• Donald D McGeary, Tom G Mayer, Robert J Gatchel, and Christopher Anagnostis.
• PRIDE Research Foundation, 5701 Maple Ave., Suite 100, Dallas, TX 75235, USA.
• Spine J. 2004 Mar 1;4(2):170-5.

Background ContextStudies have revealed smoking to have a negative impact on spinal surgery. It is assumed that this is the result of the negative impact of nicotine on revascularization of damaged tissue. However, there is a paucity of research on the role of smoking with regard to nonsurgical rehabilitation, but there exists a clear bias for believing that smoking is strongly associated with poor socioeconomic and psychosocial outcome.PurposeThis study was designed to examine the relationship between smoking and outcomes in a chronically disabled work-related spinal disorder (CDWRSD) cohort undergoing functional restoration.Study DesignA prospective comparison cohort study investigating the effects of smoking status on functional restoration treatment outcomes.Patient SampleA cohort of 1,141 consecutive CDWRSD patients were divided into four groups: Group A, patients who did not smoke (n=710); Group B, patients who smoked less than one cigarette pack/day (n=157); Group C, patients who smoked 1.0 to 1.9 packs/day (n=218); Group D, patients who smoked 2.0 or more packs/day (n=56).Outcome MeasuresBefore the start of functional restoration, and upon its completion, patients received a standard psychosocial assessment battery and were assessed on a variety of physical factors. A structured clinical interview examining socioeconomic outcomes was conducted 1 year after the program.MethodsPatients underwent an intensive functional restoration chronic pain management rehabilitation program consisting of quantitatively directed exercise progression and a multimodal disability management program for CDWRSD. The program consisted of four phases, the most significant of which involved a 3-week full-day intensive phase after preparatory preprogram phases and before a work transition phase.ResultsAnalysis revealed that the percent of males increased as the smoking level increased (Group A=51.8% vs Group D=73.2%; p<.001). Also, as smoking increased, the level of education significantly decreased. In addition, as smoking level increased, the percent of patients completing the rehabilitation program decreased (from 86.3% to 75%; p=.03). No significant differences in 1-year posttreatment socioeconomic outcomes of work status, health utilization, recurrent injury or case closure were related to smoking except work retention, which decreased with more smoking (85 to 71%, p<.05). Surprisingly, the physical cumulative score at posttreatment increased as smoking frequency increased (p<.01). This finding indicates that those who smoked more performed at a higher level on physical measures. Those who smoked more frequently before treatment also appeared more depressed (p<.001), but after treatment, these differences disappeared. Self-reported pain intensity differed only after treatment, and posttreatment disability ratings showed a significant linear trend.ConclusionsContrary to popular belief, CDWRSD patients who smoke do not differ significantly in socioeconomic or psychosocial outcomes relative to those who do not. Although this study does indicate that those who smoke more evidence lower rehabilitation completion rates, those who completed the program had identical 1-year posttreatment outcomes of socioeconomic importance except in retraining work at year end as those who did not smoke. Smokers had slightly higher posttreatment self-reported pain and disability ratings mixed and limited. Overall, there is evidence for the widely held belief that smoking negatively affects tertiary rehabilitation.

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