Date of Award


Degree Type


Degree Name

Doctor of Philosophy (PhD)




Joseph Ditre



Subject Categories

Clinical Psychology | Psychology | Social and Behavioral Sciences


Pain has been implicated in the onset and maintenance of nicotine addiction, and there is initial cross-sectional evidence of covariation between pain and use/co-use of cigarettes and e-cigarettes. The goals of the current study were to: (1) test pain severity as a predictor of initiating co-use of cigarettes/e-cigarettes, (2) examine longitudinal associations between pain severity and use/co-use of cigarette and e-cigarettes, (3) generate the first prevalence rate data regarding cigarette and/or e-cigarette use as a function of pain; and (4) examine gender as a moderator of these associations. Data were drawn from Waves 1-4 of the Population Assessment of Tobacco and Health (PATH) Study (2013-2018). Logistic regression, survival analysis, and generalized estimating equation models were conducted. Among respondents who endorsed exclusive cigarette use at Wave 1 (n = 7,719), pain severity was associated with greater likelihood of and faster trajectory to initiating co-use of cigarettes/e-cigarettes (ps < .05). A significant pain x gender interaction (p < .05) revealed this prospective relationship was stronger among women. Among adult respondents who provided at least three waves of data (n = 24,255), greater Wave 1 pain severity was positively associated with e-cigarette use, cigarette smoking, and co-use of cigarettes/e-cigarettes at Waves 2, 3, and 4 (ps < .001). At Wave 4 (n = 33,822), adults with moderate/severe pain endorsed rates of e-cigarette and cigarette use/co-use almost two times greater than participants with no/low pain (ps < .001). Collectively, these findings provide evidence that pain likely serves as an important candidate risk factor for the initiation and maintenance of cigarette and e-cigarette use. Additional research is needed to further examine trajectories and temporal precedence of pain in relation to the onset and progression of cigarette and/or e-cigarette use.


Open Access