How does smoking affect back pain. What are the effects of smoking on spine health. Can quitting smoking improve back pain. How does nicotine impact spinal discs. What is the connection between smoking and chronic pain conditions.

The Association Between Smoking and Chronic Pain

Smoking has long been associated with various chronic pain conditions, including back pain. Research has consistently shown a strong link between tobacco use and persistent pain issues. But what exactly is the nature of this relationship?

How Smoking Impacts Cellular Function

At the cellular level, nicotine and other toxic substances in cigarettes can significantly impair normal functioning. These harmful chemicals deprive cells of essential nutrients and oxygen, weakening their ability to perform vital tasks throughout the body. This cellular damage can lead to a variety of chronic pain conditions, including:

• Rheumatoid arthritis
• Degenerative disc disease
• Oral pain
• Chronic back pain

The Vicious Cycle of Smoking and Pain

Interestingly, some researchers have identified a “positive feedback loop” between smoking and chronic pain. This means that some individuals may use smoking as a coping mechanism for their pain, while simultaneously, the act of smoking can exacerbate or even cause chronic pain conditions. This cycle can trap many people, leading to worsening health outcomes over time.

The Specific Link Between Smoking and Back Pain

While the general connection between smoking and chronic pain is well-established, what about the specific relationship between smoking and back pain? Multiple studies have shed light on this particular association.

Evidence from Research

A comprehensive review of 46 studies published in 2000 found a strong positive association between active smoking and back pain. In fact, 36 of these studies reported that both men and women experienced increased back pain related to smoking. Furthermore, a 2016 study identified smoking as a significant risk factor for lumbar pain and sciatica.

How Does Smoking Cause Back Pain?

The mechanism by which smoking leads to back pain is multifaceted. Here are some key ways in which tobacco use can impact spinal health:

1. Toxic substances like carbon monoxide can damage spinal disc cells and blood vessel linings.
2. Nicotine can cause blood vessels to constrict, limiting the flow of essential nutrients like calcium to spinal tissues.
3. Over time, these effects lead to cell degeneration or death, impacting spinal cushions and breaking down vertebral discs.
4. This process can result in conditions like degenerative disc disease (DDD), which often manifests as lower back pain or spinal stiffness.

The Impact of Smoking on Overall Spine Health

Beyond the direct effects on back pain, smoking can have broader implications for spine health. Let’s explore some of the ways in which tobacco use can compromise the integrity of your spine and surrounding structures.

Smoking and Osteoporosis

One of the most significant ways smoking affects spine health is through its role in the development of osteoporosis. This condition, characterized by weakened bones, can have severe consequences for spinal health. But how exactly does smoking contribute to osteoporosis?

• Smoking interferes with the body’s ability to absorb calcium, a crucial mineral for bone health.
• Tobacco use can disrupt hormone balances that regulate bone metabolism.
• Smokers often have lower bone density compared to non-smokers, increasing the risk of fractures.

The Risk of Vertebral Compression Fractures

As a result of smoking-induced osteoporosis, individuals who smoke are at a higher risk of experiencing vertebral compression fractures. These injuries occur when weakened vertebrae collapse, leading to chronic pain, potential disability, and limited mobility. The impact of such fractures on quality of life can be substantial and long-lasting.

Smoking’s Influence on Physical Activity and Spinal Health

Beyond its direct physiological effects, smoking can indirectly impact spine health through its influence on physical activity levels. Research has consistently shown an inverse relationship between smoking and physical activity, meaning that people who smoke are generally less likely to engage in regular exercise.

The Importance of Exercise for Spinal Health

Regular physical activity plays a crucial role in maintaining strong, healthy bones and muscles, including those that support the spine. Exercise helps to:

• Improve bone density
• Strengthen core muscles that support the spine
• Enhance flexibility and reduce the risk of injury
• Promote better posture and spinal alignment

By reducing the likelihood of engaging in these beneficial activities, smoking can indirectly contribute to poor spinal health and increased risk of back pain.

Recognizing the Symptoms of Smoking-Related Spinal Issues

For individuals who smoke or have a history of smoking, it’s crucial to be aware of potential signs of spinal health issues. Early recognition can lead to prompt intervention and better outcomes. What symptoms should you be on the lookout for?

Common Symptoms of Smoking-Related Spinal Problems

People with osteoporosis or other smoking-related spinal conditions may experience a range of symptoms, including:

• Persistent pain throughout the torso or lower back
• Reduced flexibility or range of motion in the spine
• Noticeable loss of height over time
• Stooped or hunched posture
• Sudden, severe back pain that worsens with movement

If you experience any of these symptoms, especially if you have a history of smoking, it’s important to consult with a healthcare professional for proper evaluation and treatment.

The Benefits of Quitting Smoking for Spinal Health

While the negative impacts of smoking on spinal health are significant, there’s good news: quitting smoking can lead to substantial improvements in overall health, including spinal well-being. But what specific benefits can individuals expect when they quit smoking?

Immediate and Long-Term Benefits

Quitting smoking can yield both immediate and long-term benefits for spinal health:

• Improved blood flow to spinal tissues, enhancing nutrient delivery and waste removal
• Gradual restoration of normal bone metabolism, potentially slowing or halting bone loss
• Reduced inflammation throughout the body, which can alleviate pain and improve healing
• Increased likelihood of engaging in physical activity, further supporting spinal health
• Decreased risk of developing or exacerbating chronic pain conditions

Timeline for Improvement

While some benefits of quitting smoking can be felt relatively quickly, others may take more time to manifest. Here’s a general timeline of what you might expect:

1. Within 20 minutes: Blood pressure and heart rate begin to normalize, improving circulation to all parts of the body, including the spine.
2. Within 8 hours: Carbon monoxide levels in the blood drop, allowing more oxygen to reach spinal tissues.
3. Within 2-12 weeks: Circulation improves, potentially reducing back pain and improving overall physical function.
4. Within 1-9 months: Coughing and shortness of breath decrease, making physical activity easier and more enjoyable.
5. After 1 year: The risk of heart disease is half that of a smoker, reducing inflammation throughout the body and potentially alleviating chronic pain.
6. After 5-15 years: The risk of stroke and various cancers significantly decreases, promoting overall health and well-being.

Strategies for Quitting Smoking and Improving Spinal Health

Recognizing the detrimental effects of smoking on spinal health is an important first step, but taking action to quit can be challenging. What strategies can individuals employ to successfully quit smoking and improve their spinal health?

Effective Smoking Cessation Methods

There are several evidence-based approaches to quitting smoking, including:

• Nicotine Replacement Therapy (NRT): This includes products like patches, gum, or lozenges that provide controlled doses of nicotine to help manage cravings.
• Prescription Medications: Certain medications can help reduce cravings and withdrawal symptoms.
• Behavioral Therapy: Working with a therapist or counselor can help address the psychological aspects of smoking addiction.
• Support Groups: Joining a support group can provide encouragement and shared experiences with others trying to quit.
• Cold Turkey: Some individuals prefer to quit abruptly without aids, though this method can be challenging.

Complementary Strategies for Spinal Health

In addition to quitting smoking, individuals can take other steps to support their spinal health:

1. Regular Exercise: Engage in activities that strengthen core muscles and improve flexibility, such as yoga, Pilates, or swimming.
2. Proper Nutrition: Consume a diet rich in calcium, vitamin D, and other nutrients essential for bone health.
3. Ergonomic Improvements: Make adjustments to your work and home environments to promote good posture and reduce strain on your spine.
4. Stress Management: Practice stress-reduction techniques like meditation or deep breathing exercises, as stress can exacerbate back pain.
5. Regular Check-ups: Schedule regular appointments with your healthcare provider to monitor your spinal health and address any concerns promptly.

The Role of Healthcare Providers in Addressing Smoking-Related Spinal Issues

Healthcare professionals play a crucial role in helping individuals manage and overcome smoking-related spinal health issues. But what specific ways can medical experts assist in this process?

Comprehensive Evaluation and Diagnosis

When a patient presents with back pain and a history of smoking, healthcare providers should conduct a thorough evaluation, which may include:

• A detailed medical history, including smoking habits and duration
• Physical examination to assess pain, flexibility, and strength
• Imaging studies such as X-rays, MRI, or bone density scans to evaluate spinal health
• Blood tests to check for markers of inflammation or nutrient deficiencies

Personalized Treatment Plans

Based on the evaluation, healthcare providers can develop tailored treatment plans that may include:

1. Smoking cessation support and resources
2. Pain management strategies, including medication or physical therapy
3. Referrals to specialists such as orthopedists or pain management experts
4. Recommendations for lifestyle modifications to support spinal health
5. Monitoring and follow-up to track progress and adjust treatment as needed

By working closely with healthcare providers, individuals can develop comprehensive strategies to address both their smoking habits and spinal health concerns, leading to improved overall well-being and quality of life.

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February 11, 2022

By Justin Field, MD

Smoking is linked to numerous chronic pain symptoms and diseases. As of 2014, over 16 million Americans were living with a smoking-related illness. Many people who smoke cigarettes or use vaping devices also report a common symptom — back pain. This commonality has led many researchers to study the relationship between smoking and back pain.

People who experience back pain from smoking may also have undetected spinal conditions. This chronic pain may indicate degenerating cells or worsening bone health, both of which can irrevocably harm your body. However, if patients decrease their nicotine intake early enough, they could see and feel the difference of a healthier spine.

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The Link Between Smoking and Chronic Pain

Smoking cigarettes regularly ensures a consistent flow of nicotine to your brain. People who smoke inhale about 1-2 milligrams of nicotine per cigarette, equaling up to 20-40 milligrams per pack. Inhaling tobacco also releases tar and carbon monoxide into your lungs, both toxic substances that can affect your overall health in many ways.

Many researchers have found a link between smoking and chronic pain. Because cigarettes and tobacco products are filled with toxic inhalants, smoking creates many health conditions that result in persistent pain. Smoking-related diseases are certainly not limited to back pain, as cigarette ingredients can have many effects on the human body.

The scientific explanation for smoking and chronic pain comes down to your cells. Nicotine and tobacco can deprive your cells of their necessary functions, which weakens their ability to perform throughout your body. Your diminished cells can create chronic conditions such as rheumatoid arthritis, degenerative disc disease and oral pain.

Some researchers find that smoking and pain exist in a “positive feedback loop.” Some people use their chronic pain as a motivator to smoke, while smoking can also cause chronic pain conditions. This deadly cycle traps millions of Americans every day and can cause far more pain in the long run than it solves.

Can Smoking Cause Back Pain?

Current smokers may report symptoms of lower back pain that seem unrelated to their smoking habits. However, a 2000 study review found a positive association between active smoking and back pain. Out of 46 studies, 36 found that both men and women had experienced back pain from smoking. Additionally, a 2016 study found that smoking is a risk factor for lumbar pain and sciatica.

So, does smoking cause back pain? It definitely increases the risk of back pain and spinal disc degeneration. Toxic substances, like the carbon monoxide from tobacco, can damage spinal disc cells and blood vessels’ interior lining.  Nicotine can shrink blood vessels, which restricts the flow of crucial nutrients like calcium.

Over time, cells degenerate or die, which impacts spinal cushions and breaks down the vertebral discs. This process can lead to degenerative disc disease (DDD), which often causes lower back pain or stiffness in your spine. Overall, smoking cigarettes causes cell malnutrition, wreaking havoc on your spinal cushions and vertebrae.

Effects of Smoking on Spine Health

Some people who smoke will not experience a direct connection between smoking and lower back pain like DDD. However, smoking-related diseases can be tied to several spinal conditions that create a similar effect.

Smoking is a well-known risk factor for osteoporosis, a disease that weakens your bones over time. This decreased bone density can lead to chronic back pain or spinal fractures. Smokers with developing osteoporosis are more likely to experience a life-changing vertebral compression fracture. This injury happens when weakened vertebrae induce a spinal collapse. A vertebral compression fracture can create chronic pain, lead to a disability or limit your mobility.

Aside from the effects of osteoporosis, smoking can reduce your physical activity and create other forms of chronic back pain. Researchers have found that smoking and physical activity have an inverse relationship, which means that people who smoke are less likely to be active adults. Because regular exercise improves bone density, smoking could negatively affect a person’s spinal health both physically and behaviorally.

PEOPLE WITH OSTEOPOROSIS OR OTHER BONE-RELATED ISSUES MAY FEEL A RANGE OF SYMPTOMS, INCLUDING:

• Pain throughout the torso or lower back
• Weakness in the legs
• Pain when sitting, bending over or lifting items
• Feelings of distress, anxiety or depression

How Smoking Affects the Back’s Ability to Heal

Some active smokers will recognize intense lower back pain and assume the damage has been done. Fortunately, you can alleviate your back pain and mitigate the risks of further spinal degeneration. The best way to begin healing is to stop or significantly reduce smoking.

Recovering from chronic back pain may involve any range of physical therapies, surgeries or habit changes. Quitting smoking is one of the best things you can do for your body. Researchers have found that smoking cessation can improve spine health and reduce the risk of diseases like sciatica. You may see excellent progress without surgery when you quit smoking.

Your chronic pain recovery begins when you get rid of the toxic substance that has weakened your body over time. Studies have found that smoking can increase your pain sensitivity, meaning your chronic back pain may feel worse because you smoke. In turn, you may feel less pain once you quit smoking and speak with a specialist about your lower back pain.

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Smoking and chronic pain have what some researchers call a comorbid relationship. Pain can lead people to begin smoking and may be similar to what they feel later in life because of smoking. This cycle can cause irreversible damage to your spine.

Chronic back pain is a prevalent condition that affects millions of adults. Its worst cases can prevent you from enjoying many simple pleasures of life. At Desert Institute for Spine Care, we treat hundreds of patients with chronic back pain. Our personalized diagnostic approach finds the source of your pain and helps you address solutions or appropriate treatment.

If you smoke and have noticed symptoms of chronic back pain, our specialists can help you identify solutions. We begin with the root and create an individualized plan to help you feel better. We start with minimally-invasive treatments, such as medication or therapeutic injections, but can also perform innovative surgical procedures.

DISC specialists are Arizona’s leaders in minimally invasive spine care. Our procedures range from traditional treatments to complex spine surgery. We will always recommend the least invasive option to alleviate your pain. If you want to know more about our services, you can contact us online. Call 602-944-2900 if you have questions.

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4 Ways Smoking Wrecks Your Back

Back pain: Yet another reason to quit smoking.

We’ve all seen those jarring anti-smoking ads over the years, the ones created by The American Lung Association or American Cancer Society that show longtime smokers with tracheotomies or carrying around oxygen tanks. And although these ads are powerful, people do continue to smoke. In fact, according to the Centers for Disease Control and Prevention (CDC), as of 2016, around 38 million people still smoked every day or some days.

There are many documented risks associated with smoking, including:

• Greatly increased risk of many cancers, especially lung

• Increased risk of heart disease and atherosclerosis

• Slower wound healing and increased infection risk after surgery

• Aggravation of existing health conditions such as asthma

Along with these dire outcomes, smoking can also greatly exacerbate back pain.

“Many people know that smoking cigarettes can cause lung cancer or heart disease, but most people are not aware that smoking is also bad for your back,” says Ofer M. Zikel, M.D., FACS, director of Neurological and Spinal Surgery at Wisconsin’s Aurora Medical Center Kenosha. “In my opinion, which is shared by many others, smoking greatly contributes to the incidence and severity of low back pain in the community. ”

If you are currently smoking and experiencing back pain, among other health concerns, read on to learn even more information on smoking, back pain, and how it affects your body.

Smoking not only causes back pain—it brings on all-over pain and overwhelms the vascular system—your blood vessels (veins, arteries, and capillaries).

“Primarily, smoking has a bad impact on blood flow and circulation,” explains Ai Mukai, M.D., physiatrist at Texas Orthopedics, Sports and Rehabilitation Associates in Austin, TX. “This can damage muscles and tendons as well as the other spinal structures, such as the disc.”

She adds that smokers don’t heal well from injuries, “which means if you injure a disc, it will take smokers longer to heal—or it may not heal at all.”

As for pain elsewhere in the body, Dr. Mukai says that smoking encourages increased inflammation, and that in and of itself can cause pain. Smoking can also interfere with medications that are prescribed to help pain and its absorption and function in the body.

So, why does smoking lead to pain?

Dr. Zikel says that there are several theories on this, “including the neuroexcitatory role of nicotine, as well as the harmful effects of many of the other chemicals and toxins in smoke damaging the spinal discs and facets, or the joints of the spine.”

There are myriad painful conditions, from desiccated discs to osteoporosis, that are either caused or worsened by smoking. Some procedures can also be jeopardized due to smoking.

1. Degenerative Disc Disease: “Smoking is linked to the development of degenerative disc disease, otherwise known as disc dehydration among other terms,” says Dr. Zikel. He details that dehydrated discs are “likely due to the effects of nicotine on the vascular system as well as the cellular damage caused by smoke toxins.”

2. Osteoporosis: Dr. Mukai says, “Smoking is also associated with higher risk of osteoporosis, or thin bones, and this can lead to increased risk of spine fractures. ”

3. Fibromyalgia: According to a Mayo Clinic study, smokers with fibromyalgia reported an increased severity in their symptoms, a worse quality of life, and increased anxiety when compared to non-smokers with fibromyalgia.

4. Spinal Fusion: When it comes to smoking and spinal fusion, it’s known that smoking can delay or prevent healing and fusion, something that can be quite detrimental when trying to permanently connect two or more vertebrae in one’s spine. Actually, it can negatively affect spine surgeries in general. Dr. Zikel says, “I, like many surgeons, require smoking cessation prior to some spine operations, especially ones involving spinal fusion. There is extensive data that shows smoking negatively impacts fusion of bones, which can lead to worse surgical outcomes.”

Beyond pain, smoking can additionally influence mood and sleep quality.

“Smoking has a negative association with three factors—mood, sleep, and pain,” Dr. Mukai says. “It’s a negative, vicious cycle, since people who are depressed, have pain, or experience anxiety tend to smoke more to cope in an unhealthy way, which then leads to worse pain and health.” She adds that depression, anxiety, and other mood disorders have been found to have a negative impact on spine surgery outcomes.

Have all of these facts convinced you to quit smoking? We really hope so. If so, you should know that it absolutely can be done, with the right resources.

“There’s just nothing good that comes out of smoking,” Dr. Mukai asserts, adding that quitting smoking can help with pain in the long run. She believes that several therapies can help someone quit smoking, such as medications, cognitive behavioral therapy, and she’s also seen good results from hypnosis and acupuncture.

“There are many reasons to quit smoking today,” Dr. Zikel says. “Quitting not only increases your lifespan, but the quality of life, with less risk of chronic disease and pain. I recommend that those who want to quit talk to their primary care physicians about a treatment plan which, depending on the individual, can include nicotine replacement therapy, counseling, and support.”

He shares a final thought, saying, “As I tell my patients, smoking cessation is one of the greatest achievements of your life.”

• Intro: Centers for Disease Control and Prevention. (January 2018) “Smoking is down, but almost 38 million American adults still smoke” https://www.cdc.gov/media/releases/2018/p0118-smoking-rates-declining.html
• Intro: Cureus. (September 2016) “Association Between Smoking and Back Pain in a Cross-Section of Adult Americans” https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5081254/
• The Effects on Chronic Pain and the Vascular System: Pain. (October 2019) “Effects of smoking on patients with chronic pain: a propensity-weighted analysis on the Collaborative Health Outcomes Information Registry” https://journals. lww.com/pain/Abstract/2019/10000/Effects_of_smoking_on_patients_with_chronic_pain_.22.aspx
• Conditions Worsened by Smoking: Spine. (March 2004) “Effect of Nicotine on Spinal Disc Cells: A Cellular Mechanism for Disc Degeneration” https://journals.lww.com/spinejournal/Abstract/2004/03010/Effect_of_Nicotine_on_Spinal_Disc_Cells__A.18.aspx
• Conditions Worsened by Smoking: Mayo Clinic Proceedings: Innovations, Quality & Outcomes. (February 2019) “Tobacco Use in Fibromyalgia Is Associated With Cognitive Dysfunction” https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6408684/
• Conditions Worsened by Smoking: Global Spine Journal. (January 2016) “The Effects of Smoking and Smoking Cessation on Spine Surgery: A Systematic Review of the Literature” https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5077710/

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How does smoking affect back pain?

It turns out that smokers are much more likely to have lower back pain. We understand why this happens.

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Back pain is one of the most popular reasons we seek medical help. Earlier, Men Today already wrote about its main reasons. Today we will talk about the prevention of back pain.

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Back pain can affect anyone, from the elderly to the child. But there are factors that can increase the risk of developing it. Below are the most important ones.

Age . Back pain often occurs with age, starting from 30-40 years.

Lack of exercise. Weak, untrained back and abdominal muscles can cause back pain.

Overweight. Being overweight puts extra stress on your back.

Diseases. Some types of arthritis and cancer can cause back pain.

Incorrect lifting. Using your back instead of your legs when you are trying to lift a heavy load can cause pain.

Psychological conditions. People prone to depression and anxiety also have a greater risk of pain.

Smoking. Smokers are more likely to experience back pain. This may be because smoking reduces blood flow to the spine and increases the risk of osteoporosis.

( See also: Pain while running: why it occurs and how to treat it)

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Prevention

You can avoid or prevent back pain by improving your fitness and learning and practicing proper body mechanics. To keep your back healthy and strong you need:

Exercise. Regular low-impact aerobic exercise—those that don’t strain or jar your back—can increase your back’s strength and endurance and allow your muscles to function better. Walking and swimming are good choices. Talk to your doctor about what activities you can try.

Build muscle strength and flexibility. Abdominal and Back Workouts that Strengthen Your Core helps to train these muscles to work together like a natural back brace.

Maintain a healthy weight. Being overweight strains the back muscles. If this is your situation, losing weight can help prevent back pain.

Stop smoking. Smoking increases the risk of back pain. The risk increases with the number of cigarettes smoked per day, so quitting smoking should help reduce this risk.

( Read also: 9 habits that threaten the health of your joints)

Back pain? It’s time to quit smoking! — HealthInfo

The bag is too heavy. Intensive exercise in the gym. Uncomfortable office chair. Permanent computer seat . Yes, and just “unsuccessfully turned.” How many different reasons we find to explain why the back hurts. And doctors add one more. It has been established that smoking has a detrimental effect on the condition of the spine. So you want the back to pass? Quit smoking !

Tobacco is the enemy of intervertebral discs

A few years ago, Chinese scientists conducted a study on mice. They exposed the animals to tobacco smoke, simulating regular smoking (4 cigarettes a day, 5 days a week for six months). After this “smoking” period, the composition of the intervertebral cartilage of mice was studied. It turned out that the content of proteoglycans in it (components that provide flexibility and elasticity of the disc) was only 63% of the norm. The synthesis of new proteoglycans and collagen significantly decreased – almost two times.

At the same time, the researchers noticed that the “smoking” mice accelerated the processes of cellular aging almost twice.

All this led to an unequivocal conclusion: smoking has a negative effect on the condition of the intervertebral discs, which means it leads to back pain .

Smoking affects the blood vessels

The dependence of the degree of pain in the spine on smoking was revealed several years ago by American scientists. At Emory University (Atlanta), doctors examined the results of computed tomography of 182 patients. One third, 34% of them, were smokers. CT scan assessed the condition of each intervertebral disc and the spine as a whole. As a result, scientists came to the conclusion that the condition of the spine in smokers was worse, and the degree of osteochondrosis was higher.

This is due not only to the disruption of the synthesis of substances that make up the cartilage of the intervertebral disc. Smoking also affects microcirculation, causing spasm of blood vessels and capillaries. This means that the intervertebral discs do not receive sufficient nutrition, the process of their degeneration is accelerated.

Smoking reduces bone density

Nicotine damages bone tissue. Normally, the processes of destruction and formation of bone substance are ongoing, and the balance of these processes allows the bones to maintain strength. Smoking shifts the balance towards bone destruction, as it affects the osteocyte cells that form the basis of bone tissue. As a result, the bone substance loses its density, acquires a structure resembling a sponge.

Osteoporosis, or a decrease in bone density, in the spine leads to deformation of the bodies of the vertebrae themselves. This means that various pinched nerves are possible, which leads to constant back pain.

Smoking is a risk factor for arthritis

Nicotine negatively affects not only bone and cartilage tissue. Smoking is one of the important provoking factors of rheumatoid arthritis, a serious joint disease that not only causes pain, but also seriously limits a person’s mobility.

Three years ago, scientists from Sweden conducted a survey of 1,200 people already diagnosed with rheumatoid arthritis and 900 healthy people. The following relationship was established: those people who smoked 20 cigarettes a day for 20 years (and this is the “norm” for many experienced smokers) were 2.5 times more likely to experience the most severe form of rheumatoid arthritis.