Stop Smoking With Hypnotherapy Training Day Ursula James Mark Feldman.

Stop Smoking With Hypnotherapy Training Day

Ursula James

Mark Feldman

Who are we?

Ursula James

• Vice principal London college of clinical hypnosis

• Vice president British society of clinical hypnosis

• Executive member of the British association of

medical hypnosis.

Ursula James

• Lecturing – LCCH– Oxford University medical students

• Research– Pain control– Dermatology– Heart function

Ursula James

• Expert systems– For hypnotherapy in smoking cessation

Mark Feldman

• Senior partner general practice

• Trainer in general practice

– Regional GP selection

– Allocation

Mark Feldman

• Petersfield Screening

– Health Screening

– Occupational health

– Private General practice

• Stress lecturing

– IPD

– Corporate clients

Mark Feldman

• Hypnotherapy

– BAMH

– Research

– Practice

Who are You?

• Already experts– Experienced hypnotherapists

– Own methadologies

• Special group– Todays presentation specifically for this

audience

Aims of the Day

Become a Superhero

Aims and Objectives

• Find out about– Stop smoking clinics– Role of Sure-start

• Understand– Which diseases are due to smoking– Scale of problem– Advantages of Stopping– Theories of addiction

Aims and Objectives

• Discover

– How hypnotherapy fits in to EBM

– Details of the LCCH study

Aims and Objectives

• Appreciate

– Importance of

• consistent approach

• reproducibility for research

– Acquire

• A technique which you can ‘ buy in to’

Aims and Objectives

• Learn

– formulaic ‘Expert system’ smoking session

which will become a research protocol/NHS

standard

Aims and Objectives

• Long term aims

– Of initial project:

• To help those in Sure-start project, who wish to use

this facility, to stop smoking

• To produce sufficient initial data on replicability

and efficiency of protocol to obtain funding for area

then nationwide project

Aims and Objectives

• Long Term Aims

– To produce an ‘Expert system’ in the use of

clinical hypnosis as effective in smoking

cessation in one session’

– To obtain NHS approved status for this method

Aims and Objectives

• Long Term Possibilities for You

– To be involved in the research phase – with

payment from NHS funds

– To become the first practitioners to have this

NHS approved status

– To become lecturers on the programme

Stop smoking clinics

• Tobacco Advisory Board of the Royal College of

Physicians

‘nicotine delivered through tobacco smoke should be

regarded as an addictive drug and tobacco use as

the means of nicotine self administration’


• Launched in health action zones in 1999

• Cost £60 m over 3 yrs

• Between April 2000 and March 2001

– 127000 smokers set a quit date

– 48% stop at one month


• Estimate

– £ 600 per life year gain for smokers 35-44

– £750 per life year gain for smokers 45 –54

• Compare this with statins for cholesterol

– £13000 per life year gained

• NICE – says < £30,000 per life year is ok for new

treatments


• Local Clinics

– 2 tiered approach

• Group clinics

• One to one sessions through community pharmacists

– Validated by carbon monoxide monitor


• Local Clinics

– Patients screened

– Offered either

• Nicotine

• Zyban


• Local Clinics

– Costs £114 000 per yr

– 3 full time staff

– Consumables / CO monitor

– Training

– Pharmacists time


• Local Clinics

– From April 2001 – March 2002

• 836 set quit date

• 441 ( 51%) successful at 4 weeks from quit date

• 30% stop at 12 weeks

• Expected 20% at 52 weeks

Sure Start

• New government initiative

– To break the cycle of disadvantage for current

generation of young children

• 10 yr programme

• £3m budget for 3 yrs

Sure Start

• Brings together

– Parents, professionals, community groups

• Focuses on

– Parents, pregnant and children < 4 yrs

• Works with

– Specific postcode areas – patients either ‘in’ or ‘out’

Sure Start Objectives

• Improving social development

– Reducing the number of kids < 3 yr on at risk register

by 20%

• Improving health

– Supporting parents in caring for their children

• Target 10% reduction of mothers who smoke whilst

pregnant by 2004

Sure Start Objectives

• Improving ability to learn

– Better play areas

– More libraries for parents

• Strengthening communities and families

– Links with job centres

– Accessible childcare for 0-3 yr olds

Smoking Stats

• Introduced from New World in 15th Century

• Only a mass habit after 2nd world war

• 13 million adults in UK smoke

– 29% men

– 25% women

• In 1974 about 50% of adults smoked

Smoking Stats

• Varying rates throughout country

– 30% Scotland

– 26% East Anglia

• Highest amongst age 20-34

– 35% men

• In the over 60’s

– Only 16% smoke

Smoking Stats

• Highest amongst working class

– 39% men social class 4/5 vs 15% men class 1

• 80% start as teenagers

• 450 Children start every day

Smoking Stats

• Smoking kills 120 000 per year in UK

• That’s 6x more than – the below all together

• RTA 3391

• Accidents 8933

• Poisoning and OD 3157

• Murder 0495

• HIV 0180

• Suicide 4485

Smoking Stats

• Half of all smokers are killed by smoking

• Smoking causes– 30% of all cancer deaths [ 80 % of all lung

cancer]– 17% of all heart disease– 80% of all COAD

Smoking and Cancer

• What is Cancer?

– Normal contact inhibition

– Abnormal proliferation

The definitive study

• Doll and Peto – British Doctors Study 1947-49 – Established link between smoking and lung

cancer– Resulted in most UK doctors stopping almost

overnight– Initially thought 1:4 would die due to smoking– Follow up 40 yrs later 1:2.5

Smoking and Cancer

• Result– Local pressure / destruction

• Nerves

• Bone

• Blood vessels

• Organs

• Bronchial tree

Smoking and Cancer

• Result– Lymph node spread

• Eg Breast to axilla

– Metastatic spread - typically• To bone from

– Breast, Bronchus, Kidney , Thyroid , Prostate

• To Liver from– Colon, Stomach

• To brain from– Lung

Smoking and Cancer

• Result

– Cachexia

– Hormonal effects

• Inappropriate ADH

• Calcitonin – raised calcium – bones, moans,abdominal groans

• Neuropathy

• Acanthosis Nigrans

• ACTH

Smoking and Cancer

• Lung cancer

– 90% of all deaths are due to smoking

– About 30 000 in UK per year due to smoking

– Only 5% will survive 5 yrs

Smoking and Cancer

• Lung cancer

Smoking and Cancer

• Other cancers

– Oesophagus

• 60% of all due to smoking

• 4500 per yr

– Bladder

• 35% of all due to smoking

• 2000 per yr

Smoking and Cancer

• Other cancers

– Throat and mouth

• 60% due to smoking

• 2000 per yr

– Kidney

• 30% due to smoking

• 800 per yr

Smoking and Cancer

• Other cancers

– Stomach 30% from smoking – 2000/yr

– Pancreas 23% from smoking –1500/yr

– Leukaemia 15% from smoking- 300 /yr

Cancer Survival

Ischaemic heart disease

• Smoking

– 17% of all heart disease deaths – 26000 /yr

– If smoke 25 per day 15 x more likely to die

– Women who smoke 1-4 / day 2.5x more likely


• What is it ?

– Angina - chest pain on exertion due to

narrowing of coronary arteries

– Myocardial infarction - death of a part of heart

muscle


• What is it ?


• What is it ?


• Caused by

– Raised cholesterol

• Diet

• Weight

• Family history

– Raised Blood pressure

– Smoking


• Smoking

– Raises the BP and pulse, makes the heart work harder

– Coronary artery spasm

– Encourages atherosclerosis

– Increases platelet stickiness

– Reduces lung function

– Carboxyhaemaglobin

Other vascular diseases

• Stroke

– 11% of stroke deaths due to smoking

– Relative risk about 1.5 vs non smokers

– If smoke 20 per day 4x risk vs non smokers


• Ruptured aortic aneurism


• Peripheral vascular disease 15 x more

common

• Buergers disease – only in smokers

Smoking and Lung Disease

• Asthma

• COPD – 27 000 deaths at least 80% due to

smoking

– Continued decline in lung function

• Pneumonia 9000 deaths last year

Smoking and reproduction

• Reduced female fertility

– Only 72% that of non smokers

• Increase pill risk

– 10 yrs older

• Pregnancy

– 23% smoke – govt target reduce to 15%


• Light babies– on average 8 oz lighter

• Spontaneous abortion

• Premature detachment of placenta

• Ectopic pregnancy increased

• Increased perinatal mortality– 420 per year England and Wales


• Less milk production

• Lower IQ of children

• Menopause 2 yrs earlier


• Reduced sperm counts

– Less Y sperm due to toxins

• Impotence

– 50% increase in smokers 120 000 men affected

Other Illnesses

• GIT– DU– Colon polyps

• Eyes– Cataract– Optic neuritis– Macular degeneration– Tobacco amblyobia

Other Illnesses

• Worsening of– Diabetes

• Retinopathy• Arterial problems

– Asthma– MS

• Infections– Cold– Flu– TB

Other Illnesses

• How you look

– Tooth loss

– 2x incidence wrinkles

– Psoriasis worse

– Bad breath

Passive Smoking

• Passive smoking

– Causes 600 deaths from lung cancer each year

– Causes 12 000 deaths from heart disease each

year

Passive Smoking in children

• Passive smoking

– Exacerbation of asthma

– Increase frequency of Cot death

– Children have 72% increase risk of respiratory

problems if both parents smoke

Passive Smoking in children

• Passive smoking

– Increase risk of otitis media

– 17000 children < 5 yrs admitted each year

– May affect mental development

Stopping Smoking

• Heart attack risk - after 5 years risk

approaches that of non smoker

• Halves chance of recurrence

• Stroke risk same as non smokers after 5 yrs

Theories of smoking behaviour

• Peer group

• Drive for separateness

• Role Models

• Mind alteration– Studies show effects on smokers brains

equivalent to antidepressants– Withdrawal symptoms

Theories of smoking behaviour

• Weight loss

• Depression

• Low self esteem

• Poor relationships– School– Parents

Neurology of smoking

• Nicotine causes a rise of dopamine in the brain [ due to depressing MAO-a]

• This leads to addictive behaviour in an attempt to continually reproduce this effect

• A feeling of high dopamine gives a ‘ high’ cocaine has a very similar effect

Neurology of Smoking

• Normal PET • High dopamine after nicotine

Neurology of smoking

Contents of cigarettes

• Nicotine– Raises BP, Pulse, – Causes vasocontriction– 60 mg will kill you

• Acetone– Used in nail polish remover


• Ammonia– Used in fertilisers and cleaning fluids– Increases addictive properties– Lung irritant– Stomach irritant

• Benzene– Aromatic solvent– Causes cancer cf leukaemia


• Cadmium

– Used in batteries

– Liver Kidney and Brain damage

• Carbon Monoxide

– Often associated with deaths from faulty boilers

– Carboxyhaemaglobin


• Formaldehyde

– Powerful antiseptic preservative

– Causes allergies

– Gut problems

• Hydrogen cyanide

– Headaches dizziness vomiting


• Lead

– Heavy metal –

– Damages brain, nervous system, kidneys

– Red blood cells

– Reduces IQ in children


• Tar

– Paralyses cilia

– Stains teeth, fingers

• Shellac

– From insect cocoons

– Used in wood varnish

Bupropion studies

• 615 smokers – randomised to drug 100mg,

150mg, 300mg or placebo for 7 weeks

• Try to stop at one week

Bupropion studies

• For 300 mg - at 7 weeks[course end]– 10.5% stop with placebo – 24.4% stop with drug

• At one year point prevalence [ no smoking for last week]– 12.4% placebo– 23.1% drug

Bupropion studies

• 893 smokers one of 4 treatments for 9 weeks – 12 month point prevalence

– Placebo oral + placebo patch 15.6%

– Bupropion 300mg + placebo patch 30.3%

– Nicotine patch + oral placebo 16.4%

– Bupropion 300mg + nicotine patch 35.5%

Bupropion studies

• Continuous absence rates =– Bupropion alone 18.4%– Bupropion +patch 22.5%

• Cost– £86 + counselling – 5 sessions

Bupropion studies

• Problems with Bupropion

– 11% dry mouth

– 42% insomnia

– 6% hypertension { if given with patch}

– 1:1000 - fitting

Bupropion studies

• Contraindications– Epilepsy– Pregnancy– History of fits– History of head injury– Diabetes on drugs or insulin– Patients on

• Theophylline Systemic steroids• Antipsychotics• Antidepressants

Hypnotherapy Studies

• Hypnotherapy

– Safe

– Specific

• Difficult to generalise

• Few published single session studies


• 226 Smokers [ Spiegel Frishholz Spiegel]

– Single session treatment

– 2 year follow up

• 53% stop at one week

• 23% stop at two years


• 40 patients [Berkowitz Townsend Kohberger]

– Single session

• 25% stop at 6/12


• 2810 patients 1997 [ Ahijevych K, Ohio]

– Single session group hypnotherapy

• 22% not smoking one month prior to interview

– Telephone interview at 5-15 months


• But

– Cochrane review – inadequate data to support

hypnotherapy

– International Journal Clinical and Experimental

Hypnosis [ 2000] – 59 studies insufficient evidence

to support hypnotherapy for smoking


• LCCH method

• Single sessions

• Easily learned

• No side effects

• Does it work ??


• LCCH study

– Single hypnotherapist

– LCCH method

• One hour session only

– Follow up one month to one year

– Postal Questionnaire

Stop Smoking With Hypnosis Study Dear Sir or Madam:

You recently had hypnotherapy to help stop you smoking. We are conducting a study to assess the effectiveness of this treatment. We would be very grateful if you would be willing to spend a few minutes to complete this questionnaire and return it in the stamped addressed envelope enclosed. Date of Hypnotherapy Name of Hypnotherapist

Before Hypnotherapy How long had you been smoking ? Years

How many did you smoke a day?

After Hypnotherapy Stopped Cut

down Continued unchanged Did you Stop smoking

completely ,cut down or continue smoking the same number [ tick one only ]

Less than 1 month

1-3 months

4-6 months 1 year I have not restarted

If You stopped completely please indicate how long you stopped for by ticking the relevant box

So far I have stopped for

months

Number Smoked per day Less than 1 month after treatment

1-3 months

4-6 months 1 year If you cut down please write the number of cigarettes you have been smoking in each of the periods after hypnotherapy

Did you use any additional treatment such as nicotine patches, or chewing gum at the time of hypnotherapy

Yes No

If yes please describe

P E T E R S F I E L D S C R E E N I N G M F / j e t / 6 9 9 7

M r J o e L u c k i n g 4 A l l e n C l o s e M i t c h a m S u r r e y C R 4 1 T L 3 r d O c t o b e r 2 0 0 0 D e a r M r L u c k i n g P l e a s e f i n d j u s t o n e m i n u t e t o c o m p l e t e t h e e n c l o s e d q u e s t i o n n a i r e . I t i s e q u a l l y i m p o r t a n t t h a t y o u r e p l y w h e t h e r y o u r h y p n o t h e r a p y w a s s u c c e s s f u l o r n o t . T h e r e h a s b e e n v e r y l i t t l e s c i e n t i f i c r e s e a r c h o n h y p n o t h e r a p y a n d t h i s s t u d y m a y h a v e i m p o r t a n t i m p l i c a t i o n s f o r n a t i o n a l p u b l i c h e a l t h s p e n d i n g . T h a n k y o u v e r y m u c h f o r y o u r t i m e . Y o u r s s i n c e r e l y D r M a r k F e l d m a n M B B S M R C G P ( D i s t ) D F F P D o c c M e d M D C H

P E T E R S F I E L D S C R E E N I N G M F / j e t / 6 9 9 7

M r J o e L u c k i n g 4 A l l e n C l o s e M i t c h a m S u r r e y C R 4 1 T L 1 s t N o v e m b e r 2 0 0 0 D e a r M r L u c k i n g P l e a s e f i n d j u s t o n e m i n u t e t o c o m p l e t e t h e e n c l o s e d q u e s t i o n n a i r e . I t i s e q u a l l y i m p o r t a n t t h a t y o u r e p l y w h e t h e r y o u r h y p n o t h e r a p y w a s s u c c e s s f u l o r n o t . T h e r e h a s b e e n v e r y l i t t l e s c i e n t i f i c r e s e a r c h o n h y p n o t h e r a p y a n d t h i s s t u d y m a y h a v e i m p o r t a n t i m p l i c a t i o n s f o r n a t i o n a l p u b l i c h e a l t h s p e n d i n g . T h a n k y o u v e r y m u c h f o r y o u r t i m e . Y o u r s s i n c e r e l y D r M a r k F e l d m a n M B B S M R C G P ( D i s t ) D F F P D o c c M e d M D C H

LCCH Study Results

• 59 questionnaires sent { follow up 1/12 to 1 yr }

– 35 Returned 59.3%

• Of those returned

– 30 stopped 85%

– 1 cut down 2.8%

– 4 continued unchanged 11..4%

• At one month

– 23 stay stopped 65.7% [ 38% if presume all lost to follow up

continue ]

LCCH Study Results

• Results beyond this unsatisfactory due to lack of follow up

• BUT no known restarters after 6 months– Restarters

• 3 at less than one month• 4 at 1-3/12• 2 at 4-6/12

– We have a definite 12 stopped at one year { 34% } but as data is incomplete [ Could not be worse than 20% even if all incomplete data showed restarts – some incomplete due to short duration since study started]

• Could presume 21 stopped at one year which would be 60% stop at one year

LCCH Study Results

• Hypnosis Retrosepective Study ResutlsS=Stop C=cut down R=restarted I= incomplete data U = Unchanged NRT=Nicotine Replacement Therapy

Numbers Sent = 59

Number Returned Study Number Sex Yrs smoked Cigs/day Initial Result <1/12 1-3/12 4-6/12 1 yr data in months Additional aidsNotes

1 36 F 16 20 S S S S S 20 N2 41 M 23 45 S S S S S 18 N3 44 F 20 20 S S S S S 15 N4 27 F 7 20 S S S S S 16 N5 31 F 11 20 S S S S S 14 N6 30 F 5 15 S S S S S 14 N7 17 F 30 35 S S S S S 17 N8 2 F 13 30 S S S S S 20 N Restarted at 20 months9 49 F 10 30 S S S S S 21 N

10 32 F 20 25 S S S S S 20 N11 42 M 31 40 S S S S S 14 N12 16 F 20 30 S S S S S 15 N Restarted at 15 months after drinking with smoking friend. Had furthur hypnotherapy - unsuccessful13 11 F 30 10 S S S S I 9 N14 34 M 10 12 S S S S I 8 N15 33 F 7 15 S S S S I 7 N16 3 F 15 25 S S S S I 7 N17 28 F 12 20 S S S I I 7 N18 52 F 40 45 S S S I I 4 N19 14 F 1 7 S S S I I 3 N20 40 F 30 25 S S S I I 3 N21 50 F 33 30 S S S I I 2 N22 6 M 13 20 S S R R R NRT gum, Restarted at < 1/1223 13 F 14 22 S S R R R NRT gum, Restarted at < 1/1224 5 M 20 20 S S R R R Now stopped with zyban25 57 M 20 20 S S R R R 3 N26 58 F 15 20 S S S R S 7 N Restarted at 4-6/12 then had furthur session and is now stopped27 19 F 16 10 S S S R R NRT gum, Restarted at < 1-3/1228 35 M 16 15 S RC RC I I 6 N Stopped for one month then restarted at lower rate of 5 per day29 46 F 20 12 S RC RC I I 6 N Stopped for one month then restarted at lower rate o f4per day30 55 F 24 15 C C U I I 2 N Cut down for < 1/12 then back to normal amount31 10 M 26 30 U U U U U N32 24 F 30 20 U U U U I 6 N 3 sessions33 53 F 16 20 U U U I I 3 I34 45 M 27 7 S RC R I I 4 N Stopped for 2 days35 29 F 38 20 U U U I I 4

Summary of results59 sent35 back = 59.32 percent

29 stop = 82.86 percent

LCCH Study

• Recently accepted for publication in

– European Journal of General Practice

The Expert System

• Criteria

– Formulaic process

– Fixed selection criteria

– Trackable decisions

The Expert System - method

• Fixed selection criteria

– Three induction types only

– Universal contents to be applied to all patients

– Unique contents to be applied dependent on

patient responses

The Expert System-method

• Trackable decisions

– Each unique selection to be made on the

response of patient to specific questions

– Session to be written up in ‘tick box’ formula

so decisions can be logged at each stage


• Introduction session : Questions – Type one question:Identify

• Behaviours

• Moods

• Situations

– Purpose • To tailor script suggestions


– Type two question: Identify• Modality of relaxation

• Modality of recall

– Purpose• Ensure rapid trance

• Tailor feedback modality in trance


– Type three question: Identify

• Relapse traps

– Purpose

• To stop patient tricking themselves back into

smoking


• Introduction statements– Binds and double binds– Purpose

• To prevent patient from having to ask questions which might lead into justification statements for holding onto their habits


• Why hypnotherapy will work for them– Willpower– Character– Nicotine

• Model 3 days

– Habits• Model 3 weeks - psychocybernetics


• Replacements– Selection criteria

• Behaviours

• Habits

• Moods

• Chemical changes

• Situations

• External triggers


3 induction types only– Visual

• Focus on the back of your hand

– Auditory• Listen to the sound of my voice

– Kinasthetic• Focus your attention on your breathing


• Simplification of selection criteria– Select induction based on modality in which

patient recalls relaxed state

• ‘What do you do for relaxation/what do you enjoy doing/what are you good at doing?’


• Deepener– Universal contents applied to all patients– Simplification of process

• 10 1

• Now

• Script formula - Early learning set


– Unique contents to be applied dependent on patient responses

• Modality of script suggestions

• Modality of recall

• Left brain/right brain variances


• Therapeutic script suggestions– Behaviours– Moods– Situations

• Left or right brain dominence– L logical feedback in same order as

present their habits– R creative The garden script


• Awakenings– After in a few moments time I’m going to

wake you

• Relapse traps

• Character re-inforcement


• Session closure– Post formal hypnosis direct suggestions

– Behavioural binds

• Remember this is not only about stopping – but it is about

not starting again

• The more other people try to make you…

• Try hard to tell no-one that you have stopped…

• The only thing that will come to your lips is a smile…


• Session closure– Post formal hypnosis direct suggestions

– Behavioural binds

• Do not discuss the session today

• Re-emphasis of what are you going to do next – future pace

• Owning the outcome – hypnosis as amplifier

• Importance of awareness, ‘if ever you go into a mood,

behaviour or situation

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Stop Smoking With Hypnotherapy Training Day Ursula James Mark Feldman.

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