Stopping Smoking – A Review of Methods

As a preliminary follow-up to my previous article, I thought it would be useful to review some of the existing smoking cessation approaches from the point of view of someone who has worked extensively with smokers. I’m going to touch upon NRT (nicotine replacement therapy), group counselling, hypnotherapy, and acupuncture. There are others out there, of course.

NRT – Nicotine Replacement Therapy

When I was still myself a smoker, NRT was just emerging and beginning to obtain the acceptance it has now. The idea behind it is a simple one: people get addicted to nicotine rather than to smoking, so let’s give them an alternative source of the nicotine and wean them off it. It’s assumed that gradually reducing nicotine intake will be accompanied by a lessening dependence upon it, which assumes in turn that a dependence upon nicotine was present in the first place. When NRT first came onto the scene, the second of these assumptions had some decent evidence behind it – it was established that nicotine was psychoactive, although only since the advent of superior brain scanners of different kinds have we understood some aspects of how nicotine acts in the brain and body. The first assumption remains just that, an assumption, a hope to cling to.

In the United Kingdom, advertising for NRT claims, correctly, that it more than doubles your success at quitting. I’m afraid that doesn’t say very much. The most favourable peer-reviewed NRT research I’ve been able to find is this from the British Medical Journal – the researchers chose a laudably long reference period, giving follow-up results after six years. The study was concerned with comparing success rates between a group of smokers using nicotine patches only and a group using both patches and nicotine inhalators:

After 6 years, 1 out of 6 participants was still abstinent in the treatment group compared with 1 out of 12 in the patch only group.

I’m assuming that people looking to stop smoking are interested in stopping for more than six years. In these circumstances, the figures are deeply depressing. More depressing still is that the figures obtained by this study are actually higher than those obtained by practically every other (and there are hundreds of properly run studies of this kind going on all the time – try Cochrane Tobacco Addiction Group Specialized Register and the databases MEDLINE, EMBASE, AMED, SCI, SSCI and CISCOM for starters).

And more depressing still is that no one seems to notice how terrible these figures actually are. Given that nicotine is a dangerous substance in its own right, over and above any tendency to create dependence, given NRT’s proneness to side-effects, and given the sheer demand from smokers for effective cessation methods, I would have hoped to come across at least one researcher’s comment expressing regret at the enormous failure rates experienced by NRT patients.

My hunch is that NRT is driven largely by people who have themselves never smoked and who are therefore looking from the outside in. There’s long been a desperate desire for “drugs to fight drug addiction”, especially given that psychotherapy has, by and large, failed to provide any breakthroughs.

I reflect on one thing. I must have spoken to thousands of people who have succeeded in stopping smoking, the majority of them with no assistance whatsoever from an outside source. In every case, I was the first person with a serious professional interest in their success to have asked. I’d like to see a series of studies that interview, in-depth, 10,000+ successfully stopped smokers to see if the same patterns emerge as emerged for me when I undertook my own, more limited and subjective, interview research.

Group Counselling

NHS Smoking Cessation services keep reasonably good statistics, albeit in the short term. Here is a summary of the state of play as of mid-2001. 48% of participants were still abstinent after four weeks. The same document assumes that only 60-65% of that 48% will relapse by the end of the year, without giving any grounds for that assumption. If that were true, NHS clinics would be managing a success rate of one-third, which would be headline news if true – that’s the sort of figure we can start to get to work with, after all. But the true story is almost certainly sadder and darker.

Eugene Mill’s BMJ paper looked at Tyne and Wear. He says:

In 2003-4, 20 103 people in the region used smoking cessation services, of whom 9910 had still quit after four weeks (49.3%). Of these, I estimated 35-40% would still have quit after a year,2 a long term figure of 3500-4000.

Again, there are no reasons given for that estimate, and I think it’s too high. One reason is the sheer scale of drop-out from these services, as seen in the Scottish experience.

Of the 46,466 quit attempts made between 1st January and 31
st December 2006, there were 45,641 for which one month follow-up
data was available. Of these, 15,471 were recorded as successful
quits. This figure is based on client self-reported ‘not smoked, even a
puff, in the last two weeks’. Follow-up may have been undertaken ‘face to
face’, by telephone or by letter/written questionnaire. Of the remaining
30,170 cases, 15,384 had smoked in the last two weeks and
14,786 were ‘lost to follow-up’/unknown.

Information on exactly what kind of support is given in NHS clinics is relatively hard to come by, not for any sinister reason but because practice varies from place to place, there are pilot schemes to take account of and so forth.

Nevertheless, these are still depressing figures.

Whenever NHS attempts to improve matters in these areas are concerned, funding is always an issue – one quarter of the British population smoke, of whom a substantial number not only want to stop but actively try. There are not enough NHS clinics around to dent the numbers, and if I find the figures depressing, I hope that’s not taken as criticism of the people working in that system and doing their best to achieve the impossible with the minimum.

Hypnotherapy

As a qualified hypnotherapist, let me give a word of warning. Two, in fact. If you are thinking about “trying” hypnotherapy, here is what to avoid.

Avoid any therapist who cites, without source, studies “indicating” that their “new methods” are achieving a 95% success rate. Where they exist, and quite often they don’t, these “studies” are not what I mean by study i.e. properly conducted, peer-reviewed research. One hypnotherapist I know contacts 100 or so of his smoking clients after a year and takes his success rate from that – which strikes me as a reasonable approach in the circumstances. Most won’t.

Avoid anyone claiming that a “new combination of NLP and hypnosis/hypnotherapy” is bringing home the goods. NLP is a marrying of some ideas from CBT and hypnosis, so the statement is tautologous and merely displays that the advertiser is ignorant of their own field.

There is an almost complete lack of smoking cessation studies in relation to hypnosis. In fact, there is an almost complete lack of any studies whatsoever outside of NRT and behavioural therapy (whether individually or in groups). This is a consequence of the lack of a standard hypnotherapy procedure for smoking cessation, the lack of a single governing body for the field, and the sheer difficulty of excluding certain variables from study. It’s also the result of contemporary hypnotherapy’s deliberate positioning of itself outside the medical mainstream, for all that the BMA has accepted it as a valid approach since the 1950s and the existence of the British Society of Clinical and Academic Hypnosis.

At root, hypnotherapy’s approach to smoking cessation is entirely psychological, and there are two principal approaches. On the one hand, some practitioners will attempt to take and magnify your anti-smoking feelings and magnify them to the point where the iidea of smoking is too disgusting to contemplate. On the other, some practitioners will attempt to replace your smoking habits and the benefits you gain from smoking with more helpful habits and feelings – to replace the psychological experience of smoking with a superior experience or set of experiences.

Few studies, and not a lot worth reading. There’s this, from the New Scientist in 1992, which cites a metaanalysis undertaken on behalf of ASH (which I can’t find a confirmatory source for – I’d like to know how they overcame the heterogeneity of existing studies that other attempted analyses complain about) and also this more general article from Scientific American, but it’s not much to lean on.

My gut feeling from my own practice is that I achieved between 40% and 60% success rates over 12 months. I receive the occasional email from people years on who are still smoke-free. But I suspect that a significant number of my former clients who did go back to smoking simply didn’t blame me or the therapy for it.

You’ll excuse me if I leave the placebo effect out of it for now. We are going to know what that is, in measurable terms, in the not too distant future, and I’ll discuss it then. It’s no more than a phrase describing something we don’t understand for now.

Acupuncture

Again, practices vary: the word of mouth accounts I’ve had are black and white, either instantly and effortlessly successful or not at all.

The impression I gain is that it works better for the type As amongst us.

I suspect that the Cochrane Review Summary here – which complains about the paucity of studies – has it about right.

Allen Carr’s Easyway

I’d say worth a try, because the Allen Carr Clinic approach is both an actual process you can go through, but it respects your intellgence and invites your dissent and argument. That makes it highly unusual in the therapy field to put it mildly.

No other approach has created quite the wave of enthusiasm, yet there are no proper studies to add to it. That’s a shame; I’d be fascinated to see them.

The core idea, for what it’s worth, is that nicotine sets up a chain reaction – the relief afforded you by a cigarette is not genuine relief but merely temporary respite from the symptoms of nicotine withdrawal. A host of psychological consequences follow. Frankly, the outcome thus far of research in brain scanners bears Allen Carr out more than it bears out the wean-them-off ideas of the NRT adherents, but there are problems involving the relationship between the interval between cigarettes and the active life of nicotine in the brain. Nevertheless, it’s an idea worth pursuing further than it has been.

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9 responses to “Stopping Smoking – A Review of Methods

  1. Has anyone tried moving cigarette smokers onto pipe smoking? I understand that it’s far less dangerous and it’s certainly (in my view) far less objectionable to others.

  2. Hi James. For a humble GP with an interest in smoking these 2 posts have been great. Your reference to hypnotism though immediately reminded me of this: http://www.youtube.com/watch?v=w2UqhVEAPOs

    Cheers

  3. @Tony: yes; I can’t disagree. I understand that the long-mooted state regulation of hypnotherapy has been put off yet again, which means many more years of this kind of thing.

    @Bill: I began smoking with a pipe, which I’ll enlarge upon. Essentially, a move from cigarettes to pipes would be a large-scale lifesave and would have many side benefits beside. But it won’t be possible. Once someone is accustomed to the two-stage inhalation style of cigarettes, it’s virtually impossible to take the step back into the gentler, mouth-only inhalation style of pipesmokers.

    So long as the pipe is filtered, I’d positively recommend pipesmoking as something liable to improve the lives of those who do it. It did mine; but I was a pipeman in my early twenties, and grew tired of so much ignorant/malignant staring.

  4. From todays’ FT:_
    “There is, however, one country that’s doing better. This is Sweden, where only 13 per cent of males were daily smokers in 2005. The reason is that many Swedish men get their nicotine fix not from cigarettes but from a Scandinavian product called snus (rhymes with loose), a moist tobacco contained in a small sachet that is placed under the top lip. Because snus does not cause spitting, it is cleaner and more socially acceptable than traditional chewing tobacco.

    The point about snus is that, although controversial even in Sweden, it appears to be much safer to use than cigarettes. Nicotine, after all, may be powerfully addictive, but it is not particularly harmful; it is the smoke produced when tobacco is burned that carries the carcinogens. Because the Swedes have found a way of getting their nicotine without the smoke, they have the lowest lung cancer rate in Europe. Unlike smoking, snus also appears to carry little or no risk of mouth cancer.”

    Just one prob: it’s banned throughout the EU, save for an exemption for Sweden.

  5. “You’ll excuse me if I leave the placebo effect out of it for now. We are going to know what that is, in measurable terms, in the not too distant future”

    This is interesting, James. Are you referring to the placebo effect wrt smoking cessation or the placebo effect in general? Could you – perhaps in a follow-up post – tell us about progress in quantifying the placebo effect? This looks, to a pleb, like a real advance.

  6. @dave heasman: I’m referring to the placebo effect in general. Essentially, once the (largely philosophical) work on human consciousness and our growing ability to monitor and measure brain activity meet in the middle, that’ll be the job done. Placebo is a self-generated response to a stimulus that is believed to be relevant but (chemically etc.) actually isn’t; that response will take place chemically and electrically within the brain and body and can therefore be observed and measured. The interpretation of those observations and measurements will combine other relevant, similar measured results and our concurrent thinking on consciousness (in my opinon). Give it 20-30 years. I’ll try to come up with something on it when opportunity presents.

  7. There was somethin in the paper the other day about testing acupuncture for something or other – it worked a treat, but it was almost entirely a placebo effect.

  8. Great article, nice to see some commonsense written about hypnotherapy and smoking cessation.

    Dave Sabat DCH DHP

    Clinical Hypnotherapy

    Stop Smoking Hypnotherapy

  9. I’ve visited your website thrice so far. Nice blog! Great job done!!