American Journal of Clinical Hypnosis Copyright © 2010 by the American Society of Clinical Hypnosis

52:3, January 2010

Hypnosis and Smoking Cessation:

The State of the Science

Steven Jay Lynn - Binghamton University (SUNY)

Joseph P. Green - The Ohio State University at Lima
Michelle Accardi - Binghamton University (SUNY)
Colleen Cleere - Binghamton University (SUNY)

In his letter to the editor in this Journal, Dr. Yager (2009) is spot on target
when he suggests that clinicians may mistakenly come to view the immediate results
of hypnotic smoking cessation treatments (and by implication, other hypnotic
treatments) as representative of long-term treatment success. Dr. Yager wisely calls
for formal research in place of anecdotal case reports that lack the benefit of follow-up
data. To his credit, Dr. Yager analyzed a colleague’s outcome data and determined
that after a period of 60 days, 22% of patients surveyed did not resume smoking.
Evaluating clinical findings is of paramount importance insofar as hypnosis is
a widely used smoking cessation method. In one survey (Sood, Ebbert, Sood, & Stevens,
2006) of 1,177 patients at an outpatient tobacco treatment specialty clinic, 27% reported
they used complementary and alternative medicine techniques such as hypnosis,
relaxation, acupuncture, and meditation. Respondents indicated that the treatment of
greatest interest for use in the future was hypnosis. Yet the fact that a treatment is
widely used provides no warrant that it has an empirical base that supports its ubiquity.
We (Lynn & Green) entered the arena of smoking cessation treatment more
than 25 years ago in response to the overblown claims of itinerant hypnotists who set up
shop in hotels in our community and touted hypnosis as a highly effective technique that
virtually locked-in success in achieving nicotine abstinence. Even at that time, a cursory
review of the literature revealed that neither hypnosis, nor any other intervention, could
reliably alleviate nicotine addiction. In this article, we examine smoking cessation studies
from anecdotal case studies that date back to 1847, when hypnotic techniques were first
used to control the use of tobacco, to increasingly sophisticated contemporary research.
Early studies well illustrate Yager’s point about the dangers of relying on
anecdotal reports. In fact, in one of the first reviews on hypnosis and smoking cessation,
Johnston and Donoghue (1971) reported success rates as high as 94% (Von Dedenroth,
1964) based largely on anecdotal or clinical case reports.
Nearly a decade later, Holroyd (1980) examined 17 reports and concluded that
more sessions are better than fewer sessions, that individualized treatments are superior
to standardized suggestions, and that adjunctive treatment such as telephone contact
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and counseling increase the likelihood of successful outcome. Holroyd concluded that when
these conditions were fulfilled, more than half of those treated remain abstinent at 6 months.
Unfortunately, the reports reviewed by Holroyd were mostly clinical reports. Interestingly, the
best controlled investigations yielded outcomes in the range of 0-50%, in the lower range of the
studies reviewed by Holroyd (Green & Lynn, 2000).
Viswesvaran and Schmidt (1992) performed a meta-analysis on 633 studies of smoking
cessation and examined 48 studies in the “hypnosis” category that encompassed a total
sample of 6,020 participants. To be included in this category, it was necessary that the study
refer to the presence of a “hypnotherapist.” Hypnosis achieved a success rate of 36%, higher
than virtually any of the other treatments it was compared with (e.g., nicotine chewing gum,
smoke aversion, 5 day plans). Still, the authors acknowledged that the therapeutic techniques
used “range from simple suggestions to a complex sequence of imagery, relaxation, and
counseling. Many studies fail to report in sufficient detail the techniques used” (p. 557). In
short, because the term “hypnosis” in this context is of little descriptive value, it is therefore
difficult to isolate the role of hypnosis, make much sense of the relatively high quit rates
reported, and understand the clinical significance of the results obtained (Green & Lynn, 2000).
In a systematic review of the efficiency of methods intended to promote smoking
abstinence, Law and Tang (1995) analyzed 188 randomized controlled trials. Because of the
same concern specified by Dr. Yager—that short-term trials may overestimate treatment
effects—Law and Tang restricted their analyses to studies with follow-ups of at least 6
months. Although the 10 randomized trials of hypnosis indicated an estimate of efficacy of
23% (very close to what Dr. Yager reported), the authors argued that the effect is unproved
in that none of the trials confirmed verbal reports with biochemical measures. Law and Tang
also noted that there was considerable heterogeneity across the entire set of trials examined.
In 2000, we (Green & Lynn, 2000) reviewed 59 studies on hypnosis and smoking
cessation with the goal of determining whether the research base provided support for
hypnosis as an empirically supported treatment using criteria developed by Chambless and
Hollon (1998). In instances where dropout rates were reported but not included in the data
analyses, we computed abstinence rates to take dropouts into consideration and treated
them as failures. For these studies, we performed new statistical tests on the revised abstinence
rates. We noted that a difficulty in comparing abstinence rates across studies is the use of
different criteria for abstinence (e.g., one month of abstinence prior to a 6 month follow-up,
versus continuous abstinence), and also observed that in a number of instances it was
difficult to ascertain whether random assignment of participants to conditions was used.
We concluded that hypnotic procedures generally yield higher rates of abstinence
compared to wait list and no treatment conditions, and that hypnotic interventions are
generally equivalent to a variety of non-hypnotic treatments. However, few of the studies
reported confirmation of self-reports with biochemical measures. Moreover, the evidence for
whether hypnosis yields outcomes superior to placebos is mixed, as is the evidence that
high hypnotizability improves treatment outcomes. We observed that hypnosis could not
be considered to be a specific and efficacious treatment for smoking cessation. Furthermore,
in many cases, it is impossible to rule out cognitive/behavioral and educational interventions
as the source of positive treatment gains associated with hypnotic treatments. That is,
virtually none of the studies reviewed compared the same intervention with and without
hypnosis. The hypnotic and non-hypnotic treatment contained different suggestions and
procedures, thereby making it impossible to identify the specific therapeutic contribution of
hypnosis. Although hypnosis could not be regarded as a well-established treatment for
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smoking cessation, we maintained there was warrant to conclude that hypnosis is a possibly
efficacious treatment.
We concluded our review by emphasizing that most of the extant studies failed to
meet one or more criteria to gauge whether hypnosis is an empirically supported treatment:
1) randomization of participants; 2) collection of adequate samples of participants per
condition; 3) the inclusion of well-defined, manualized, and replicable hypnotic and non-
hypnotic treatments; and 4) clear delineation of the treatment population (e.g., smoking
history, previous quit attempts, social support, hypnotizability). We also made the following
recommendations: (a) abstinence should be defined as complete and continuous abstinence
following treatment with self-reports confirmed by biochemical measures; (b) follow-up should
extend to at least 6 months; (c) supplementary information should be garnered regarding
withdrawal symptoms, reasons for relapse, and weight gain; (d) the use of cigarette substitutes
including pipes, cigars, and smokeless tobacco should be examined; and (e) future
investigators should strive to develop powerful treatment approaches that combine hypnosis
with other interventions yet examine their independent effects.
A recent Cochrane report (Abbott, Stead, White, & Barnes, 2008) echoed many of our
conclusions and concerns. The review identified nine studies that met the criteria for inclusion:
(a) randomized controlled trials with at least 6 month follow-up; and (b) abstinence-validated
based on biochemical markers and abstinence based on self-reports by telephone and postal
questionnaires. The authors concluded that the “review of trials did not find enough good
evidence to show whether or not hypnotherapy can help people trying to quit smoking.” The
authors found no conclusive evidence that hypnosis is better than no treatment, alternative
treatments, or placebo treatments, although they did report that the findings were often mixed
and some trials did suggest that hypnosis was a promising treatment. The reviewers further
noted that methodological difficulties precluded evaluating alternative treatments, and
acknowledged that there is still a need to evaluate hypnosis for smoking cessation in large
trials using procedures that are clearly defined and described, with comparisons made with
other interventions, preferably matching for therapist contact time. The most recent Clinical
Practice Guidelines for treating tobacco use and dependence (Fiore et al., 2008) reached similar
conclusions about the inadequate research base for evaluating the efficacy of hypnosis.
Two recent studies not cited in the Cochrane review secured data in support of the
value of hypnosis for smoking cessation. Elkins and his colleagues (Elkins, Marcus, Bates,
Rajab, & Cook, 2006) randomly assigned 20 participants recruited from physicians and
advertisements to either an intensive hypnotherapy condition (8 visits over 2 months) or to a wait
list control condition. Patients were evaluated at the end of treatment and at 3 and 6 months. Self-
reported abstinence was confirmed with a biochemical measure. No participant in the control
condition was abstinent at the 3 or 6 month follow-up. However, 30% of the participants in the
hypnosis condition reported continuous abstinence at each visit, and after 6 months, 40% of
individuals who underwent hypnosis reported they were abstinent during the previous 7 days,
with the report confirmed by carbon monoxide values. The results of this study are very
encouraging, although the small sample size precludes definitive conclusions.
A recent randomized trial (Carmody et al., 2008) that recruited a larger sample and
used biochemical confirmation was based on a protocol we (Green, 1996, 1999; Lynn et al.,
1993) developed. The researchers compared hypnosis with standard behavioral counseling
when both interventions were combined with nicotine patches. The investigators enrolled
286 current smokers at the San Francisco Veterans Affairs Medical Center in both treatment
conditions that involved two 60-minute sessions, three follow-up phone calls, and 2 months

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of nicotine patches. At 6 months, 29% of the hypnosis group reported 7-day point-prevalence
abstinence, compared with 23% of the behavioral counseling group. Based on biochemical or
proxy confirmation, 26% of the individuals in the hypnosis group were abstinent at 6 months
compared with 18% of the behavioral group. At 12 months, the self-reported 7-day point
prevalence quit rate was 24% for the hypnosis group (again comparable to data reported
by Dr. Yager) and 16% for the behavioral group, with proxy or biochemical confirmation of 20%
of the hypnosis participants compared with 14% of the behavioral group.
The authors concluded “hypnosis combined with nicotine patch compares favorably
with standard behavioral counseling in generating long-term quit rates” (p. 811). Interestingly,
participants with depression exhibited higher quit rates at 6 and 12-month follow-up, and the
number of dropouts was lower in the hypnosis compared with the behavioral counseling group.
Notably, we have revised our earlier protocol used by Carmody, et al. (2008) and
have achieved 6-month success rates as high as 35% with experienced hypnotists. We are
currently developing a 2-session hypnosis cessation program that includes procedures for
enhancing suggestibility and reinforcing and generalizing treatment gains with DVD-
augmented home practice. Of course, our program must be evaluated with “formal research,”
as Dr. Yager suggests, before any claims can be made regarding its effectiveness.
In conclusion, hypnosis is one of a number of treatments that can play a valuable
role in smoking cessation. Dr. Yager’s reported success rate is generally comparable to
outcomes of well-controlled studies, and implies that the claims of itinerant hypnotists—
and those who seek to promote the value of hypnosis based on immediate reports of success—
dramatically exaggerate long-term success rates based on rigorous clinical research. We
have much to learn about which variables moderate the effects of hypnosis treatments, the
populations that benefit most from hypnotic interventions, and “how and why” hypnosis
“works” when it is successful. But for now, clinicians can accurately inform patients that 20-
35% of individuals will benefit, long-term, from hypnotically assisted smoking interventions.
Clinicians like Dr. Yager can play a valuable role in bridging the gap between formal experimental
research and everyday clinical practice, and we hope that his example will serve as a model
for clinicians in their work with hypnosis in treating a variety of disorders and conditions.

References
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