Stop Smoking











Smoking Cessation and Hypnosis
A comparative review of the effectiveness of hypnosis, an advanced method of hypnosis, and other interventions used for the cessation of smokingin the U.S. and UK
Prepared By
Michael O' Driscoll B.Sc., M.Sc. (Oxon)

Contents
1.      Introduction    3
What's the problem?: Smoking - the biggest cause of preventable death in
the developed world 3
2.   Hypnosis and other interventions for smoking cessation.. 4
Effectiveness of hypnotherapy in bringing about smoking cessation compared
to other methods.. 4
High quit rates for hypnosis compared to other methods.. 4
Other interventions for smoking cessation. 6
(1) Nicotine replacement therapy 6
(2) Non-nicotine Pharmacological treatments. 7
(3) Intervention by health practitioners. 8
(4) Self-help' interventions 8
(5) Acupuncture 8
(6) Other methods of facilitating smoking cessation. 9
Other methods--Summary. 9
3.   Tailored' hypnosis - taking it to the next level      10
4.   Practice Builders Study (2000)      14
For all subjects: 14
For subjects treated with the standard technique: 15
For subjects treated with our technique: 15
Findings.. 15
6.      References/Bibliography    18

1.         
Introduction
This paper presents the findings from a study looking at all methods of smoking cessation, including standard hypnotherapy techniques and compares those to a specially developed advanced method of hypnotherapy for smoking cessation; quit rates are compared; some tentative concussions are suggested.
What's the problem?: Smoking--the biggest cause of preventable death in the developed world


It is estimated that there are 1.1 billion smokers worldwide and that smoking-related illness costs the National Health Service £400m and kills 111,000 people a year in the UK. In view of the human and financial costs of tobacco smoking it is not surprising that there is large demand from individuals and from governments for products or techniques which may help the cessation of smoking. The market for nicotine replacement products alone is estimated at $1billion dollars in the U.S. annually and £80m per year in the UK.

New Scientist, February 1993

2.         
Hypnosis and other interventions for smoking cessation
Effectiveness of hypnotherapy in bringing about smoking cessation compared to other methods
High quit rates for hypnosis compared to other methods
A larger meta-analysis of research into hypnosis to aid smoking cessation (Chockalingam and Schmidt 1992) (48 studies, 6,020 subjects) found that the average quit rate for those using hypnosis was 36%, making hypnosis the most effective method found in this review with the exception of a programme which encouraged pulmonary and cardiac patients to quit smoking using advice from their doctor (such subjects are obviously atypical as they have life-threatening illnesses which are aggravated by smoking and therefore these people have very strong incentives to quit).














Table 1:         Effectiveness of different types of intervention to achieve smoking cessation adapted from data in Chockalingam and Schmidt (1992)

Law and Tang (1995) looked at 10 randomised trials, carried out between 1975 and 1988, of hypnosis in smoking cessation. They found that the effect of hypnosis was highly statistically significant. The research they examined involved 646 subjects and cessation rates at 6 months post-treatment ranged from 10% to 38% (the average figure was 24%).















Table 2:         Effectiveness of different types of intervention to achieve
smoking cessation (adapted from data in Law and Tang 1995)
Table 2 (above) shows that the meta-analysis of Law and Tang confirms, to a large extent, the meta-analysis of Chockalingam and Schmidt (1992); in both cases hypnosis appears as the most effective form of intervention to achieve smoking cessation with the exception of groups who are highly motivated to quit for medical reasons, such as those with existing heart or pulmonary problems.
A more recent study, by Ahijevych et al (2000), produces a similar overall figure for the success of hypnosis. This study looked at a randomly selected sample of 2,810 smokers who participated in single-session, group hypnotherapy smoking cessation programs sponsored by the American Lung Association of Ohio. A randomly selected sample of 452 participants completed telephone interviews 5 to 15 months after attending a treatment session. 22% percent of participants reported not smoking during the month prior to the interview.

Combined results were statistically significant at the .001 level, meaning that there is less than a one in a thousand chance that these results happened by chance.

2.         
Hypnosis and other interventions for smoking cessation
Effectiveness of hypnotherapy in bringing about smoking cessation compared to other methods
High quit rates for hypnosis compared to other methods
A larger meta-analysis of research into hypnosis to aid smoking cessation (Chockalingam and Schmidt 1992) (48 studies, 6,020 subjects) found that the average quit rate for those using hypnosis was 36%, making hypnosis the most effective method found in this review with the exception of a programme which encouraged pulmonary and cardiac patients to quit smoking using advice from their doctor (such subjects are obviously atypical as they have life-threatening illnesses which are aggravated by smoking and therefore these people have very strong incentives to quit).
















Table 1:         Effectiveness of different types of intervention to achieve smoking cessation adapted from data in Chockalingam and Schmidt (1992)

Law and Tang (1995) looked at 10 randomised trials, carried out between 1975 and 1988, of hypnosis in smoking cessation. They found that the effect of hypnosis was highly statistically significant . The research they examined involved 646 subjects and cessation rates at 6 months post-treatment ranged from 10% to 38% (the average figure was 24%).














Table 2:         Effectiveness of different types of intervention to achieve
smoking cessation (adapted from data in Law and Tang 1995)
Table 2 (above) shows that the meta-analysis of Law and Tang confirms, to a large extent, the meta-analysis of Chockalingam and Schmidt (1992); in both cases hypnosis appears as the most effective form of intervention to achieve smoking cessation with the exception of groups who are highly motivated to quit for medical reasons, such as those with existing heart or pulmonary problems.
A more recent study, by Ahijevych et al (2000), produces a similar overall figure for the success of hypnosis. This study looked at a randomly selected sample of 2,810 smokers who participated in single-session, group hypnotherapy smoking cessation programs sponsored by the American Lung Association of Ohio. A randomly selected sample of 452 participants completed telephone interviews 5 to 15 months after attending a treatment session. 22% percent of participants reported not smoking during the month prior to the interview.

Combined results were statistically significant at the .001 level, meaning that there is less than a one in a thousand chance that these results happened by chance.










2.         Other interventions for smoking cessation
(1)            Nicotine replacement therapy
Although this can consist of gum, spray, tablets or patches, the latter are by far the most popular form of nicotine replacement. Nicotine replacement patches became available over the counter (without prescription) in the UK in November 1992, and became free (the user only pays the prescription charge) to smokers in 2001, on condition that the smoker's GP consider this form of therapy advisable. In effect this means that the UK government has subsidised the use of nicotine replacement therapy, in the hope of offsetting the huge annual costs of smoking-related diseases to the NHS. There is a growing discussion about whether nicotine replacement therapy is an effective way of encouraging smoking cessation.
The New Scientist (editorial comment: vol 137 issue 1860 Feb 93, p.3) points out that in the U.S. patches are perceived as merely one component of a quitting programme -manufacturers of NRT are in fact expressly forbidden to suggest that their products can alone be a successful means to quitting smoking - no such regulation exists in the UK as yet leading to what some people might feel is a misconception that patches alone can result in successful cessation of smoking.
The evidence on the efficacy of NRT, considered alone, is fairly clear; it is better than quitting without any form of intervention and support but only to a limited extent in absolute terms (e.g. Hughes 1993). The meta-review of smoking cessation interventions referred to previously (Law 1995) found that, for subjects who were recommended nicotine gum or patches by their GP, without prior request from the subject for advice on giving up smoking, the quit rates were 3% for gum and 4% for patches. Quit rates for self-referred smokers (i.e. those specifically consulting their GP for advice on giving up smoking) were considerable higher at 11% (gum) and 13% (patches). The quit rates using gum or patches, even amongst those who have specifically come forward seeking help in quitting, are many times lower than the quote rates which were found for hypnotherapy in the same review, and are in fact amongst the least successful of all the smoking cessation interventions which were reviewed. Tang et al (1994) claim that with higher doses of nicotine replacement and more careful targeting of subjects based on their current level of dependence, it may be possible to achieve a quit rate of one-third amongst self-referred smokers.
Chockalingam and Schmidt (1992) found an average quit rate of 16% for the 4,866 subjects in 40 studies which looked at the efficacy of nicotine gum. This equates to less than half the average quit rate achieved using hypnosis (36%), which they found in the same review (referred to earlier).
Davidson et al (1998) (in a study carried out after the two meta-analyses discussed above) evaluated the efficacy and safety of nicotine patches in an over-the-counter setting. They used a multi-site, double-blind, randomised, placebo-controlled design in a trial of 6-week duration with 18 weeks of follow-up.










"Your mind can block the perception of discomfort, as when your finger felt insensitive to the pressure of the sharp nail file ... Your mind will function in such a manner that you will no longer crave for a habit that has negatively affected your life with every drag of cigarette smoke you have taken into your lungs. . . You will block the craving for tobacco ... a habit that is causing your heart and your lungs to work much harder than necessary, forcing your lungs to labor beyond all necessity, stressing and straining these vital organs . . . like a car constantly driven in low gear. . . constantly laboring uphill . . . stressing and straining the motor. . . But because of the great control of your unconscious mind, the craving for this vicious and lethal habit will grow steadily and markedly less until it rapidly reaches a permanent zero level. . . You simply will not crave for cigarettes again. . . . You will be relaxed and at ease, pleased that you are giving up a habit which has such a negative effect upon your life and well-being. . . You are improving your life by giving up cigarettes and you will continue to do so... You w/y/not smoke cigarettes again. . . You will not be hungry or eat excessively . . . your craving will reach a permanent zero level."
After each use of hypnosis the patient was encouraged to discuss unusual dreams, thoughts, or feelings that he might have experienced.
The first three hypnotic sessions were given on consecutive days. Between the third session and the fourth, which was scheduled one month later, the patient was instructed to call the office daily for the first week, twice the second week, and then once a week until the fourth induction of hypnosis. In some cases, where reinforcement was deemed very important, the patient was asked to call daily for the entire month. The patient was told that each call would reinforce the posthypnotic suggestion and increase his resistance to smoking. This telephone report was usually given to a secretary, though they talked to the patient directly if there was some unusual difficulty. They requested that each patient walk at least one mile each day as a means of decreasing tension and improving pulmonary ventilation. If the patient wished, other forms of exercise might be substituted. Each patient returned one month after the third induction for their last hypnotic session.
A questionnaire was sent to the 75 patients to determine if they were still non-smokers. All subjects who received the questionnaire had gone at least one year beyond their last visit, although the range between the last hypnotic session and the time of sampling varied between one and four years, with a mean of 26 months. In addition to the structured questionnaire, spontaneous comments were solicited; anonymity was suggested if it would permit the respondent to be more frank
Of the 75 questionnaires sent, 67 were returned, an 89% response rate. Of those responding, 82% had not smoked cigarettes at all since the fourth reinforcement session. Of these, 78% had not substituted any 'oral habit'. Of those who had substituted, however, no substitute seemed as serious as the previous habit of cigarettes. Several who substituted indicated that they now smoked cigars or a pipe or had begun to chew gum regularly. The cigar smokers uniformly claimed not to inhale smoke.
Of the total group, 64% were no longer smoking, nor substituting any other oral habit. Some 18%, however, had continued smoking at the pre-treatment rate. The remaining 18% were not smoking cigarettes; they had substituted another oral habit, usually of the comparatively innocuous type previously mentioned.
4.          Current Study (2000) (96% success rate)
This research was carried out on 300 subjects (beginning in January 2000 and continuing until March 2002) who responded to an advertisement. A 'blind trial' technique was used - subjects were not aware that they were taking part in a research project although they all ticked a box on their intake forms saying that they understood that the hypnotist's methods were always being measured tested and improved, and that results would be collated and studied. Client confidentiality was assured so that their data could be used but not their names and these subjects were randomly allocated to receive either 'standard' hypnotherapy or a special formulation of hypnotherapy which Practice Builders has termed 'advanced therapy'. 51% of respondents were male and 49% female; the median age of all subjects was 44 years.
No respondents had previous experience of hypnosis - 51% of subjects had tried nicotine patches, 14% had tried nicotine gum, 7% had tried acupuncture, 6% had tried using a nicotine inhaler and 30% had previously tried to quit using will-power alone. 11% of subjects had not previously tried to quit smoking.
For all subjects:
The client was interviewed to make sure that they wanted to stop smoking for their own reasons, and were not being pressured into it by someone else (doctor, loved one etc.).
The price was kept high (£250) to establish commitment, and to avoid people who were casually or speculatively trying hypnosis (as opposed to those who have some commitment, confidence or belief that hypnosis would help them to stop smoking).
All subjects waited a minimum of three weeks for an appointment in order to build expectancy - subjects were already thinking about, and planning being, a non-smoker for weeks before the treatment began.
Before the actual hypnosis, the client (or subject) is asked a series of questions about their smoking habit and their beliefs. This allows the hypnotherapist and the client to build rapport and also lets the hypnotherapist become aware of any thought patterns based on myths or misconceptions that need to be cleared up before the hypnosis. They are asked, for example:
'Do you believe you are addicted to nicotine?'
'What fears do you have about stopping?'
'What do you know about hypnosis?'
Hypnosis was then fully explained to the client, as well as how the conscious and the unconscious mind works, and any myths debunked (such as, you cannot make someone do something they don't want to do, hypnosis is not sleep or unconsciousness, you will be aware of everything that is going on and will remember everything that happened in hypnosis after the session, you can stop the session at any time, etc.). This is called the "pre-talk".
A hypnotic contract is then entered into, in which the client agrees to go along with all techniques and to accept all the suggestions that are for their benefit.
For subjects treated with the standard technique:
The client then reclines in the chair, and a basic stop smoking script is read. This type of standard technique doesn't allow for much in the way of personalizing a session, as it is the same for every client. The wording of some of the best basic techniques uses hypnotic language patterns (Neuro Linguistic Programming). The client is then emerged.
For subjects treated with the advanced technique:
Hypnosis is induced using a progressive test induction tailored to the client. Ideo motor techniques are used to gain unconscious communication. The client's own motivations, Meta programmes, and values are utilized in the session using a combination of metaphor and suggestion.  NLP sub-modality and anchoring techniques are used according to the client's processing style. At the end of the session, the client is emerged from hypnosis and the change is tested, then future paced and ratified.
Findings
Quit rates were established thorough telephone interviews 1 month and 6 months after the first session of treatment.
After 1 session 95% of those who received 'advanced therapy' had quit smoking. The remaining 5% received a second session of treatment leading to a further 1.3% of the group quitting smoking. In total therefore, at 6 months, 97% of those who received 'advanced therapy' had quit smoking.
Of those who received 'standard therapy' 51% quit smoking after one session and a further 6% quit after a second session--a total of 57% had quit smoking at 6 months.
Those who were still smoking at 6 months did not differ from those who had successfully quit in terms of gender, age or therapies previously tried. These results mean that for both standard treatments and the 'advanced treatment' quit rates are extraordinarily high and well above what has hitherto been reported in the literature. Results for both treatments were significant at the 0.001 level (chi-square).
Outcomes for the 'advanced therapy' are considerably higher than any findings previously reported in the literature. In addition, the success rate achieved using the standard technique was considerably higher than expected and this may be due to the fact that the elements that the standard treatment and 'advanced treatment' have in common (price, waiting period for the session, advertising exposure, and pre-talk etc.) have powerful effects on outcomes.

5.          Conclusions
As the evidence which has been presented demonstrates, hypnosis would seem to be one of the most effective methods in aiding smoking cessation (and arguably the most effective). The study carried out by Practice Builders achieved quit rates very close to 100% and indicated what can be achieved with hypnosis when it is appropriately tailored to the individual seeking help to quit smoking.
Given the apparent superiority of hypnosis as a smoking cessation intervention it is worth considering why hypnosis is not more widely used and, in particular, why the NHS and its international equivalents have not attempted to promote or subsidise hypnotherapy to any significant degree. Some of the possible reasons for this are examined below.
There are a variety of methodological issues in relation to many smoking cessation studies and these are not restricted to those studies looking at the use of hypnosis. Cepeda-Benito (1993:827) says that:
'...a serious problem with the studies reviewed was the overall lack of consistency across research teams regarding what and how variables were measured. This was mainly manifested in the description of the subjects' characteristics and smoking histories, the great diversity of cutoff values used to validate abstinence within each of the biochemical verification methods, the various definitions of abstinence, and the specificity with which the experimental procedures were described'.
The Department of Public Health & Policy (1992:2) point out that:
'Studies of smoking cessation interventions have traditionally been plagued by inadequate sample sizes. In order to detect clinically meaningful differences in outcome between intervention and control groups, and therefore attribute cessation rates to the intervention rather than other factors, a minimum of 100 subjects per group is needed'.
Further methodological problems of smoking cessation studies are outlined by Chockalingham and Schmidt (1993) and Berglund et al (1974) who draw attention to the problem of non-response during the follow-up to studies. Most of the primary studies are based on participants who reply to follow-up calls or questionnaires - it may be that these people disproportionately represent the successful quitters, which would result in a response bias. It is quite possible that there may be a social desirability effect pertaining to people who are simply asked if they have refrained from smoking over a given period - they may want to give the answer which they perceive the interviewer would like them to give. Chockalingam and Schmidt suggest countering this through comparing the quit rates of the experimental and control groups (rather than just quoting the quit rate of the experimental group). Response bias can be countered by assuming that those not contacted have in fact started smoking again (this is basically a way of erring on the side of caution).
However, the only way to be sure about whether or not individuals have given up smoking is through the use of blood tests. Lando (1989) found that in studies using self-reports of cessation, 25-28% of subjects who had claimed to have stopped smoking are in fact found to be smoking when their smoking status is validated using biochemical tests.'
In some, if not all studies of smoking cessation through hypnosis, there is no use of biochemical markers (blood tests) in follow-up. This may be because such studies are conducted by people who haven't been trained in a classical 'medical paradigm'. Nonetheless, if comparisons of hypnosis and other methods are to be valid then there needs to be standardisation of methods and procedures.
There was great variability in the range of results from the meta-analysis carried out by Chockalingam (1992) and that carried out by Law (1995). This confirms the points made earlier in this paper about the difference between a 'bespoke' program of hypnosis and very general hypnotic procedures carried out under less than ideal conditions. In other words it may be that even 'basic' hypnotic techniques are very effective in helping people to quit smoking but that the real power of hypnosis can only be released in the hands of skilled practitioners who are sensitive to the needs of their clients. Research is obviously required to isolate those techniques and procedures that are particularly effective.
It is worth noting that sections of what might be termed the 'western medical establishment' is biased towards 'medical' treatments and against 'alternative' therapies (which is how many would see hypnosis). Although there is some progress in changing old prejudices against non-pharmacological interventions there is still much conservatism in this area.
One other factor may be that, although it would seem that hypnosis has a higher rate of effectiveness in achieving smoking cessation than other types of intervention, this does not mean that there will necessarily be a high take up of hypnosis amongst the public, even if it were to be subsidised or made free. Unlike a nicotine patch, hypnosis does require a certain amount of commitment from participants and it is certainly the case that many people still associate hypnosis with being out of control or somehow making themselves vulnerable.
If hypnosis is to be adopted as a 'mainstream' treatment for smoking cessation then it will be necessary at some stage for hypnosis to prove itself within the medical paradigm of the health establishment in the UK and elsewhere. This could best be done by large randomised clinical trials and, crucially, these trials should adopt a methodology of confirming smoking cessation through the use of biochemical markers (i.e. blood tests) as this is one of the most frequently raised challenges to the high rates of success which appear to pertain in relation to hypnotherapy for smoking cessation.
Finally, it is worth bearing in mind that individuals have different needs and desires in terms of the smoking cessation therapy which is suitable for them. Shiffman (1993: 719) argues that, The era of the single-approach program is over. Smoking cessation has come to be dominated by multi-component, all-inclusive programs that combine elements of many approaches.' It is perhaps time that hypnosis moved from being considered an alternative therapy to being used as a key part of a national smoking cessation programme.
These clients were seen by Dr. Barry Neale, Ph.D. in his practice, The Accelerated Change Centre (UK).


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