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Intl. Journal of Clinical and Experimental Hypnosis, 54(3): 303–315, 2006
Copyright © International Journal of Clinical and Experimental Hypnosis
ISSN: 0020-7144 print / 1744-5183 online
DOI: 10.1080/00207140600689512
303
NHYP0020-71441744-5183Journal of Clinical and Experimenta l Hypnosis, Vol. 54, N o. 03, April 2006: pp . 0–0Intl. Journal of Clinical and Experimental Hypnosis
INTENSIVE HYPNOTHERAPY FOR
SMOKING CESSATION:
A Prospective Study1
INTENSIVE HYPNOTHERAPY FOR SMOKING CES SATIONGARY ELKINS ET AL. GARY ELKINS, JOEL MARCUS, JEFF BATES, AND
M. HASAN RAJAB2
Scott and White Memorial Hospital and Clinic, Temple, Texas, USA
TERESA COOK
Baylor University, Waco, Texas, USA
Abstract: This study reports on a prospective pilot trial of intensive
hypnotherapy for smoking cessation. The hypnotherapy involved mul-
tiple individual sessions (8 visits) over approximately 2 months, indi-
vidualization of hypnotic suggestions, and a supportive therapeutic
relationship. Twenty subjects were randomly assigned to either an
intensive hypnotherapy condition or to a wait-list control condition.
The target quitting date was 1 week after beginning treatment. Patients
were evaluated for smoking cessation at the end of treatment and at
Weeks 12 and 26. Self-reported abstinence was confirmed by a carbon-
monoxide concentration in expired air of 8 ppm or less. The rates of
point prevalence smoking cessation, as confirmed by carbon-monoxide
measurements for the intensive hypnotherapy group, was 40% at the
end of treatment; 60% at 12 weeks, and 40% at 26 weeks (p < .05).
Cigarette smoking is a major preventable cause of disease and it is a
major cause of premature death. Smoking is a leading risk factor in
chronic obstructive pulmonary disease, cancer, and vascular disease
and mortality (U.S. Department of Health and Human Services, 1990).
Most people who smoke are aware of the fact that smoking is associ-
ated with health risks, and as many as 80% of current smokers express
a desire to stop smoking (USDHHS, 1990), however most smokers
are unlikely to be successful in quitting smoking without assistance
(Giovino, Henningfield, Tomar, Escobedo, & Slade, 1995).
Manuscript submitted May 20, 2005; final revision received August 29, 2005.
1The authors wish to thank Paul Cinciripini at University of Texas M.D. Anderson
Cancer Center for his guidance in selection of outcome measures and study design. Also,
appreciation is expressed to Matthew Ridley and Jennifer Gibbons-Rameriz who served
as study coordinators.
2Address correspondence to Gary Elkins, Ph.D., ABPP, ABPH, Scott & White Clinic,
2401 South 31 Street, Temple, TX 76508, USA. E-mail: gelkins@swmail.sw.org
304 GARY ELKINS ET AL.
Several retrospective clinical studies of hypnotherapy have shown
some encouraging promise for smoking cessation (Crasilneck, 1990;
Elkins & Rajab, 2004). However, most of the outcome studies of hypno-
therapy for smoking cessation, to date, have failed to achieve random-
ization and have not included biological markers of smoking cessation
(Fiore et al., 1996; 2000). As a result, the potential effectiveness of hyp-
nosis remains largely unknown (Greene & Lynn, 2000).
Further, many of the randomized studies of hypnosis have examined
a minimal approach to hypnotherapy involving one or two sessions or
group interventions (Berkowitz, Ross-Townsend, & Kohberger, 1979;
Cornwell, Burrows, & McMurray, 1981; Hyman, Stanley, Burrows,
& Horne, 1986; Javel, 1980; Neufeld & Lynn, 1988; Pederson, Scrimgeour,
& Lefcoe, 1975; Rabkin, Boyko, Shane, & Kaufert, 1984; Spanos,
Mondoux, & Burgess, 1995; Spanos, Sims, deFaye, Mondoux, & Gabora,
1992; D. Spiegel, Frischholz, Fleiss, & Spiegel, 1993; H. Spiegel, 1970;
Stanton, 1978; Williams & Hall, 1988). The findings regarding this minimal
approach to hypnosis for smoking cessation have indicated outcomes of
about 20% to 25% cessation (Cornwell et al.; Rabkin et al.). Recently, Green
& Lynn (2000) completed a comprehensive review of studies utilizing
hypnosis for smoking cessation and concluded that it seems apparent
that minimal hypnotic interventions, such as that developed by H. Spiegel
(1970) and group hypnosis interventions (Lynn, Neufeld, Rhue, & Matorin,
1993) achieve abstinence rates of only around 20% or less.
Hypnosis may yet be shown to be a very effective treatment for smok-
ing, however, an intensive treatment approach may be necessary for hyp-
nosis to be of greater benefit for smoking cessation (Green & Lynn, 2000).
Also, it has been suggested that more intensive interventions with more
contact in general may result in higher cessation rates (Fiore et al., 2000).
We have developed an innovative new intensive approach to hypnosis for
smoking cessation that is consistent with these recommendations.
The purpose of the present study was to establish the beneficial
effect of an intensive approach to hypnotherapy for smoking cessation
in a prospective randomized pilot study using biological markers of
abstinence. We hypothesized that the intervention would result in
smoking-cessation rates of 30% or higher that would be sustained at
6-month follow-up visits.
METHOD
Subjects
Subjects were recruited from physician referral and advertise-
ments. A total of 28 volunteers who were interested in stopping
smoking were evaluated, of whom 20 met the study criteria (see
below). This study was approved by the Scott and White Clinic and
Hospital Institutional Review Board. After the initial screening, subjects
INTENSIVE HYPNOTHERAPY FOR SMOKING CESSATION 305
attended an informational meeting at which the study was explained,
questionnaires completed, and written informed consent provided.
The subjects were eligible for inclusion if they were at least 18 years
of age, reported smoking 10 or more cigarettes per day, were inter-
ested in quitting smoking in the next 30 days, had the ability to attend
weekly sessions and spoke English. Exclusion criteria included regular
use of any noncigarette tobacco product, reported current abuse of
alcohol or psychoactive drugs, current use of any other smoking-cessa-
tion treatments, any reported history of borderline personality disor-
der, or currently using hypnotherapy for any reason.
The baseline characteristics of the participants are shown in Table 1.
The average age of the participants was early to mid-40s and the
majority were female; Caucasian; married; with a high school edu-
cation; were smoking more than 20 cigarettes per day; and had a
Fagerstrom score of slightly greater than 10.
Table 1
Baseline Characteristics of the Subjects
Characteristic Control Hypnotherapy
Age 41.7 ± 10.2 43.7 ± 8.4
Female Gender 80% 60%
Caucasian Race 100% 90%
No. cigarettes
Smoked/day 25.7 ± 9.6 22.2 ± 6.1
Fagerstrom Score 10.9 ± 1.2 10.7 ± 8
Marital Status (%)
Married/living
with partner 70% 90%
Single 0% 10%
Divorced 30% 0%
Education
HS/GED 60% 80%
1–3 yrs coll. 20% 0%
Coll. degree 10% 1%
Post grad.
Degree 10% 1%
Reasons for wanting to stop smoking
Health 100% 100%
Expensive 50% 80%
Spouse/family request 30% 30%
Job requirement 10% 0%
Insurance costs 40% 10%
Smells bad 80% 40%
Other 30% 20%
306 GARY ELKINS ET AL.
Measures
Baseline data assessments were completed regarding demographic
information, smoking behaviors, reasons for wanting to stop smoking,
and perceived benefits from smoking cessation. Also at baseline,
nicotine dependence was assessed with the 8-item Fagerstrom Test for
Nicotine Dependence (FTND) scale. The FTND is a widely used mea-
sure of nicotine dependence with a score ranging from 0 to 11; a score
of 6 or greater indicates higher levels of dependence (Fagerstrom &
Schneider, 1989). Self-reported abstinence was confirmed by expired
carbon monoxide (CO) measured at baseline, at the end of treatment
(Week 8) and at Weeks 12 and 26. Subjects were classified as abstainers
if they reported no smoking in the 7 days prior to assessment and had
CO values of less than 8 ppm (Cinciripini et al., 2003). Inconsistencies
in self-reports and CO values were noted in 7% of measurements. Any
inconsistency in self-reports and CO values was resolved with saliva
cotinine analysis less than 20 ng/mL.
Procedure
At the baseline visit, subjects were randomly assigned to either
receive intensive hypnotherapy for smoking cessation or to a waiting-
list control group. Subjects in the waiting-list control group received
self-help material from the National Cancer Institute (Glynn & Manley,
1990) and encouraged to set a date to quit smoking. Assessments of
smoking cessation were completed at Weeks 8, 12, and 26. Participants
received $25 for each follow-up appointment attended. Research staff
provided brief supportive phone calls to all of the participants at 3
days after the target quit date and at Weeks 2, 4, and 5. The supportive
phone call lasted 5 to 10 minutes each.
The intensive hypnotherapy intervention was provided by a doc-
toral clinical psychologist (PsyD) or physician (MD). The therapists
completed 40 hours of training in hypnotherapy provided by the pri-
mary investigator. Training followed the guidelines and learning
objectives outlined in the publication, Standards of Training in Clinical
Hypnosis (Hammond & Elkins, 1994). Therapists also received addi-
tional training in the hypnotherapy treatment used in the study.
Subjects assigned to the intensive hypnotherapy intervention met
with a research therapist and at the first visit (preparation visit) were
provided with a brief discussion regarding myths and misconceptions
about hypnosis and the process used in hypnotic induction (Elkins &
Handel, 2001). At the first visit (preparation visit), subjects also
received self-help material from the National Cancer Institute (Glynn &
Manley, 1990). Subjects received a 30-minute counseling session that
included exploring ambivalence about quitting, preparing to quit,
problem solving difficult situations, and commitment following semis-
tructured counseling scripts. Subjects were asked to set a target quit
INTENSIVE HYPNOTHERAPY FOR SMOKING CESSATION 307
date approximately 7 days later. Also, subjects in the intensive hypno-
therapy group were provided with a self-hypnosis tape recording and
a tape player and instructed in the daily practice of self-hypnosis.
We collected self-reports of average number of cigarettes smoked
per day for each of the 7 days prior to assessment of abstinence.
Subjects who were unavailable for assessment were counted as non-
abstainers. We allowed participants to miss no more than one in-
person visit prior to each assessment. The 26-week outcome period
was chosen because there is evidence to suggest that cessation rates at
26 and 52 weeks do not differ substantially (Fagerstrom, 1989;
Hjalmarson, 1984; Hughes, Gust, Keenan, Fenwick, & Healey, 1989;
Hurt et al., 1994; Kornitzer, Boutsen, Dramaix, Thijs, & Gustavsson,
1995; Russell et al., 1993; Fee & Stewart, 1982; Sachs, Sawe, & Leischow,
1993; Tonnesen, Norregaad, Simonsen, & Sawe, 1991).
Subjects in the intensive hypnotherapy intervention group received
eight sessions, and each session lasted approximately 1 hour. A brief
counseling session occurred at each visit at which time subjects
received encouragement to practice self-hypnosis. The hypnotic induc-
tions were completed at Sessions 1, 2, 4, and 7 and were standardized
following a transcript. Suggestions were given for deepening relax-
ation, absorption in relaxing imagery, commitment to stop smoking,
decreased craving for nicotine, posthypnotic suggestions, practice of
self-hypnosis, and visualization of the positive benefits of smoking
cessation. Subjects were asked at each session for their preferences for
specific imagery for relaxation and dissociation. The suggestions fol-
lowed a transcript; however, the specific imagery for relaxation and
the positive benefits for smoking cessation were individualized based
upon questions to determine the patient’s preference regarding such
imagery. The hypnotic induction used is summarized below.
(a) Eye-focus induction. Begin by focusing your attention on a spot on
the wall. As you concentrate, begin to feel more relaxed. Concentrate
intensely so that other things begin to fade into the background. As this
occurs, noticing a relaxed and heavy feeling and allowing your eye-lids
to close.
(b) Relaxation. Noticing a wave of relaxation that begins at the top of
your head and spreads across your forehead, face, neck, and shoulders.
Every muscle and every fiber of your body becoming more and more
completely relaxed. More and more noticing a feeling of letting go and
becoming so deeply relaxed.
(c) Comfort. . . . and as you become and remain more relaxed, finding a feel-
ing of comfort. Feeling safe and secure. A peaceful feeling, calm and secure.
Feeling so calm that nothing bothers or interferes with this feeling of comfort.
(d) Mental imagery for relaxation. As you can hear my voice with a
part of your mind, with another part going to a place where you feel safe
308 GARY ELKINS ET AL.
and secure. A place where you become so deeply relaxed that you are
able to respond to each suggestion just as you would like to, feeling
everything you need to feel and to experience.
(e) Commitment for smoking cessation. . . . and today becoming a non-
smoker, becoming free from nicotine and free from cigarettes . . . you
will not smoke cigarettes or use tobacco again. With each day that
passesh, your commitment to remain free from cigarettes will become
stronger and each time you enter this relaxed state you will remember
the reasons you want to stop smoking.
(f) Dissociation from cravings. As you enter an even deeper level of hyp-
nosis, you may notice a floating sensation, less aware of your body, just
floating in space. Your body floating in a feeling of comfort and your mind,
just so aware of being in that pleasant place [individualized imagery for a
pleasant place]. As your body floats, you will not be bothered by craving
nicotine. Your mind blocks from conscious awareness any cravings and you
can feel more detached from your body as you become more relaxed.
(g) Posthypnotic suggestions. . . . and as you become and as you
remain free from nicotine and free from cigarettes, you will find a sense
of satisfaction and accomplishment. You will find that, more and more,
you are able to sleep very well, your sense of smell will improve, and
your sense of taste will improve. You will not eat excessively and you
will find an appropriate amount of food to be satisfying to you.
(h) Self-hypnosis. Each time you practice self-hypnosis or listen to the tape
recording that I will provide to you today, you will be able to enter a very
deep state of relaxation, just as deep as you are today . . . and within this
relaxed state, you will find a feeling of control. You will be able to become
so deeply relaxed that you will become very comfortable and you will be
able to have a feeling of dissociation that keeps from conscious awareness
any excessive craving for nicotine. Within this relaxed state, your commit-
ment to remain free from cigarettes will become even stronger, and you will
find a kind of strength from your practice of self-hypnosis.
(i) Positive imagery for benefits of smoking cessation. ...now,seeing
yourself in the future as a nonsmoker, free from nicotine and cigarettes.
Notice all of the good things going on around you, how healthy you feel,
and [here, individualized imagery is introduced, depending on the patients
perceived benefits from smoking cessation]. Seeing how well you are able to
feel and you will not smoke, no matter if times become stressful or difficult.
You will be able to remain calm and relaxed, both now and in the future.
RESULTS
The efficacy of the intervention for smoking cessation was evaluated
with the use of weekly point-prevalence abstinence rates and rates of
continuous abstinence. In all cases, an intention-to-treat analysis was
performed. For the point-prevalence rates, subjects were classified as
INTENSIVE HYPNOTHERAPY FOR SMOKING CESSATION 309
abstinent if they reported not smoking during the previous 7 days and
this report was confirmed by an expired carbon monoxide value of
8 ppm or less. To be classified as continuously abstinent, the subject
had to be confirmed as not smoking on the basis of carbon monoxide
measurement at each visit.
The biochemically confirmed point-prevalence smoking-cessation
rates are shown in Table 2. Fisher’s Exact Test was utilized to compare
the intervention to wait-list control. The respective point-prevalence
smoking-cessation rates for the intensive hypnotherapy intervention
and waiting-list control condition at the end of treatment, 12 weeks,
and 26 weeks was 40% vs. 10% (p < .15), 60% vs. 0% (p < .005), and 40%
vs. 0% (p < .043).
The rates of continuous abstinence from the target quitting date
through the end of treatment are shown in Figure 1. Results indicated
30% continuous abstinence at the end of the treatment period. None of
the subjects in the control group achieved continuous abstinence.
The average numbers of cigarettes smoked per day at each assess-
ment point are shown in Figure 2. At Week 26, the average number of
cigarettes smoked by those in the intensive hypnotherapy group was
three. In comparison, the average number of cigarettes smoked by those
in the waiting-list control group remained stable at 20 cigarettes per day.
DISCUSSION
The results of the present study revealed that an intensive hypno-
therapy intervention can be an effective means of achieving smoking
cessation. The rate of smoking cessation at 26-week follow-up was
40%, as confirmed by an expired carbon monoxide value of 8 ppm or
less. This rate of smoking cessation is comparable to or higher than
that achieved through pharmacological or nonhypnotic behavioral
interventions. In this small sample, the hypnosis intervention was well
accepted, and the overall results of the present study support the effi-
cacy of an intensive approach to hypnotherapy for adult smokers.
Table 2
Point-Prevalence Smoking Cessation Rates Confirmed by Carbon Monoxide Measurements
Time after target
quitting date
% of Subjects not smoking
p valueControl Intensive Hypnotherapy
8 weeks 10% 40% .15*
12 weeks 0% 60% .005
26 weeks 0% 40% .043
*Fisher’s Exact Test.
310 GARY ELKINS ET AL.
Our hypothesis that the intervention would result in smoking-cessa-
tion rates of 30% or higher and would be sustained at 26-week follow-
up visits was confirmed and is consistent with previous observations
that have suggested that interventions that involve considerable
patient contact and are extended over a longer period of time may be
more effective than minimal-interventions rates (Fiore et al., 2000). For
example, Holroyd (1980) suggested that the likelihood of success for
hypnosis in treatment of tobacco dependency may be increased by an
approach that includes: (a) multiple sessions; (b) individualized hyp-
notic suggestions; (c) individualized counseling with follow-up; and
(d) an intense interpersonal relationship. The present intervention was
consistent with these observations and adds support to this approach
to hypnotherapy for smoking cessation.
However, the present study has limitations, and these include a
small sample size and the lack of measurements of hypnotizability.
Additional research with a larger sample size would enhance confi-
dence in the generalizability of the results and allow exploration of
potential variables that may relate to the success of the intervention.
For example, it would be important to assess the subjects’ levels of
F
igure 1. Percentage of subjects who maintained continuous abstinence from smoking
from Week 1 through Week 7.
INTENSIVE HYPNOTHERAPY FOR SMOKING CESSATION 311
hypnotizability, as some previous studies have suggested that hypno-
tizability may be associated with responses to hypnotic interventions
for smoking cessation (Marcovitch, Gelfand, & Perry, 1980; Perry &
Mullen, 1975). Also, the effect of hypnosis on reducing withdrawal
symptoms from tobacco cessation needs to be determined (Hughes &
Hatsukami, 1986).
Further investigation of this intensive hypnotherapy for smoking ces-
sation is warranted and may provide an innovative new focus for
behavioral research. For example, Fiore et al. (2000) recently observed
that there have been few innovations in developing new nonpharmaco-
logical interventions for smoking cessation in the past 20 years (Niaura &
Abrams, 2002; Shiffman, 1993). Innovative new behavioral interventions
for smoking cessation are clearly needed. Pharmacological interventions
such as bupropion and nicotine replacements have yielded cessation
rates of up to 35% when used in combination with each other (Jorenby
et al., 1999) or in combination with behavioral interventions (Cinciripini,
Cinciripini, Walfisch, Van Vunakis, & Haque, 1996). However, up to
30% or more of smokers may reject pharmacological interventions
because of unpleasant or unacceptable side effects (Jorenby et al.) or for
other reasons discontinue use. Further, pharmacological and/or com-
bined interventions are ineffective for others (Hurt et al., 1997). Because
F
igure 2. Average number of cigarettes smoked per day from baseline to 26 weeks by
intensive hypnosis group and control group.
312 GARY ELKINS ET AL.
of this, many smokers prefer and seek nonpharmacological interven-
tions such as intensive hypnotherapy.
In conclusion, an intensive hypnotherapy intervention was effec-
tive for smoking cessation and resulted in cessation rates that are
higher than previously achieved by minimal approaches in random-
ized prospective studies. Based on the results of this initial pilot
study, it would appear that intensive hypnotherapy may be an inno-
vative behavioral intervention of significant benefit to some smokers.
A larger, randomized study that integrates state-of-the-art methods
for achieving high follow-up rates (Scott, 2004) is warranted to fully
determine the effects of the intervention. Such a study could also
reveal potential cost savings and mediating factors such as hypnotic
susceptibility and expectancies.
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Intensiv-Hypnosetherapie zur Raucherentwöhnung: Eine
prospektive Studie
Gary Elkins, Joel Marcus, Jeff Bates, M. Hasan Rajab und Teresa Cook
Zusammenfassung: In diesem Artikel wird eine prospektive Pilotstudie einer
intensiven Hypnosetherapie zur Raucherentwöhnung vorgestellt. Die
Hypnosetherapie bestand aus mehrfachen Einzelsitzungen (acht Sitzungen)
über einen Zeitraum von etwa zwei Monaten, der Individualisierung der
hypnotischen Suggestionen und einer supportiven Therapeutenbeziehung. 20
Teilnehmer wurden zufällig einer Gruppe mit intensiver Hypnosetherapie
oder einer Wartelistenkontrollgruppe zugeteilt. Das Zieldatum zur Beendigung
des Rauchens lag 1 Woche nach Aufnahme der Behandlung. Die Patienten
wurden am Ende der Behandlung sowie nach 12 und 26 Wochen evaluiert.
Selbstberichtete Abstinenz wurde durch einen Kohlenmonoxid-Test der
ausgeatmeten Luft (weniger als 8 ppm) bestätigt. Die Punktprävalenz für
Rauchabstinenz, welche mithilfe die Kohlenmonoxid-Messung objektiviert
INTENSIVE HYPNOTHERAPY FOR SMOKING CESSATION 315
wurde, lag in der Hypnosetherapie-Gruppe am Ende der Behandlung bei 40%,
nach 12 Wochen bei 60% und nach 26 Wochen bei 40% (p < 0.05).
RALF SCHMAELZLE
University of Konstanz, Konstanz, Germany
Hypnothérapie intensive pour arreter de fumer: Une étude prospective
Gary Elkins, Joel Marcus, Jeff Bates, M. Hasan Rajab et Teresa Cook
Résumé: Cette étude rend compte d’un essai exploratoire prospectif
d’hypnothérapie intensive pour arreter de fumer. L’hypnothérapie intensive
impliquait des séances individuelles multiples (8 consultations) au cours
d’environ deux mois, l’individualisation de suggestions hypnotiques et une
relation thérapeutique étayante. Vingt sujets étaient affectés au hasard soit à
une condition d’hypnothérapie intensive, soit à une condition de contrôle
sur liste d’attente. La date d’arret envisagée était d’une semaine après le
début du traitement. Les patients étaient évalués par rapport à l’arrêt du
tabac à la fin du traitement et après 12 et 26 semaines. L’auto-déscription
d’abstinence était confirmée par une concentration de monoxyde de carbone
dans l’air expirée de 8 ppm ou moins. La ratio de prévalence d’arrêt du tabac,
tels que confirmés par les mesures de monoxyde de carbone pour le groupe
d’hypnothérapie intensive, étaient de 40% à la fin du traitement, 60% après
12 semaines et 40% après 26 semaines (p < .05)
URSULA KNAPP-MCINNES
Clinical psychologist, Boulogne-Billancourt,
France
La hipnoterapia intensiva para dejar de fumar: Un estudio prospectivo
Gary Elkins, Joel Marcus, Jeff Batea, M. Hasan Rajab, y Teresa Cook
Resumen: Este es un estudio prospectivo piloto de hipnoterapia intensiva
para dejar de fumar. La hipnoterapia intensiva incluyó múltiples sesiones
individuales (8 visitas) durante aproximadamente 2 meses, individualización
de sugestiones hipnóticas, y una relación terapéutica de apoyo. Asignamos
aleatoriamente a 20 participantes a una condición intensiva de la hipnoterapia
o a una lista de espera como control. El objetivo era dejar de fumar 1 semana
después de empezar el tratamiento. Evaluamos la abstinencia de los pacientes
al finalizar el tratamiento y en las semanas 12 y 26. Informes de abstinencia
fueron confirmads por una concentración de monóxido de carbono en aire
expirado de 8 ppm o menos. Las tasas de abstención de fumar, confirmadas
por medidas de monóxido de carbono para el grupo intensivo de
hipnoterapia, fueron de 40% al finalizar el tratamiento, 60% a las 12
semanas, y 40% a las 26 semanas (P < . 05).
ETZEL CARDEÑA
University of Lund, Sweden
