Previous studies showed equivocal findings regarding the efficacy of focused attention and distraction to experimental pain. This study examined the relative efficacy of these strategies on perception of cold pressor pain in 41 chronic back pain patients and 41 healthy control participants. Participants were randomized to the 2 strategies and then completed a 7-minute cold pressor test. Pain intensity and discomfort ratings were obtained during the task. Participants who completed the first task were asked to complete a second cold pressor task without instructions. Pain and discomfort ratings differed by condition across time. In the distraction condition, pain levels started low but continued to rise throughout the cold pressor immersion, whereas in the focused attention condition, pain levels started higher, rose less quickly, and then decreased from the middle of the task. Focused attention was associated with higher pain and lower completion rates in chronic pain patients compared with healthy control subjects. Focused attention might therefore not be an effective intervention strategy for individuals with chronic back pain. Finally, in the second cold pressor test, patients' pain reports rose more rapidly than those of healthy control subjects. The results of this study can be explained in terms of differences in cognitive appraisal between pain patients and healthy control participants. Perspective: Marked differences were found between chronic back pain patients and control participants regarding focused attention as compared with distraction as a means of coping with cold pressor-induced pain. These differences underline the importance of taking into account previous experience with pain when recommending strategies to cope with painful procedures. (C) 2006 by the American Pain Society.