tephly TR. Human UGT2B7 catalyzes morphine glucuronidation. Drug Metab Dispos 1997;25:1–4.

62. Zevin S, Benowitz NL. Drug interactions with tobacco smoking. An update. Clin Pharmacokinet 1999;36:425–438.

63. Hooten WM, Shi Y, Gazelka HM, Warner DO. The effects of depression and smoking on pain severity and opioid use in patients with chronic pain. Pain 2011;152:223–229.

64. Spiga R, Schmitz J, Day J, 2nd. Effects of nicotine on metha-done self-administration in humans. Drug Alcohol Depend 1998;50:157–165.

65. Schmitz JM, Grabowski J, Rhoades H. The effects of high and low doses of methadone on cigarette smoking. Drug Alcohol Depend 1994;34:237–242.

66. Brett K, Parker R, Wittenauer S, et al. Impact of chronic nicotine on sciatic nerve injury in the rat. J Neuroimmunol 2007;186:37–44.

67. Lian B, Vera-Portocarrero L, King T, Ossipov MH, Por-reca F. Opioid-induced latent sensitization in a model of noninflammatory viscerosomatic hypersensitivity. Brain Res;1358:64–70.

68. Ditre JW, Brandon TH. Pain as a motivator of smoking: Effects of pain induction on smoking urge and behavior. J Abnorm Psychol 2008;117:467–472.

69. Hooten WM, Vickers KS, Shi Y, et al. Smoking cessation and chronic pain: Patient and pain medicine physician attitudes. Pain Pract 2011;11:552–563.

70. Zvolensky MJ, McMillan K, Gonzalez A, Asmundson GJ. Chronic pain and cigarette smoking and nicotine dependence among a representative sample of adults. Nicotine Tob Res 2009;11:1407–1414.

71. Carraway MS, Ghio AJ, Suliman HB, et al. Carbon monoxide promotes hypoxic pulmonary vascular remodeling. Am J Physiol Lung Cell Mol Physiol 2002;282:L693–702.

72. Mirza A, Eder V, Rochefort GY, et al. CO inhalation at dose corresponding to tobacco smoke worsens cardiac remodeling after experimental myocardial infarction in rats. Toxicol Sci 2005;85:976–982.

73. Slebos DJ, Ryter SW, Choi AM. Heme oxygenase-1 and carbon monoxide in pulmonary medicine. Respir Res 2003;4:7.