Charles M. Citrenbaum, Ph.D. & Associates

specializing in practical and strategic counseling and clinical hypnosis

by Charles M. Citrenbaum, Ph. D. and Mark E. King, Ph. D.
(This article was originally published in Straight Forward, Medical & Chirugical Faculty of Maryland, Vol VI, Spring 1995).

The modern medical approach to cigarette smoking or nicotine addiction is the use of the nicotine patch or gum, which dispenses a small dose of nicotine to the patient over time, helping to alleviate uncomfortable withdrawal symptoms. This approach assumes, of course, that physical or pharmacological processes provide the primary basis of cigarette smoking and that treatment must address these processes. However, cigarette smoking, like most patterns of human behavior is a complex phenomenon. To reduce smoking to nothing more than a mindless pharmacological response is a mistake. Consistently, studies have shown that nicotine replacement is not better or only slightly better than placebo treatments.

On reflection, the basis of cigarette smoking is obviously more than just simply a pharmacological process similar to that of heroin addiction or alcoholism, two patterns to which smoking is often paralleled. An active heroin addict or an alcoholic (who in contrast to an episodic drinker consistently maintains a measurable blood-alcohol level) will display uncomfortable withdrawal symptoms 100% of the time upon cessation of the addicting substance.

In contrast, tens of millions of people have stopped smoking cigarettes, many of them with relative ease and with no pharmacological support. Most women will stop smoking on learning they are pregnant, even though they may choose to resume the habit after childbirth. Millions of workers will not smoke all day in the workplace, and religious people will abstain on a holy day.

Such data certainly seems to indicate that more than pharmacological or tolerance-dependence producing processes are involved with cigarette smoking. Nonmedical treatments for smoking are based on this understanding. One such psychological treatment available for cigarette smokers involves the use of clinical hypnosis.

The surgeon general declared smoking addictive and cited a number of points in support of this conclusion. For example, treatments such as weekly group meetings that use educational input, scare tactics, peer support, and behavioral modification techniques have existed for decades. Most of these programs have a 10% to 25% cessation rate. They also, however, have poor, if any, follow-up procedures to gather data on relapse rates, which are probably high. The surgeon general cited the low success rates of these programs in declaring cigarettes an addiction.

However, keep in mind that smokers who don't stop on their own and who request or require treatment are a harder-core group than the average smoker. Many of these smokers may not choose to go through some feared discomfort upon cessation; they also enter treatment programs as rationalization for themselves or as a presentation to others that they have tried to stop.

The surgeon general and others have cited irritability upon cessation of smoking as theprimary nicotine withdrawal symptom. However, any cessation or interruption of a sustained behavioral pattern will produce irritability. A jogger prevented from running will feel irritated or stressed. A worker who has stepped outside and stretched every afternoon at the same time for years will feel irritated if unable to take that break. Are these people addicted just like heroin addicts or alcoholics?

The surgeon general highlighted a group of surveys that reported that 95% to 99% of smokers would like to stop smoking. From this, the surgeon general concluded that cigarette smoking must be a difficult addiction if so many smokers would like to stop but do not.

The problem with this conclusion is that most of these surveys asked, "Would you like to stop smoking if it were easy?" We wonder how the responses would change if the question asked was, "Would you like to stop even if it were difficult, but you could?" We guess that fewer people would answer yes.

Expectancies of patients about drug effects can be very powerful and are well-documented. Therefore, messages to patients that nicotine is a powerfully addicting drug with withdrawal symptoms similar to heroin withdrawal might be quite counterproductive in many cases. We also wonder about the self-fulfilling prophecy effects of labeling cigarettes addicting. Do we really want teenagers who naturally experiment with different behaviors to believe that if they try a cigarette, they will become hooked or addicted to smoking?

In consideration of these factors, and after being involved in the treatment of heroin addicts and alcoholics before dealing with cigarette smokers, we have concluded that psycholgical factors are the primary basis of cigarette smoking, and addressing these psychological factors is necessary to help the hard-core smoker to stop. Like many health care providers, we have observed two- or three-pack-a-day smokers stop with relative ease while half-pack-a-day smokers have a terrible time. The psychological realities of such patients are the critical variables.

About 75% of those patients that we see for an intensive, two and a half hour treatment session successfully stop smoking. About 15% of the group have relapsed one year later. However, many of these patients can stop again after a telephone consult or after another one hour face-to-face session. We screen all of our patients beforehand by telephone interview for adequate motivation, to rule out heavy drinking or significant emotional disorders, and to insure that it is an opportune time to stop smoking (not during a highly stressful time period). Treatment, usually on an individual basis, addresses the individual needs of patients and consists of the following:

  1. an in-depth interview;
  2. a sharing of our realities about smoking, that it is an unhealthy habit sustained primarily by psychological factors, to help the patient buy into the treatment;
  3. communication to establish rapport with the patient and to recruit as much commitment from the patient as possible;
  4. demystification of hypnosis;
  5. a hypnotherapeutic session of approximately one hour's duration; and
  6. directives given to the patient for post-treatment care (self hypnosis daily, exercise, and other strategies).


The hypnotherapeutic intervention addresses the psychological payoffs, benefits, or secondary gains ofsmoking and helps the patient to identify healthier alternatives for these payoffs. Often, many secondary gains exist at unconscious levels. Common payoffs or gains are stress management/self tranquilization, assertion of one's independence, to reward oneself on the completion of a job, to model, honor, or be more connected to loved ones who have smoked or died from a smoking related illness, to eat less and not gain weight, to fit in with the group. Hypnosis increases awareness, suspends critical judgement, increases the influence of the clinical communication, and provides a helpful placebo effect to enhance treatment. Self-hypnosis, taught to all patients, provides a healthier alternative that cigarettes for stress management and also reinforces treatment when used daily.

We feel strongly that psychological treatments for cigarette smoking should only be employed by providers well-trained in human behavior. Clinical hypnosis should be used only by those trained and experienced in its use. Under such circumstances, these nonmedical approaches offer effective treatment, which addresses processes other than the physical and pharmacological, for cigarette smokers who want to stop.

References

Citrenbaum C, King M, Cohen W. Modern Clinical Hypnosis for Habit Control. New York: W.W. Norton, 1985
Eiser JR, Sutton S, Wober N. "Consonant" and "dissonant" smokers and the self attribution of addiction. Addictive Behaviors 1987; 3:99-108.
Gottleib A, Killen J, Marlott GA, Taylor CB. Psychological and pharmacological influences in cigarette smoking withdrawal: Effects of nicotine gum and expectancy on smoking withdrawal symptoms and relapse. Journal of Consulting and Clinical Psychology 1987; 55(4):606-608.
Gritz E. Smoking behavior and tobacco abuse. In: Advance in Substance Abuse. New York 1980; JAI Press:91-158.
Hughes JR, Gust SW, Keenan RM, Fenwick JS, Healy ML. Nicotine vs. placebo gum in general medical practice. JAMA 1989; 261(9):1300-1305.
King M, Citrenbaum C. Existential Hypnotherapy. New York: Guilford Press, 1993.
The surgeon general's report on nutrition and health: summary and recommendations. United States Department of Health and Human Services, Public Health Service, 1988.