International Journal of Behavioral Medicine

, Volume 25, Issue 1, pp 67–73 | Cite as

Low Income as a Multiplicative Risk Factor for Oral Pain and Dental Problems Among U.S. Veteran Smokers

  • Terrell A. HicksEmail author
  • Sarah M. Wilson
  • Shaun P. Thomas
  • Paul A. Dennis
  • Julia M. Neal
  • Patrick S. Calhoun



Compared to the United States (U.S.) general population, military veterans are at an increased risk of experiencing dental problems. This study documented associations between cigarette use and measures of dental/oral concern in a population of U.S. veterans who served in Iraq and Afghanistan.


A cross-sectional analysis of survey data from the Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) Veterans Health and Needs Study, a study of U.S. military veterans. Out of 5000 surveys mailed to a random sample of OEF/OIF veterans, 1161 surveys were completed and returned. Among study respondents, N = 1114 had non-missing dental/oral pain data and were included for analysis. The survey also included smoking history and demographic information. Univariate and multivariate logistic regression analyses were used to cross-sectionally model the odds of experiencing dental/oral concerns as a function of smoking status. We also examined moderating effects of income and gender on the association between smoking and dental/oral concerns.


In univariate and multivariate models, current smoking was associated with risk for dental/oral concerns. However, this association was qualified by a Smoking × Income interaction. For those earning above US$20,000, smoking was not associated with dental/oral concerns. Among veterans with low income, smoking was associated with three times higher odds of increased dental/oral concerns. There was no significant Gender × Smoking interaction.


These findings underscore the relevance of factors that moderate the association between smoking and dental/oral concern, namely income. Findings also underscore the importance of interventions to mitigate income disparities in oral healthcare.


Veteran Tobacco Smoking Cigarettes Oral pain Nicotine 



This work was supported in part by the Department of Veterans Affairs (VA) Mid-Atlantic Mental Illness Research Education and Clinical Center (MIRECC). Dr. Wilson’s contributions were also supported by the VA Office of Academic Affiliations Advanced Fellowship Program in Mental Illness Research and Treatment. Mr. Hicks was also supported by the National Cancer Institute of the National Institutes of Health (NIH) under award number R01CA196304-02S1. Funding sources had no role in the design, execution, analysis, interpretation of the data, or the decision to submit results for publication. The content is solely the responsibility of the authors and does not necessarily represent the official views of the VA, NIH, US Government, or any of the institutions with which the authors are affiliated.

Compliance with Ethical Standards

Research Involving Human Participants and/or Animals

All procedures performed in studies involving human participants were in accordance with the ethical standards of the Durham Veterans Affairs Medical Center Institutional Review Board and the U.S. Office of Management and Budget (OMB 2900-0728) 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.

Informed Consent

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

Conflict of Interest

The authors declare that they have no conflicts of interest.


  1. 1.
    Bennadi D, Reddy CVK. Oral health related quality of life. Journal of International Society of Preventive & Community Dentistry. 2013;3(1):1. doi: 10.4103/2231-0762.115700.CrossRefGoogle Scholar
  2. 2.
    Bergström J. Cigarette smoking as risk factor in chronic periodontal disease. Community Dent Oral Epidemiol. 1989;17(5):245–7.CrossRefPubMedGoogle Scholar
  3. 3.
    Sham ASK, Cheung LK, Jin LJ, Corbet EF. The effects of tobacco use on oral health. Hong Kong Med J. 2003;Google Scholar
  4. 4.
    Eke PI, Dye BA, Wei L, Thornton-Evans GO, Genco RJ. Prevalence of periodontitis in adults in the United States: 2009 and 2010. J Dent Res. 2012;91(10):914–20. doi: 10.1177/0022034512457373.CrossRefPubMedGoogle Scholar
  5. 5.
    Machuca G, Rosales I, Lacalle JR, Machuca C, Bullón P. Effect of cigarette smoking on periodontal status of healthy young adults. J Periodontol. 2000;71(1):73–8. doi: 10.1902/jop.2000.71.1.73.CrossRefPubMedGoogle Scholar
  6. 6.
    Millar WJ, Locker D. Smoking and oral health status. J Can Dent Assoc. 2007;73(2):155.PubMedGoogle Scholar
  7. 7.
    Johnson GK, Slach NA. Impact of tobacco use on periodontal status. J Dent Educ. 2001;65(4):313–21.PubMedGoogle Scholar
  8. 8.
    Kinane DF, Chestnutt IG. Smoking and periodontal disease. Critical Reviews in Oral Biology & Medicine. 2000;11(3):356–65.CrossRefGoogle Scholar
  9. 9.
    Winn DM. Tobacco use and oral disease. J Dent Educ. 2001;65(4):306–12.PubMedGoogle Scholar
  10. 10.
    Johnson GK, Hill M. Cigarette smoking and the periodontal patient. J Periodontol. 2004;75(2):196–209. doi: 10.1902/jop.2004.75.2.196.CrossRefPubMedGoogle Scholar
  11. 11.
    Blot WJ, McLaughlin JK, Winn DM, Austin DF, Greenberg RS, Preston-Martin S, et al. Smoking and drinking in relation to oral and pharyngeal cancer. Cancer Res. 1988;48(11):3282–7.PubMedGoogle Scholar
  12. 12.
    McCoy GD, Hecht SS, Wynder EL. The roles of tobacco, alcohol, and diet in the etiology of upper alimentary and respiratory tract cancers. Prev Med. 1980;9(5):622–9.CrossRefPubMedGoogle Scholar
  13. 13.
    Centers for Disease Control and Prevention. Adult oral health. 2013.
  14. 14.
    Riley JL, Tomar SL, Gilbert GH. Smoking and smokeless tobacco: increased risk for oral pain. J Pain. 2004;5(4):218–25. doi: 10.1016/j.jpain.2004.03.003.CrossRefPubMedGoogle Scholar
  15. 15.
    Weingarten TN, Moeschler SM, Ptaszynski AE, Hooten WM, Beebe TJ, Warner DO. An assessment of the association between smoking status, pain intensity, and functional interference in patients with chronic pain. Pain Physician. 2008;11(5):643–53.PubMedGoogle Scholar
  16. 16.
    Locker D, Maggirias J, Quiñonez C. Income, dental insurance coverage, and financial barriers to dental care among Canadian adults. J Public Health Dent. 2011;71(4):327–34. doi: 10.1111/j.1752-7325.2011.00277.x.CrossRefPubMedGoogle Scholar
  17. 17.
    Wamala S, Merlo J, Boström G. Inequity in access to dental care services explains current socioeconomic disparities in oral health: the Swedish National Surveys of Public Health 2004–2005. J Epidemiol Community Health. 2006;60(12):1027–33. doi: 10.1136/jech.2006.046896.CrossRefPubMedPubMedCentralGoogle Scholar
  18. 18.
    Manski RJ, Brown Jr. E. Dental coverage of adults ages 21 to 64, United States, 1997 and 2007. Medical Expenditure Panel Survey: Statistical Brief #295. 2010.Google Scholar
  19. 19.
    Bernabe E, Sheiham A, Sabbah W. Income, income inequality, dental caries and dental care levels: an ecological study in rich countries. Caries Res. 2009;43(4):294–301.CrossRefPubMedGoogle Scholar
  20. 20.
    Hoerster KD, Lehavot K, Simpson T, McFall M, Reiber G, Nelson KM. Health and health behavior differences: US military, veteran, and civilian men. Am J Prev Med. 2012;43(5):483–9.CrossRefPubMedGoogle Scholar
  21. 21.
    Bondurant S, Wedge R. Combating tobacco use in military and veteran populations. National Academies Press; 2009.Google Scholar
  22. 22.
    Acheson SK, Straits-Tröster K, Calhoun PS, Beckham JC, Hamlett-Berry K. Characteristics and correlates of cigarette use among recent US veterans. Mil Psychol. 2011;23(3):297–314. doi: 10.1080/08995605.2011.570589.CrossRefGoogle Scholar
  23. 23.
    Smith B, Ryan MAK, Wingard DL, Patterson TL, Slymen DJ, Macera CA, et al. Cigarette smoking and military deployment: a prospective evaluation. Am J Prev Med. 2008;35(6):539–46. doi: 10.1016/j.amepre.2008.07.009.CrossRefPubMedGoogle Scholar
  24. 24.
    Bergman HE, Hunt YM, Augustson E. Smokeless tobacco use in the United States military: a systematic review. Nicotine Tob Res. 2012;14(5):507–15.CrossRefPubMedGoogle Scholar
  25. 25.
    Feigelman W. Cigarette-smoking among former military service personnel: a neglected social issue. Prev Med. 1994;23(2):235–41.CrossRefPubMedGoogle Scholar
  26. 26.
    McKinney WP, McIntire DD, Carmody TJ, Joseph A. Comparing the smoking behavior of veterans and nonveterans. Public Health Rep. 1997;112(3):212.PubMedPubMedCentralGoogle Scholar
  27. 27.
    Fargo J. Prevalence and risk of homelessness among US veterans. Prev Chronic Dis. 2012;9.Google Scholar
  28. 28.
    Dillman DA. Mail and internet surveys: the tailored design method—2007 update with new internet, visual, and mixed-mode guide (2nd ed). New York: John Wiley & Sons; 2000.Google Scholar
  29. 29.
    Calhoun PS, Schry AR, Wagner HR, Kimbrel NA, Dennis P, McDonald SD, et al. The prevalence of binge drinking and receipt of provider drinking advice among US veterans with military service in Iraq or Afghanistan. Am J Drug Alcohol Abuse. 2015:1–10. doi: 10.3109/00952990.2015.1051185.
  30. 30.
    Dillon KH, Crawford EF, Kudler H, Straits-Troster KA, Elbogen EB, Calhoun PS. An investigation of treatment engagement among returning veterans with problematic anger. J Nerv Ment Dis. 2017;205(2):119–26.PubMedPubMedCentralGoogle Scholar
  31. 31.
    Green KT, Wilson SM, Dennis PA, Runnals JJ, Williams RA, Bastian LA, et al. Cigarette smoking and musculoskeletal pain severity among male and female Afghanistan/Iraq era veterans. Pain Med (Malden). 2017.Google Scholar
  32. 32.
    Lin I, Schaeffer N. Using survey participants to estimate the impact of nonparticipation. Public Opinion Quarterly. 1995;59:236–58.CrossRefGoogle Scholar
  33. 33.
    Voogt R, Saris W, Niemoller B. Non-response and the gulf between the public and politicians. Acta Politica. 1998;33:250–80.Google Scholar
  34. 34.
    Evaluation OotASfPa. U.S. Federal Poverty Guidelines Used to Determine Financial Eligibility for Certain Federal Programs. U.S. Department of Health and Human Services. 2017. Accessed 8 Mar 2017.
  35. 35.
    Cypel YS, Hamlett-Berry K, Barth SK, Christofferson DE, Davey VJ, Eber S, et al. Cigarette smoking and Sociodemographic, military, and health characteristics of Operation Enduring Freedom and Operation Iraqi Freedom veterans: 2009–2011 National Health Study for a new generation of US veterans. Public Health Rep. 2016;131(5):714–27.CrossRefPubMedPubMedCentralGoogle Scholar
  36. 36.
    Weathers FW, Litz BT, Keane TM, Palmieri PA, Marx BP, Schnurr PP. The PTSD checklist for DSM-5 (PCL-5). Scale available from the National Center for PTSD at www ptsd va gov. 2013.Google Scholar
  37. 37.
    Kroenke K, Spitzer RL, Williams JBW. The patient health questionnaire-2: validity of a two-item depression screener. Med Care. 2003;41(11):1284–92. doi: 10.1097/01.MLR.0000093487.78664.3C.CrossRefPubMedGoogle Scholar
  38. 38.
    Weathers FW, Litz BT, Herman DS, Huska JA, Keane TM. The PTSD Checklist (PCL): reliability, validity, and diagnostic utility. annual convention of the international society for traumatic stress studies. International Society for Traumatic Stress Studies San Antonio. 1993;Google Scholar
  39. 39.
    McDonald SD, Calhoun PS. The diagnostic accuracy of the PTSD checklist: a critical review. Clin Psychol Rev. 2010;30(8):976–87. doi: 10.1016/j.cpr.2010.06.012.CrossRefPubMedGoogle Scholar
  40. 40.
    Arroll B, Goodyear-Smith F, Crengle S, Gunn J, Kerse N, Fishman T, et al. Validation of PHQ-2 and PHQ-9 to screen for major depression in the primary care population. The Annals of Family Medicine. 2010;8(4):348–53. doi: 10.1370/afm.1139.CrossRefPubMedGoogle Scholar
  41. 41.
    Straits-Troster K, Gierisch J, Calhoun PS, Strauss JL, Voils C, Kudler H, et al. Living in transition: young veterans’ health and the postdeployment shift to family life. Treating young veterans: promoting resilience through practice and advocacy. 2011:153–174.Google Scholar
  42. 42.
    World Health Organization. Oral health: fact sheet. 2012.
  43. 43.
    Wallace BB, MacEntee MI. Access to dental care for low-income adults: perceptions of affordability, availability and acceptability. J Community Health. 2012;37(1):32–9. doi: 10.1007/s10900-011-9412-4.CrossRefPubMedGoogle Scholar
  44. 44.
    U.S. Department of Veterans Affairs. IB 10-442: Dental benefits for veterans. 2014.
  45. 45.
    Gibson G, Reifenstahl EF, Wehler CJ, Rich SE, Kressin NR, King TB, et al. Dental treatment improves self-rated oral health in homeless veterans–a brief communication. J Public Health Dent. 2008;68(2):111–5. doi: 10.1111/j.1752-7325.2007.00081.x.CrossRefPubMedPubMedCentralGoogle Scholar
  46. 46.
    Jones JA, Spiro A, Miller DR, Garcia RI, Kressin NR. Need for dental care in older veterans: assessment of patient-based measures. J Am Geriatr Soc. 2002;50(1):163–8.CrossRefPubMedGoogle Scholar
  47. 47.
    Lipton J, Ship J, Larach-Robinson D. Estimated prevalence and distribution of reported orofacial pain in the United States. J Am Dent Assoc. 1993;124(10):115–25.CrossRefPubMedGoogle Scholar
  48. 48.
    Riley JL, Gilbert GH, Heft MW. Orofacial pain symptom prevalence: selective sex differences in the elderly? Pain. 1998;76(1):97–104.CrossRefPubMedGoogle Scholar
  49. 49.
    Riley JL, Gilbert GH, Heft MW. Orofacial pain: racial and sex differences among older adults. J Public Health Dent. 2002;62(3):132–9.CrossRefPubMedGoogle Scholar
  50. 50.
    Locker D, Grushka M. Prevalence of oral and facial pain and discomfort: preliminary results of a mail survey. Community Dent Oral Epidemiol. 1987;15(3):169–72. doi: 10.1111/j.1600-0528.1987.tb00508.x.CrossRefPubMedGoogle Scholar
  51. 51.
    MacEntee MI, Stolar E, Glick N. Influence of age and gender on oral health and related behaviour in an independent elderly population. Community Dent Oral Epidemiol. 1993;21(4):234–9. doi: 10.1111/j.1600-0528.1993.tb00763.x.CrossRefPubMedGoogle Scholar
  52. 52.
    Vogt D, Vaughn R, Glickman ME, Schultz M, Drainoni ML, Elwy R, et al. Gender differences in combat-related stressors and their association with postdeployment mental health in a nationally representative sample of U.S. OEF/OIF veterans. J Abnorm Psychol. 2011;120:797–806. doi: 10.1037/a0023452.CrossRefPubMedGoogle Scholar

Copyright information

© International Society of Behavioral Medicine 2017

Authors and Affiliations

  • Terrell A. Hicks
    • 1
    • 2
    • 3
    Email author
  • Sarah M. Wilson
    • 2
    • 4
  • Shaun P. Thomas
    • 1
    • 2
  • Paul A. Dennis
    • 1
    • 2
  • Julia M. Neal
    • 2
  • Patrick S. Calhoun
    • 1
    • 2
    • 4
    • 5
  1. 1.Department of Psychiatry and Behavioral SciencesDuke University Medical CenterDurhamUSA
  2. 2.Durham Veterans Affairs (VA) Health Care SystemDurhamUSA
  3. 3.Durham Veterans Affairs Medical CenterDurhamUSA
  4. 4.VA Mid-Atlantic Mental Illness ResearchEducation and Clinical Center (MIRECC)DurhamUSA
  5. 5.Center for Health Services Research in Primary CareDurham VA Health Care SystemDurhamUSA

Personalised recommendations