Cigarette smoking is the leading cause of preventable disease and death in the United States, attributing to 1 in 5 deaths annually. It is estimated that 17.8% of U.S. adults aged 18 years or older currently smoke cigarettes. 2 Regardless of why people begin smoking tobacco, it is found that smokers have a greater risk of developing lung cancer, stroke, and heart disease when compared to non-smokers. Other illnesses that have direct associations with smoking tobacco include but are not limited to Chronic Obstructive Pulmonary Disease (COPD), cancers of the larynx and mouth, oesophageal cancer, pancreatic cancer, bladder cancer, cervical cancer, acute myeloid leukaemia, colon cancer, asthma attacks, and Crohn’s disease. Those that partake are more at risk for cataracts, type 2 diabetes mellitus, and rheumatoid arthritis. Interestingly enough, it can even have an effect on fertility and increase the risk of birth defects, miscarriages, and stillbirths.
The process of smoking cessation can prove a challenge for patients and become frustrating after multiple attempts without success. The reason that is so incredibly difficult for some to refrain from smoking cigarettes after use is in part due to the chemicals contained in a cigarette. Tobacco contains a mixture of chemicals and additives including nicotine, an addictive chemical that aids in the process of dependence, tolerance and withdrawal symptoms. Nicotine was found to be the most addictive drug in the United States. Nicotine prevents the re-uptake of acetylcholine ultimately increasing the amount in the central nervous system and skeletal muscle junctions. This, in turn, triggers a chemical reaction, which increases heart rate, alertness and reaction time. When inhaled and absorbed through the alveoli in the lungs, nicotine is directly associated with cardiovascular disease and causes a multitude of other disease processes. Simultaneously as this is occurring, dopamine and endorphins are released which are neurotransmitters that play a critical role in reward-motivated behaviour and ultimately add to the pleasure associated with smoking.
Hypnotherapy as a treatment in Smoking Cessation
There are numerous treatment options that play a critical role in smoking cessation. Currently used methods for treatment are but not limited to quitting abruptly without assistance which is also known as “cold turkey”, nicotine replacement therapies (patch, gum, lozenge, inhaler, nasal spray), prescription dosed nicotine replacement therapy, anti-depressant medications (Varenicline tartrate, Bupropion SR), laser therapy, acupuncture, hypnotherapy, counselling and support groups, and Hypnotherapy. A combination of these modalities may be used such as therapy with medication or two or more therapies together. However, as with all types of therapies and medications, each method will work differently depending upon the individual patient.
Studies were performed to prove the effectiveness of Hypnotherapy is smoking cessation. In one study, hypnotherapy was compared to nicotine replacement therapy. In another RCT, hypnotherapy was compared to group relaxation therapy. Lastly, hypnotherapy was compared between the group and single sessions. The outcomes measured in the three studies included the incidence of self-reported smoking cessation and counting the number of cigarettes smoked per day. The types of studies included are 3 randomised controlled trials (RCTs); one is a free choice study and another a cluster randomised, parallel-group, controlled trial.
In a study by Dickson- Spillmann and co-authors, the outcomes measured were by counting the number of cigarettes. This was accomplished by counting the number of cigarettes smoked per day at a 2-week follow up and at a 6-month follow up. In another study by Hansan, Zagarins and co-authors the outcomes were measured by self-reported smoking abstinence. This was recorded at a 12 week and 26-week post- hospitalisations follow up. And in a study by Riegel, the outcomes were measured using a symptom checklist – 90- revised (SCL – 90 R), creative imagination scale (CIS) and questionnaire on changes in experience and behaviour called Veranderungsfragebogen des Erlebens end Verhaltens (VEV). This was recorded with quit rates at the end of treatment and again at a 3 month follow up with a tolerance interval of 2 weeks.
Results of the studies
Dickson-Spillman and co-authors conducted a study containing 223 smokers that were 18 years or older. During recruitment, they noticed the pattern of “clusters” of individuals that shared similar features (such as work colleagues) therefore this trial falls under a cluster-randomised, parallel-group, controlled trial. Participants needed to be consuming greater than or equal to 5 cigarettes per day, willing to quit and not using any type of cessation aid at the time. Participants were excluded from the study for alcohol and/or substance abuse, and signs of psychotic symptoms noticed by a therapist at the start of sessions. There was no upper limit on age. After viewing advertisements, participants were mailed information about the interventions, cost, associated risks and how randomisation worked. The therapy sessions consisted of three parts: a psycho-educational part (40 minutes), the actual intervention (40 minutes), and a debriefing about which intervention was given (20 minutes). The 37 participants that withdrew were considered “continuing smokers”. At the 2-week follow up, there was no significant difference in reported abstinence rates when comparing hypnotherapy to relaxation therapy. In addition, there was no significant difference between the mean number of cigarettes smoked in the past 7 days when comparing both interventions. At the 6-month follow up, the intervention was not significant on self-reported 30-day nicotine abstinence. The NNT was calculated to be -2.1%, so this negative number means for every 2 participants who were treated with a single session of group hypnotherapy there was one fewer incidence of smoking cessation than in the group of participants in the single group relaxation therapy. There were no adverse events found.
Hasan and co-authors studied 164 current smokers between the ages of 18 and 75 years old admitted with pulmonary or cardiac illness. Participants were excluded if they had a history of substance abuse, psychiatric illness, terminal illness, pregnant, unable to follow up due to a behavioral or language barrier and/or if they have received NRT or hypnotherapy within the last 6 months. Participants were randomized to 1 of 3 treatments: hypnotherapy, NRT or a combination or the two. Hypnotherapy consisted of one, ninety-minute session, 1-2 weeks post-hospitalization by a certified hypnotist and tobacco treatment specialist. Those in the NRT group received a free one-month supply of patches with the dose based on the amount and time they smoked prior to hospitalization. Of the initial sample size, 42 participants declined treatment and were included in a separate “self-quit” group. Patients receiving hypnotherapy were more likely to remain abstinent at 12 and 26 weeks post-hospitalization compared to those receiving NRT. Although there is no significant difference, 43.9% of patients receiving hypnotherapy remained abstinent compared with 28.2% receiving NRT at 12 weeks. At 26 weeks, smoking abstinence rates were 36.6% with hypnotherapy and 18% with NRT, showing no significant difference. NNT was calculated to be six, which is moderately small for this study. This study reports no adverse effects of the interventions found.
Riegel studied 93 smokers between the ages of 23 and 68 years old. Inclusion criteria included at least a 2-year smoking history with the use of at least 10 cigarettes per day. In this free choice study, patients were given the option of individual versus group hypnotherapy sessions. Eight patients declined consent and were excluded from this study, leaving a total of 85 patients in the final sample. Individual treatment (IT) consisted of 29 people and 3 sessions of therapy whereas group treatment (GT) consisted of 56 people that participated in 4 sessions; each session was 90 minutes long. At the end of treatment, GT reported a 48.2% quit rate whereas IT reported a 37.9% quit rate with a 95% CI. At the 3 months follow up, GT reported a 19.6% quit rate whereas IT reported a 13.8% quit rate with a 95% CI. NNT was calculated to be 10, which is very small for this study. Drop out rates were 23.5% during treatment and 34.1% missing at follow-up, which was due to stress, illness, unsatisfactory treatment, and abstinence before treatment began; they were counted for as smokers. The data collected suggests the majority of subjects did not feel the side effects of the treatment.
Hypnotherapy does appear to aid in smoking cessation; however, based on the findings in the three studies addressed in this review, there is not a statistically significant difference when using hypnotherapy to treat smoking cessation compared with alternative methods. Studying tobacco smokers is difficult for both the participant and the researcher due to the high rate of relapse in this population, the ability to keep participants blinded, sample size and associated comorbidities among this population.