Change Your Life: Living Skillfully

A long and slightly technical post this time. Bear with me.

For the National Heart Foundation smoking cessation practitioner training course I went to last week, they sent me some pre-reading, namely the NZ Ministry of Health’s Smoking Cessation Guidelines. Of course, I was interested in what they have to say about hypnotherapy.

Here it is, the sole mention: “There is evidence that hypnosis does not improve long-term abstinence rates over any intervention providing the same amount of time and attention to the participant.” This is under a heading “Evidence of no effectiveness” on the page for “Other treatments and Interventions” – “other” being in contrast here primarily to medication and advice.

Is this a fair assessment of the evidence? I set out to find out.

There’s a reference, I’m pleased to say: Abbot, N.C., Stead, L.F., White, A.R., Barnes, J. (2006). Hypnotherapy for smoking cessation. Cochrane Database of Systematic Reviews (2).

Well, my science teachers have trained me well to be a critical thinker and always check the primary source. So here I go off to the Cochrane Database.

You can read the abstract online for free, and it says, in part, “There was significant heterogeneity between the results of the individual studies, with conflicting results for the effectiveness of hypnotherapy compared to no treatment or to advice… We have not shown that hypnotherapy has a greater effect on six month quit rates than other interventions or no treatment.”

Which is rather different from “evidence of no effectiveness”, to my mind.

Let’s dig deeper.

The reviewers only considered random controlled trials which compared hypnotherapy with no treatment or with other therapies, and which followed up the results after a minimum of six months. This gave them 9 trials after searching a number of major databases using the keywords “hypnotherapy” and “smoking cessation”. These databases date back a varying number of years; the longest period was 1966-2005, but most were from sometime in the 1980s to 1995. (The 2006 date given in the Smoking Cessation Guidelines is an error, most likely the copyright date that appeared at the time it was accessed. The review was actually published in 1998.)

What a surprise, techniques varied widely between the different studies. This is one of the things that makes it difficult to make pronouncements about the effectiveness of hypnotherapy: What hypnotherapy? Whose hypnotherapy? How much hypnotherapy? It’s not like a pill that you give people which always contains the same amount of a known substance. Only three studies mentioned the type of induction used. Two used one session, one used two sessions, one used an unspecified number of sessions over nine weeks. The total session duration varied from 30 minutes to 7 hours.

(I’ll insert a note here: We need to come up with a standardized, repeatable hypnotic intervention for smoking cessation that can be rigorously and repeatedly tested, because what I’ve just described is a mess. I’d like to collect best practice from successful hypnotherapists and put such an intervention together. If you have good success with hypnotherapy for smoking cessation and are willing to share your techniques in a good cause, contact me: mikerm at hypno dot co dot nz.)

There were another nine studies that might have been included, but six weren’t followed up for a long enough period and three weren’t randomized, though they were controlled.

What the studies compared with was usually some form of counselling or advice, or else a no-treatment, waitlist condition. Two studies compared rapid or focussed smoking.

The outcome was mainly assessed by self-report (which Hyman (1986) and other studies have shown to have reasonably good agreement with biological testing). None of the studies stated that the assessor was blind to which group the participants were in.

I have listed the studies at the bottom of this post so you can check them out for yourself.

Pedersen (1975) and Williams (1988) compared a total between them of 72 smokers, and concluded that odds of quitting with hypnotherapy were significantly greater compared to a wait-list control (no treatment). A larger study, Lambe (1986), in which the waiting list group received a physician’s letter, a self-help booklet and three follow-up phone calls in which they were given encouragement, and in which half the “hypnotherapy” group didn’t actually receive hypnotherapy, didn’t find an advantage for hypnotherapy except that the hypnotherapy group gave up more quickly – the cessation rate at 3 months was higher, but by 6 months was the same.

Comparing hypnotherapy with attention/advice control groups (which is what the reference in the Smoking Cessation Guidelines is about), there are four studies. Rabkin (1984), which used a single session of hypnotherapy compared with health education and behaviour modification, found as follows: “Follow-up data three weeks after completion was available in 140 subjects. Each program showed significant reductions in reported cigarette consumption and serum thiocyanate levels, an indicator of long-term cigarette consumption, compared to entry and to the control group. However, there were no significant differences between the hypnosis, health education, or behaviour modification groups with respect to the proportion who reported quitting smoking, the number of cigarettes smoked or change in serum thiocyanate levels. Reported cigarette consumption ascertained six months later again showed no significant differences between these three approaches… Thus, hypnosis, health education, and behaviour modification are each effective programs for changing cigarette smoking and each is equally effective in this regard.” (My emphasis.)

That study sounded familiar. Why? Oh, because I’d posted about it before. When I looked into the full text of it that time, I found that the behavior modification intervention was a series of five group meetings over a three-week period taking 45-90 minutes each, the health education intervention was a lecture to a small group followed up one week later by a personal one-on-one interview including counselling, but the hypnotherapy intervention was a single 30-minute one-on-one session including instruction in self-hypnosis, an eye-roll induction, suggestions “that smoking is dangerous and that the individual must give up smoking”, and a post-hypnotic suggestion to self-hypnotize every hour and a half for a week and whenever necessary thereafter and repeat the suggestions three times. I suspect that this was the Spiegel method mentioned earlier in the review: “the most frequently used approaches are variants of the ‘one session, three point’ method developed by Spiegel… During the session the smoker is instructed that a) smoking is a poison, b) the body is entitled to protection from smoke, and c) there are advantages to life as a nonsmoker (Spiegel 1964). This approach also includes training in self hypnosis which may be as important as hypnosis by a therapist (Katz 1980). Self hypnosis can be used at will by the patient. Compliance may be higher and costs lower because only one session is required. In uncontrolled studies six-month abstinence rates using this method are reported to vary between 20 and 35%.”

Which is remarkable, really, because here we have a method developed in 1964 – hardly state-of-the art 44 years later, or even 20 years later when the Rabkin study was done – which takes just half an hour to tell smokers what they probably already believe and “train” them in self-hypnosis. I’m astonished that it has very much effectiveness at all; I’d consider that I was insulting my clients if that was all I did. Yet that one half-hour session was as effective as much longer interventions giving a lot more time and attention.

Wait on, didn’t the Smoking Cessation Guidelines say “There is evidence that hypnosis does not improve long-term abstinence rates over any intervention providing the same amount of time and attention to the participant” (my emphasis)? So which part of the footnoted review could they have been referring to?

Well, it wasn’t the comparison to the waitlist-controlled studies, clearly, or to rapid smoking or group therapy. It wasn’t Barkley (1977) or Williams (1988), two small studies which showed improved odds of quitting with hypnotherapy. It must have been Rabkin (1984) or Hyman (1986). But Rabkin doesn’t compare interventions where the same amount of time was spent – this isn’t clear from the Cochrane review, but is clear if you read the Rabkin study itself. So it must be just one study, Hyman, that they’re referencing, out of the nine in the review.

Hyman (1986) does compare hypnotherapy with an attention placebo, and finds no significant difference. His group used a four-session variation on the Spiegel method, with the same (in my view, not especially effective) suggestions. There were a total of only 60 participants, 15 assigned to each of four conditions (hypnotherapy; attention placebo; focussed smoking; waitlist control), so this is quite a small study.

So the statement in the smoking cessation guidelines, “There is evidence that hypnosis does not improve long-term abstinence rates over any intervention providing the same amount of time and attention to the participant,” is strictly true – there is one small study, over 20 years old, using very basic hypnotic methods, which does show that. However, in the same survey which the guidelines footnote, Rabkin found a single short session of hypnotherapy to be equally as effective as much more time spent in other interventions, and his group had more than twice as many participants as Hyman, so the statement is at best misleading.

There’s also the study from this year which I mentioned the other week, Hypnosis for Smoking Cessation: A Randomized Trial (Carmody et al, 2008), which set out “to determine whether hypnosis would be more effective in helping smokers quit than standard behavioral counseling when both interventions are combined with nicotine patches”. They had more than twice as many participants as Rabkin and four times as many as Hyman, 286 versus Rabkin’s 140 (followed up) and Hyman’s fewer than 60 (with dropouts). The study was a randomized controlled trial, and the outcomes were biochemically verified. At six months, the period used by the Cochrane Database study as its basis, the hypnotherapy group were verified to be 26% abstinent from smoking versus 18% for the behavioural group. Both figures declined slightly at the 12-month mark, but hypnotherapy was still ahead 20% to 16%. (Unfortunately, the Journal of Nicotine and Tobacco Research don’t make electronic copies of their articles available until 12 months after publication, and if I want to buy reprints I have to spend $450 USD and buy 100 of them, so I haven’t been able to read beyond the abstract. But it’s an informative abstract.)

So, regardless of what the Smoking Cessation Guidelines claim, I do not agree that there is “evidence of no effectiveness” or even no evidence of effectiveness for hypnotherapy, and I’ll continue to give it to my clients alongside nicotine replacement therapy.

Here are the studies from the Cochrane Database, for your further research:

• Barkley R.A., Hastings J.E., Jackson T.L. The effects of rapid smoking and hypnosis in the treatment of smoking behaviour. International Journal of Clinical and Experimental Hypnosis 1977; 25:7-17. [MEDLINE: 1977093064].
• Fee W. Searching for the simple answer to cure the smoking habit. Health and Social Services Journal 1977;87:292-3.
• Hyman G.J., Stanley R.O., Burrows G.D., Horne D.J. Treatment effectiveness of hypnosis and behaviour therapy in smoking cessation: a methodological refinement. Addictive Behaviors 1986;11:355-65. [MEDLINE: 1987123818].
• Lambe R., Osier C., Franks P. A randomised controlled trial of hypnotherapy for smoking cessation. Journal of Family Practice 1986;22:61-5. [MEDLINE: 1986087812].
• Pederson L.L., Scrimgeour W.G., Lefcoe N.M. Comparison of hypnosis plus counseling, counseling alone and hypnosis alone in a community service smoking withdrawal program. Journal of Consulting and Clinical Psychology 1975;43:920. [MEDLINE: 1976069866].
• Pederson L.L., Scrimgeour W.G., Lefcoe N.M. Variables of hypnosis which are related to success in a smoking withdrawal program. International Journal of Clinical and Experimental Hypnosis 1979;27:14-20. [MEDLINE: 1980158956].
• Pederson L.L., Scrimgeour W.G., Lefcoe N.M. Incorporation of rapid smoking in a community service smoking withdrawal program. International Journal of Addiction 1980;15:615-29. [MEDLINE: 1981025644].
• Kaufert J.M., Rabkin S.W., Syrotuik J., Boyko E., Shane F. Health beliefs as predictors of success of alternate modalities of smoking cessation: results of a controlled trial. Journal of Behavioral Medicine 1986;9:475-89. [MEDLINE: 1987086750].
• Rabkin S.W., Boyko E., Shane F., Kaufert J. A randomised trial comparing smoking cessation programs utilising behaviour modification, health education or hypnosis. Addictive Behaviors 1984;9:157-73. [MEDLINE: 1984253195].
• Williams J.M., Hall D.W. Use of single session hypnosis for smoking cessation. Addictive Behaviors 1988;9:205-8. [MEDLINE: 1988220111].

Spiegel’s article is: Spiegel H. A single treatment method to stop smoking using ancillary self-hypnosis. International Journal of Clinical and Experimental Hypnosis 1964;12:230-8.

(And here’s my free ebook, How to Stop Smoking.)

Technorati Tags: nicotine, tobacco, smoking, cessation, quitting, hypnosis, hypnotherapy, therapy, randomized controlled trial, scientific study, evidence, critical thinking

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