American Journal of Clinical Hypnosis

ISSN: 0002-9157 (Print) 2160-0562 (Online) Journal homepage: https://www.tandfonline.com/loi/ujhy20

Strategies and Design of Hypnosis Intervention for

Tobacco Cessation

Mary Herring

To cite this article: Mary Herring (2019) Strategies and Design of Hypnosis Intervention
for Tobacco Cessation, American Journal of Clinical Hypnosis, 61:4, 345-369, DOI:
10.1080/00029157.2018.1491386

To link to this article: https://doi.org/10.1080/00029157.2018.1491386

Published online: 24 Apr 2019.

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American Journal of Clinical Hypnosis, 61: 345–369
© 2019 American Society of Clinical Hypnosis
ISSN: 0002-9157 print / 2160-0562 online
DOI: https://doi.org/10.1080/00029157.2018.1491386

Strategies and Design of Hypnosis Intervention for Tobacco

Cessation
Mary Herring
Healing Interventions, PC

The purpose of this article is to share approaches and program design to assist healthcare profes-
sionals trained in hypnosis help tobacco users become tobacco free. Helping tobacco users over-
come their tobacco dependency is generally seen as challenging to healthcare professionals. Efforts
to stop a tobacco habit have components which are both physical and emotional in nature and
which produce periods of discomfort and high relapse rates. Hypnosis can be supportive for both
the physical and emotional aspects necessary for successful cessation. Health risks of tobacco use
cannot be overlooked, and individuals burdened by tobacco habits will benefit from health profes-
sionals’ greater appreciation for the contributions hypnosis can offer. Tobacco cessation incorpor-
ating hypnosis can be successful when careful attention is given to the program design.
Keywords: hypnosis, nicotine, smoking, smoking cessation, tobacco, tobacco cessation

Healthcare professionals face a wide range of pressing health issues, as well as challenges
from the healthcare system itself. Smoking and other forms of tobacco use have existed for
centuries, and the negative consequences of tobacco use have been recognized for decades,
so interventions for tobacco cessation may seem mundane. Fewer people in the United
States smoke today than in years past, and helping consumers become free of tobacco does
not offer the excitement of high-tech medical interventions that reduce morbidity and
mortality. Furthermore, successfully overcoming a tobacco addiction can be viewed as
a monumental challenge by healthcare providers and consumers alike. Consumers can
become desensitized to the warnings and messages urging them to remove tobacco from
their lives. Healthcare providers may value helping patients to become tobacco free, but
with limited time to spend with patients, challenges of multiple issues and mandates to
address during patient visits, as well as the challenge of tackling a problem with high
recidivism, it can be easy for tobacco cessation interventions to be postponed. Butt [sic]
this author has a burning passion for assisting patients become free of their tobacco habits,
and she hopes to light a fire under readers to extinguish doubts and inspire confidence that
they can significantly change tobacco use by incorporating hypnosis into patient care.

Address correspondance to Mary Herring, Healing Interventions, PC, 7737 E. Vista Bonita Dr., Scottsdale, AZ
85255. E-mail: mr-herring@cox.net
Color versions of one or more of the figures in the article can be found online at www.tandfonline.com/ujhy.
346 HERRING

Health Risks of Tobacco Use

Put succinctly, “[c]igarette smoking remains the single leading cause of preventable
mortality in the United States and causes a high morbidity burden” (U.S. Department
of Health and Human Services, 2014, p. 678). Health risks of tobacco use, especially
smoking, are well documented. Each year in the United States more than 480,000 deaths
are the result of smoking tobacco products (Centers for Disease Control and Prevention
[CDC] Health Effects of Cigarette Smoking). Providers and consumers know that
tobacco use, whether by smoking or chewing, causes heart disease, stroke, and various
lung diseases. Smoking is a leading cause of chronic obstructive pulmonary disease
(COPD), which includes emphysema and chronic bronchitis (Mayo Clinic, 2017). Lung
cancer is a known risk from smoking, but consumers may not realize that risks of other
forms of cancer are also associated with tobacco use, including cancers of the oral cavity,
pharynx, larynx, esophagus, stomach, pancreas, cervix, kidney, and bladder, in addition to
myeloid leukemia (U.S. Department of Health and Human Services, 2004).
Consumers also may not realize that tobacco use causes erectile dysfunction in men, as
well as increases the risks for tuberculosis and problems of the immune system, including
rheumatoid arthritis and certain eye diseases (CDC, Health Effects of Cigarette Smoking).
Even fewer people may know that smoking increases sensitivity to and intensity of pain
(Weingarten et al., 2008). Smokers are nearly three times more likely to have lower back
pain than nonsmokers (Cleveland Clinic, 2017). Smoking interferes with sleep and is even
associated with nocturnal bruxism (Lavigne, Lobbezoo, Rompré, Nielsen, & Montplaisir,
1997). It has been known for decades by the medical community that tobacco use increases
risks related to fractures, osteoporosis, delay in wound healing, and impairment of the
immune system leading to increasing risk of infection (Kwiatkowski, Hanley, & Ramp,
1996), but consumers may not know of these additional risks.
And consumers may not realize that elimination of tobacco brings substantial reversal
of health risks. For example, smoking cessation drops the risk of developing COPD
approximately in half (Laniado-Laborín, 2009). Efforts by consumers and interventions
by healthcare professionals to help consumers become tobacco free are very worthwhile.

Demographics of Tobacco Use

Estimates are that every day 3,200 to 3,800 individuals younger than age 18 smoke
their first cigarette (CDC, Smoking and Tobacco Use-Data and Statistics; U.S.
Department of Health and Human Services, 2012). Many will go on to be smokers
for decades before successfully stopping. Despite efforts over several decades—and
goals found in the Healthy People 2000, 2010, and 2020 reports to reduce prevalence
of smoking— consequences of smoking and exposure to secondhand smoke remain
a burden to individuals, families, the healthcare system, and employee productivity.
 HYPNOSIS INTERVENTION FOR TOBACCO CESSATION 347

Progress has been made, but some might say that all of the low-hanging fruit has
already been picked and multifocal efforts to support individuals to successfully
overcome tobacco are still needed, perhaps now more than ever.
In 1965, 42% of the U.S. population smoked (Drope et al., 2018); however, “[t]he
proportion of U.S. adults who smoke cigarettes declined from 20.9% in 2005 to 15.1%
in 2015, and the proportion of daily smokers declined from 16.9% to 11.4%” (Jamal
et al., 2016, p. 1205). Estimates are that 38 million to 40 million adults in the United
States are still smokers (Drope et al., 2018; Jamal et al., 2016). And unfortunately, for
the first time in a decade, data from the 2016 National Health Interview Survey
(NHIS) reflected a 0.4% increase in adult cigarette smokers over the 2015 data,
reporting prevalence of 15.5% (Boyles; Jamal et al., 2018). Of the individuals who
reported smoking daily, the mean number of cigarettes decreased from 16.7 in 2005 to
13.8 in 2014, but then the mean number of cigarettes smoked daily rose to 14.2 in
2015 and remained unchanged at 14.1 in 2016 (Jamal et al., 2016, 2018).
In the 2018 report, Jamal et al. state, “During 2005–2016, increases occurred in the
proportion of daily smokers who smoked 1–9 cigarettes per day (from 16.4% to
25.0%) or 10–19 (from 36.0% to 39.0%) cigarettes per day” (p. 55). In 2005, 34.9%
of smokers smoked 20 to 29 cigarettes per day. That percentage reached a low point of
27.4% in 2014, increased to 29.3% in 2015, and decreased to 28.4% in 2016 (Jamal
et al., 2016, 2018). In the Weekly MMWR of November 11, 2016, Jamal et al. stated
that between 2014 and 2015 the percentage of daily smokers who reported smoking 30
or more cigarettes remained essentially flat (6.9% to 6.8%). While the change from
12.7% in 2005 to 7.5% in 2016 (Jamal et al., 2018) reflects an encouraging trend, it
unfortunately shows a slight increase of daily smokers smoking 30 or more cigarettes
per day between 2015 and 2016. The January 19, 2018, MMWR stated, “No significant
changes in any category of number of cigarettes smoked per day occurred during
2015–2016” (p. 55). Nonetheless, a 0.7% increase in percentage of smokers who
smoke 30 or more cigarettes per day represents a health risk to a sizable number of
people and an undesirable trend. So while we have made strides to decrease the overall
percentage of the American population that smokes, it seems the past few years have
shown flat progress or slight setbacks (see Figure 1; (Jamal et al., 2018).
Regarding age and gender of smokers, as of 2015, 16.7% of adult men and 13.6% of
adult women smoked (Jamal et al., 2016). For ages 18 to 24, 15% of men and 11% of
women smoked. For ages 25 to 44, 19.8% of men smoked and 15.8% of women
smoked. By ages 45 to 64, 17.9% of men and 16.1% of women were smokers. By age
65 and older, 9.7% of men and 7.3% of women smoked (Jamal et al., 2016). These
numbers reflect decreases in smokers from 2005 to 2015 across most ages and genders.
Smoking decreased most in the ages 18 to 24 group for both men and women (46.5%
and 47%). There was a 26% and 26.4% smoking decrease for men and women,
respectively, between the ages of 25 and 44. And while smoking decreased by
348 HERRING

FIGURE 1 Percentages of daily smokers aged 18 years and older

who smoked 1 to 9, 10 to 19, 20 to 29, and 30 or more cigarettes per day
(National Health Interview Survey, United States, 2005–2016, p. 58).

28.9% for men ages 45 to 64, women of the same age decreased only 14.6%. Women
age 65 and older had an 11.6% decrease in smoking, but for men of that age smoking
rates increased 8.7% (CDC; Jamal et al., 2016). Between 2015 and 2016 there were no
significant changes in number of cigarettes smoked daily across any age category
(Jamal et al., 2018). (See Figure 2 for comparison of smoking rates by gender between
2005 and 2015; Jamal et al., 2018.)
Beyond disparities in smoking by age, certain groups of adults continue to have high
smoking prevalence, and they bear a heavier morbidity and mortality burden related to
smoking: “These populations include individuals in lower education and/or socioeco-
nomic groups; from certain racial/ethnic groups; in the lesbian, gay, bisexual, and trans-
gender community; with mental illness; and in the military, particularly among those in the
lowest pay grades” (Drope et al., 2018, p. 1). Smoking among military personnel has
decreased from a rate of more than 50% in 1980 to less than 25% by 2011, but it clearly
remains significantly higher than in the general population. While the smoking rate for the
highest six pay grades of commissioned officers has dropped below 5%, the rate for the
lowest four pay grades of enlisted personnel was still 30% in 2011 (Drope et al. 2018).
Unfortunately, 21.6% of veterans are smokers. Even more disheartening, 56.8% of
veterans between ages 18 and 25 identified themselves as smokers. The Veterans Health
Administration and U.S. Department of Defense are working to increase tobacco cessation
 HYPNOSIS INTERVENTION FOR TOBACCO CESSATION 349

FIGURE 2 Percentages of adults who were current cigarette smo-

kers, overall and by sex (National Health Interview Survey, United
States, 2005–2016; Jamal et al., 2016, p. 1207).

treatment options, as well as develop tighter regulations of tobacco availability in military

facilities and bases (Boyles, 2018, January 12).
Substantial geographic disparities in smoking prevalence exist across cities, counties,
and states. Rates are higher in some states in the Midwest, South, and Appalachia. For
example, Utah has a national low smoking rate of 8.7%, while Kentucky reports 26.2%
(Drope et al., 2018).
There is good news in that proportion of adults who were former smokers increased
from 50.8% in 2005 to 59.0% in 2016 (Jamal et al., 2018). Clearly, progress has been made
over the years, but progress has stalled in the past few years (see Figure 3; Jamal et al.,
2018). Indeed, “after declines during previous years, the mean number of cigarettes
smoked per day among daily smokers did not change significantly from 2014 to 2015”
(Jamal et al., 2016, p. 1209).

Social Incentives and Factors for Decline in Tobacco Use

Reasons for the decline in tobacco rates can be attributed to a combination of

interventions. Social and political efforts have contributed to declining tobacco use.
Programs in schools and media campaigns are reinforcing risks and offering motiva-
tional messages to discourage initiation of smoking and to encourage users to stop.
One can debate the overall effectiveness of these campaigns, but individually or
collectively they seem to have impacted smoking rates (Golechha, 2016).
350 HERRING

FIGURE 3 Quit ratios* among ever smokers aged 18 years and

older, overall and by age group (National Health Interview Survey,
United States, 2005–2016; Jamal et al., 2018, p. 58).

States and municipalities have increased cost of tobacco products through taxation
that puts financial pressure on smokers. This is one of the factors thought to put the
most direct pressure on smoking habits. Smokers have expressed that higher costs have
had the intended effects of reducing their smoking rates. This was found to be
especially helpful in discouraging teen smokers (Editorial Board, The Washington
Post, 2017). While local and state governments appreciate the small spike in revenue
from tobacco taxes, these revenues will decline if tobacco sales continue to decline. It
is hoped that such taxes on tobacco will continue to serve as disincentives for current
smokers and to discourage new smokers from trying tobacco.
A general decrease in the social acceptance of smoking has resulted in fewer
approved smoking areas and less-convenient smoking areas. Although smokers, and
perhaps the tobacco lobby, were initially successful in fighting laws that banned
smoking in public places, the movement to have smoke-free public spaces has gained
momentum. Laws have been passed so that both public venues and private industries
restrict areas where smoking is allowed. Today entire business campuses, even parking
lots in many industries, and all hospitals are smoke free.
It is almost inconceivable that only four decades ago hospitals allowed patients and
staff to smoke. This author can recall the head nurse of the pediatrics unit of a general
hospital in the Midwest who always brought an ashtray for one of the pediatricians to
use on the unit; this was in the late 1970s. The pediatrician would smoke at the
 HYPNOSIS INTERVENTION FOR TOBACCO CESSATION 351

pediatric unit nurses’ station while writing his medical chart entries. Indeed, it is not
difficult to find old print or TV ads that employed actual doctors, and endorsements by
doctors promoting various cigarette brands.
The Federal Cigarette Labeling and Advertising Act of 1965 required that the
side panel of each pack of cigarettes contain the warning “Caution: Cigarette
Smoking May Be Hazardous to Your Health.” On January 2, 1971, commercials
for cigarettes on radio and TV ended. The warning message on cigarette packaging
slowly grew stronger over the years, but in 1981 Congress received a report
concluding that warning labels had little effect on the public’s smoking behavior.
More restrictions came in 1998 with the Master Settlement Agreement.
Unfortunately, the health warning on packs has not been updated in the United
States in 33 years, and many other countries have stronger warnings, plain packa-
ging, or packaging with graphic images of what smoking can do to the body
(Belluz, 2018).
Decades of litigation have caused delays in progress, but legal challenges to
tobacco companies continue to push the industry to more directly communicate the
risks of smoking to the public and to decrease the appeal of tobacco product
packaging (La Vito, 2018). Federal courts ordered Philip Morris USA, Lorillard,
R.J. Reynolds Tobacco Co., and Altria Group to run newspaper and TV ads on the
health hazards of smoking and the addictive nature of nicotine (Katz, 2017). After
11 years of appeals by tobacco companies over the exact language of those
messages, which delayed those ads until November 2017, they began airing as
45-second voiceovers of black text on white background (Schultz, 2017). Whether
the frank information in those ads will influence smokers to stop or deter non-
smokers from starting is not yet known; only time will tell. Manufacturers were not
required to show images of the effects of smoking. Furthermore, during the years
of litigation and appeals, many people have shifted to online sources for their news,
and the messages are not mandated to appear in online sources. It is still hoped that
the ads will influence behavior.
The Food and Drug Administration (FDA) recently issued an advance notice of
proposed rulemaking (ANPRM) to consider requirements to lower nicotine levels in
combustible cigarettes to nonaddictive levels (Boyles, 2018a). What those levels
would be and what the consequences of such a change might be are unknown at this
time. Public commentary will be sought on the proposed change in regulations.
Whether such regulation would be helpful or overly simplistic, resulting in an unin-
tended consequence of increasing the number of cigarettes smoked or the intensity of
inhalation, can only be speculated at this time. How soon new regulations will be
determined and implemented is also unknown. Given the actions of the tobacco
industry, delay tactics are to be expected.
352 HERRING

A Continuing and Pressing Health Concern

It is tempting to take comfort in the overall decline in numbers of individuals smoking or

reduced individual cigarette consumption. What healthcare professional has not frequently
heard patients proclaim, “At least I’m not smoking as much as I did before.” This author
has periodically had clients say, “My doctor said as long as I keep it to only five cigarettes
or less per day, it’s not so bad.” That advice may be well intended—an attempt to convey
a desire to provide additional incentive and encouragement rather than criticism to some-
one who is making attempts to stop smoking. The problem with that misguided advice is
that smoking a low amount is difficult to maintain for most people for long periods of time.
The addictive elements of smoking generally cause escalation over time, especially when
life stresses peak or self-limitations become less rigorous.
Of greater significance is recently published research reporting that low smoking
consumption is not protective. Hackshaw, Morris, Boniface, Tang, and Milenković
(2018) conducted a meta-analysis of 141 cohort studies and concluded that smoking
only one to five cigarettes per day presents approximately half the risk for heart
disease and stroke as smoking 20 cigarettes per day. They state “clearly that no safe
level of smoking exists for cardiovascular disease… . Smokers need to quit completely
rather than cut down if they wish to avoid most of the risk associated with heart
disease and stroke, two common and major disorders caused by smoking” (p. 12). It
therefore behooves each of us, as healthcare professionals of whatever specialty, to
raise awareness with consumers as well as other healthcare professionals that no safe
level of smoking exists; smoking, in all forms and amounts, needs to stop completely.

Patches, Pills, and E-Cigarettes

Some providers may know of local resources for classes, counselors, or health coaches
who teach cognitive-behavioral skills to better manage habits that impact chronic
disease, but many providers may not know about community resources specializing
in tobacco cessation. In addition, the U.S. consumer all too often has the inclination or
mind-set to reach for a pill or patch to overcome years of physical addiction and
unhealthy habits. After all, it seems much easier to many folks to have a medication to
resolve a health risk than to put in the time and effort to achieve the desired health
outcome (Katch, 2015). Much of the health promotion literature addressing poor
nutrition, excess weight, and risks for chronic disease support Americans’ inclinations
to turn to medication before making behavioral changes (Carr, 2017). Changing habits
can be hard. Providers and consumers alike have been conditioned to think of drugs as
a more predictable way to attain the desired outcome.
Although it would be wonderful if pharmaceutical products for tobacco cessation
offered high success rates with low risk, they do neither. Pharmaceutical agents to
 HYPNOSIS INTERVENTION FOR TOBACCO CESSATION 353

assist tobacco cessation consist of nicotine replacement or oral prescription medica-

tions. Nicotine replacement is available over the counter (OTC) and comes in the form
of patches, gums, or lozenges. Nicotine sprays are available by prescription. Dosage
needs to be appropriate to the level of tobacco use so as not to provide more nicotine
than the individual was receiving through his or her tobacco use. But insufficient,
excess, or poorly timed nicotine replacement will hinder success as well.
Prescription medications consist of bupropion (Zyban) and varenicline (Chantix).
They are to be started one week prior to stopping tobacco use, and taken for seven to
12 weeks or perhaps longer. While generic bupropion costs approximately $225 for the
course of treatment, brand medications cost considerably more. Medication costs vary
widely for individuals in the United States, based on possible insurance coverage or
coupons, but an approximate cost for 12 weeks of treatment can be $600 to $800 or
more, according to estimates found at drugs.com.
A detailed discussion of side effects and interactions with other medications is
beyond the scope of this article. A quick review of the literature provides a rather
lengthy list of minor to severe adverse reactions for the the mentioned nonnicotine
medications. Labels include warnings for possible psychosis, paranoia, and anxiety. In
2009, the FDA required black-box warnings on Zyban and Chantix for risks of suicidal
tendencies, hostility, and depression; it announced the removal of that black-box
warning in December 2016. Debate about their safety continues. Many feel the risks
secondary to tobacco use are greater than risks posed by the medications and that
Chantix and Zyban are safe and effective (Semedo, 2017; Sterling, Windle, Filion,
Touma, & Eisenberg, 2016). For many years the literature reported no increased
cardiovascular risk with use of Chantix and Zyban. However, in 2011 the FDA issued
a safety announcement concerning possible increased adverse cardiovascular events
with Chantix use (U.S. Department of Health and Human Services, Food and Drug
Administration. Drug Safety and Availability, 2011, July 22). Results of a large
Canadian study recently published in the American Journal of Respiratory and
Critical Care Medicine found a 34% increased risk of cardiovascular events that
include arrhythmias, angina, stroke, and myocardial infarction while taking varenicline
(Gershon et al., 2018). Tobacco clearly imposes health risks to users, but the risks of
prescription medications and OTC nicotine replacement products cannot be ignored.
In addition to their costs and possible side effects, these products have disappointing
efficacy rates. Gonzales et al. (2006) reported a comparison of effectiveness of varenicline,
bupropion, and placebo. At the 12-week mark, abstinence rates were 44.0%, 29.5%, and
17.7%, respectively. At the 52-week mark, continuous abstinence rates were 21.9%,
16.1%, and 8.4%, respectively. A randomized trial of smokers with stable cardiovascular
disease by Rigotti et al. (2010) produced similar results. When comparing varenicline to
placebo at 12 weeks, the continuous abstinence rate was 47.0% and 13.9%, respectively.
At 52 weeks, continuous abstinence was 19.2% and 7.2%, respectively. There was no
354 HERRING

statistical difference in cardiovascular or all-cause mortality, but 9.6% of varenicline users

discontinued the study, while only 4.3% of the placebo group dropped out due to adverse
events. Products address only the physical aspects of tobacco addiction. Tobacco addiction
has physical, emotional, social, and behavioral components. None of these prescription or
OTC products addresses the needed skills for managing stress or behavioral skills for
coping with social and behavioral triggers that will be present for individuals after they
stop using a tobacco-cessation product. It seems reasonable to presume that the disap-
pointing success rates of these medications are due to their target being limited to physical
components of addition.
Recent entries into the market are e-cigarettes (ECs), which are various electronic or
vaporizer products that deliver nicotine in a vapor rather than smoke. These electronic
nicotine delivery systems (ENDSs), also referred to as vaporized nicotine products
(VNPs), contain batteries that heat liquid nicotine, flavorings, and other chemicals into
an aerosol. When they became available, it was hoped they would offer a safe alternative
to smoking or might help in transitioning smokers to being tobacco free. These products
avoid combustion, but little is known about the other chemicals in ECs or the long-term
effects of using them. At present there is no regulation of their nicotine levels.
In 2016 the FDA finalized a rule authorizing its Center for Tobacco Products to
regulate all tobacco products, including ENDSs. This does not include products
marketed specifically as a therapeutic product to help people stop smoking; therapeutic
products are regulated by the FDA through the Center for Drug Evaluation and
Research (CDER). The regulations related to ENDS products include not only the
products and their manufacturing but issues related to their import, packaging, label-
ing, advertising, promotion, sales, and distribution (U.S. Department of Health and
Human Services, Food and Drug Administration, Tobacco Products, 2018). Late in
2017 “FDA Commissioner Scott Gottlieb, MD, made it clear that the agency now
considers e-cigarettes to be less harmful than conventional cigarettes and a potential
tool for smoking cessation, and that it will move forward with regulation of the
products with this view in mind” (Boyles, 2018a, January 2).
In February 2018, the American Cancer Society (ACS) released its position statement on
ECs. This statement included encouraging the FDA to regulate ECs as well as all tobacco
products. The ACS continues to urge smokers to quit smoking and to urge clinicians to
support smokers to quit, no matter what approach they use, including ECs. The ACS also
states that smokers who have no intention of quitting should be encouraged to switch to ECs,
which it views as preferable to smoking combustible products, but ACS strongly discourages
the concurrent use of conventional cigarettes and ECs: “The FDA should assess whether
e-cigarettes help to reduce tobacco-related morbidity and mortality, and the impact of
marketing of e-cigarettes on consumer perceptions and behavior” (ACS, 2018).
Not everyone considers ENDS safe, perhaps not even safer. Considerable controversy
revolves around ECs’ impact on health, smoking rates, and how best to regulate their
 HYPNOSIS INTERVENTION FOR TOBACCO CESSATION 355

marketing and availability. In a recent BMJ editorial, Johnson (2018) states that despite lower
levels of carcinogens, new tobacco products, such as ECs, may still carry substantial risk for
heart disease and stroke by exposing users to high levels of ultrafine particles and toxins, and
that to consider them reduced risk is premature: “Somewhat lower emissions of many toxic
substances from heat-not-burn cigarettes do not make these products safe. Regulatory
approval of these products should be withheld. We cannot afford to wait several more
decades to document the illness, disability, and deaths caused by new recreational tobacco
and nicotine products” (Johnson, 2018, para. 11). Yet another concern regarding ECs is that
they may lead youth to start smoking (National Academies of Sciences Engineering
Medicine, 2018). In March 2018, the American Academy of Pediatrics, American Cancer
Society Cancer Action Network, American Heart Association, American Lung Association,
and several other health organizations filed suit against the FDA following its announcement
that it will delay review of ECs until 2022 (La Vito, 2018; Perrone, 2018).
The effectiveness of ENDSs for assisting smokers to stop smoking also is not
resolved. Few studies have investigated the impact of ENDSs on smoking patterns
and quit rates. Levy et al. (2017) state, “The evidence suggests a strong potential for
VNP use to improve population health by reducing or displacing cigarette use in
countries where cigarette prevalence is high and smokers are interested in quitting”
(para. 1). But Rigotti et al. (2018) found, in a randomized study of 1,357 hospitalized
adult cigarette smokers who planned to quit, that those who used ECs were less likely
to abstain from tobacco at six months than participants who did not use ECs. Because
few participants used ECs regularly, researchers acknowledge further study is needed
to determine how regularity of use of ECs affects cessation and whether ECs aid or
hinder smoking cessation.
Thus, questions about the usefulness of nicotine replacements, prescription medica-
tions, and ENDSs in assisting tobacco cessation remain. While these products may be
helpful for some tobacco users, risks, benefits, and effectiveness have not been resolved.

The Power of Medical Providers to Influence Tobacco Users

Most smokers verbalize understanding the risks of tobacco use. Even if consumers know
only one or two risks of smoking, the days when the tobacco industry actively fostered
doubt about the hazards of smoking are long gone. With the number of medical studies
reported in the media over the years, it is more difficult for smokers to deny the risks of
tobacco use. Surveys show that 68% to 70% smokers who are active smokers would prefer
to be tobacco free (Babb, Malarcher, Schauer, Asman, & Jamal, 2017).
Young adults may deny that they personally are experiencing any negative physical
effects from tobacco, but over time most smokers want to stop before they feel the
consequences, or if they continue using tobacco, they begin to recognize some physical
limitations and health problems that are being caused by tobacco use. This recognition
356 HERRING

may enhance readiness to stop smoking or chewing. Unfortunately, for some indivi-
duals it may take a health crisis to move them to a point of readiness to make
a commitment to stop. One thing is certain: Simply giving data to individuals about
the risks of smoking, badgering them in a pejorative manner, or taking other over-
zealous approaches will likely be ineffective or counterproductive.
While questions about tobacco habits are routinely included on medical history
forms, it can be difficult to squeeze discussions of tobacco cessation into busy clinic
schedules. Some healthcare providers are reluctant to bring it up to patients, assuming
that addressing smoking either will have little impact on patients’ behaviors or could
create irritation and resistance from patients. Some primary care practitioners raise the
issue, but they will move on to the next issue if patients seems ambivalent or
disinterested (Brookes, 2016).
Better training for primary care practitioners could help overcome these barriers.
Indeed, studies show that just talking about readiness to stop smoking is in fact helping
move patients along the change continuum (Center for the Advancement of Health,
2008). It is hoped that awareness of this information will result in more providers
addressing tobacco use during patient encounters. Discussions do not need to be long
or intensive; just raising the topic will move some smokers to greater consideration of
stopping. And as primary care providers and medical specialists address health risks
with smokers in more supportive ways, encouraging behavioral change in
a nonjudgmental manner, smokers may feel concern rather than pressure and be
more interested in exploration of resources to help eliminate tobacco use.
Unfortunately, not all healthcare professionals have an understanding of change
theory or have the necessary communication skills to engage patients effectively. Even
those who would like to discuss tobacco cessation with patients feel the challenge of
heavy patient loads and limited time. Demands of documenting mandated topics in the
health record can result in resistance or token attention to wellness behaviors or
problems other than the identified issue for the appointment. Some physicians are
employing health coaches, trained in techniques such as motivational interviewing, to
work with patients who need to make behavioral changes to improve their health. In
addition, providers may welcome the knowledge of other healthcare professionals in
the community to whom they can refer patients for assistance with tobacco cessation.

Hypnosis, an Underappreciated and Underutilized Tool

Most healthcare professionals are likely to recommend patches or medication before

advising a patient to consider hypnosis for tobacco cessation. Indeed, this author
suspects that, were studies available, they would demonstrate that the vast majority
of physicians, physician assistants, and nurse practitioners are disinclined to ever
suggest hypnosis. A number of reasons might account for that, including lack of
 HYPNOSIS INTERVENTION FOR TOBACCO CESSATION 357

understanding about the utility and credibility of hypnosis, heavy marketing and
ubiquitous supply of pharmaceutical tobacco cessation products, and greater likelihood
of insurance coverage for prescriptions to support tobacco cessation.
Some employers provide financial support to partly offset employees’ expenses of
treatment to stop smoking. Most companies promote conventional approaches, such as
nicotine replacement, classes/counseling, or prescription drugs, to control cravings.
When this author was employed at Motorola in the 1990s, the corporation provided
moderate financial support to any employee desiring to stop tobacco use, including
choice of nicotine replacement and support classes, as well as hypnosis. Medications
were funded through medical and pharmacy benefits. This was well in advance of local
and national movements to restrict public smoking areas. Motorola was also at the
forefront in recognizing the benefits hypnosis could offer employees who chose that
approach for tobacco cessation. In recent years, as healthcare costs continue to rise
throughout the country for both employers and employees, various employee benefit
programs have been scaled backed or eliminated. Even though having fewer employ-
ees who use tobacco results in decreased absenteeism, decreased health costs, and
increased productivity, corporate incentives for tobacco cessation programs are not as
prevalent as might be desired.
All too often, hypnosis for tobacco cessation raises the image of lay hypnotists
offering hypnosis in a local hotel ballroom for hundreds of smokers. And it is not
difficult to find webpages for lay hypnotists who promise success with claims of even
90% to 100% effectiveness. These tropes distort consumer understanding and expecta-
tions of hypnosis and tarnish the reputation of hypnosis as a credible tool. Lay
hypnotists may have good intentions, but their training in only the techniques of
hypnosis, without formal education in biopsychosocial principles of nicotine addiction,
human behavior, and change theory, limits their effectiveness.
Even when individuals, employers, and healthcare providers understand the value of
hypnosis for tobacco cessation, the low numbers of licensed medical and mental health
professionals with hypnosis training make it difficult to find qualified providers of
hypnosis. In addition, not all licensed practitioners who are qualified to offer hypnosis
as one of their professional services have an interest in tobacco cessation. Part of the
goal of this article is to encourage more licensed practitioners to consider the value and
service of helping clients eliminate tobacco dependency and addiction and to share
approaches this author has found to be practical and productive.
Outcome studies of hypnosis effectiveness for tobacco cessation are inadequate
in quantity and limited in quality. Better information from outcome studies might
stimulate the interests of more hypnosis professionals to offer tobacco cessation for
clients wanting to be tobacco free. With increased publication of studies, physicians,
dentists, and other medical specialists might be more inclined to refer tobacco users
to hypnosis professionals for therapy to stop tobacco use. Pharmaceutical companies
358 HERRING

have ample resources to fund studies and then publicize study outcomes and market
their products, yet there is little funding for hypnosis research. Certainly it would be
helpful to have more well-designed outcome studies. At present, evidence that
hypnosis demonstrates strong effectiveness is just not available. But while evidence
of the effectiveness of hypnosis in tobacco cessation is sparse, it is not nonexistent.
There is evidence that it may be as effective as some other interventions. For
a more thorough discussion, the reader is referred to a very thoughtful review by
Lynn, Green, Accardi, and Cleere (2010) titled “Hypnosis and Smoking Cessation:
The State of the Science.”
A recent Cochrane Review, published October 2010, examined randomized con-
trolled studies of hypnosis for smoking cessation that reported abstinence rates at least
six months after the intervention. The review concluded that evidence of hypnotherapy
as more effective than other interventions was insufficient (Barnes et al., 2010). The
review did not conclude hypnosis was ineffective; rather, it noted that it was possibly
effective, but good evidence was insufficient to make a determination. This distinction
is important if someone is claiming that hypnosis is ineffective.
Hasan et al. (2014) reported results of a study of 164 patients, randomized to one of
three counseling-based groups, comparing hypnosis alone to hypnosis with nicotine
replacement and to conventional nicotine replacement therapy (NRT). Hypnosis inter-
vention consisted of one 90-minute session. Outcomes of these three groups were
compared to a “self-quit” group of 35 patients who had refused intervention.
Abstinence rates for both hypnosis and hypnosis with nicotine replacement were
similar and exceeded the NRT group. At 12 and 26 weeks, abstinence for hypnosis
compared to NRT was 43.9% versus 28.2% and 36.6% versus 18%, respectively.
Carmody, Duncan, Solkowitz, Huggins, and Simon (2017) conducted a randomized
study comparing the effectiveness of hypnosis to behavioral counseling for smoking
relapse prevention. Following a three-day period of abstinence, participants were
randomized into a behavioral counseling or hypnosis group. Intervention for both
groups consisted of two 60-minute face-to-face sessions and two 20-minute phone
calls for two weeks. The hypnosis sessions were scripted and recorded, and partici-
pants were given a recording of each session for their independent practice. At
52 weeks the hypnosis group had a validated quit rate of 29%, while the behavioral
group had a quit rate of 28%. Although the hypnosis success was not significantly
higher, it was comparable to the counseling group, which is helpful to know because
many smokers find the option of hypnosis appealing.
Methodological difficulties in studies for hypnosis is challenging regardless of the issue
or problem being targeted for hypnosis. Using a standardized script so that hypnotic
intervention is uniform violates the patient-centered Ericksonian model of care. It does
not allow a shifting of emphasis for individual triggers for tobacco use. It forces sugges-
tions and metaphors to be one-size-fits-all. Standardized scripts allow for control but may
 HYPNOSIS INTERVENTION FOR TOBACCO CESSATION 359

not adequately target individual issues. Does an individual patient struggle more with
initiation of abstinence or is the challenge more on maintenance to avoid relapse? Does he
have several triggers or is he subject to a singular, unavoidable, powerful trigger? Smokers
often share some common triggers for smoking, but certainly each smoker has some
unique concerns and needs.
This author believes conclusions that hypnosis is ineffective or marginally effective
are due to weakness in research design rather than a weakness of hypnosis as an
effective modality. Heterogeneity in hypnosis study designs restricts strength of meta-
analysis. Having additional outcome studies would allow a more precise understanding
of the number and length of hypnosis sessions, type of suggestions, and overall design
of tobacco cessation programs that lead to greater success. Surely more quality
research would help gain the attention of providers, consumers, employers, and
perhaps the insurance industry to increase the credibility of hypnosis as an intervention
option for tobacco cessation.

Sample Hypnosis Protocol

Eliminating a tobacco habit may be the single most impactful change an individual can
make to improve short- and long-term health. This author enthusiastically embraces
opportunities to assist individuals in becoming tobacco free. It is hoped that the
information provided in this article regarding the risks and impacts of tobacco will
renew the readers’ commitment to develop or refine a program that incorporates
hypnosis for tobacco cessation within their own practice.
This author has fine-tuned her own approach, and the remainder of this article
highlights the program that has been successful in helping many of this author’s
clients. While no single approach is the answer for every provider or client,
a carefully designed, evaluated, and refined program offers greater potential for
success. Unfortunately, this author has heard some licensed healthcare professionals
who have training in hypnosis make statements such as “Hypnosis is not helpful for
habit changes” or “Don’t bother using hypnosis for smoking cessation.” This author
respectfully disagrees. However, like many endeavors, if we begin with self-doubts
and expectations that we will fail, we increase the chances that failure will result. The
following four-session program is offered to encourage more professionals to success-
fully help clients rid their lives of tobacco.
Not every client is appropriate for hypnosis, and not every person who schedules an
appointment to stop smoking is truly at the stage of readiness to change. Prior to
meeting with clients, this author sends history forms to them that must be completed
and returned prior to the appointment. The answers, as well as the thoroughness of the
answers, help shed light on client readiness. Knowing health history, life challenges,
smoking patterns, and triggers will help prepare the provider. Answering questions
360 HERRING

also helps the client think about what was tried in the past, what challenges are
anticipated, and what personal strengths can be. Some of the information critical to
successful planning for each individual tobacco user is knowing what he or she likes
about smoking (or chewing) and what is disliked—factors that may not be as obvious
as they seem. This author also asks clients to complete a 24-hour smoking log that
contemporaneously captures the time each cigarette is smoked, what they were doing
at the time, and how strong the desire for that particular cigarette was. It is amazing
how consistently smokers arrive and say they never realized how many cigarettes they
are smoking that they did not even have an urge or desire to smoke. All of this
information is used in the first appointment to begin developing rapport. This informa-
tion will also be used during future sessions to formulate suggestions that are person-
ally relevant for the client.
This author does not test hypnotizability. In a research study that information may be
relevant; in the clinical setting it is not essential. Clients will vary in hypnotizability, but this
program incorporates more than hypnosis. For example, during the first session, brief
information is gathered on a client’s eating habits, including timing of meals/snacks and
types of food eaten. When dealing with nicotine withdrawal, inadequate hydration or
nourishment will reduce coping ability and comfort. We also discuss plans to avoid replacing
cigarettes with candy or excess food. As metabolism drops for a period of time after removing
nicotine, it is counterproductive to supply the body with excess carbohydrates that can
quickly evolve into blood sugar spikes followed by hypoglycemia. Low blood sugar
produces physical discomfort and moodiness that a smoker may attribute to the need for
a cigarette. High-glycemic snacks also can establish a sugar addiction and weight gain.
During the first appointment it is helpful to point out prior experiences, strengths, and
any client insights that bode favorably for becoming a nonsmoker. This helps strengthen
expectancy. A few positive suggestions can be embedded in conversation. Indeed, one can
embed a subtle positive expectancy in the cover letter that goes out with history forms.
This author closes the cover letter to tobacco users with the statement “I look forward to
helping you become a nonsmoker for good.” The words “quit smoking” are never used in
written or verbal communication with clients. “Quitting” and being “a quitter” can have
negative connotations. This program is designed to empower clients.
Using information gained in the interview, from the history forms, and from the 24-
hour smoking log, the author chooses one smoking location or activity and, with the
client’s agreement, gets a commitment that from now on, this very moment, he will no
longer smoke in that situation. Many clients smoke in their car, so that is an easy
situation to establish as a tobacco-free activity. Clients can stand outside their car and
smoke before departing or upon arrival at a destination. They can even pull off the
road to a safe location, get out of the car to smoke, and then get back in the car and
continue on to their destination when the cigarette is done, but they cannot smoke
while driving, being a passenger, or even sitting in a car.
 HYPNOSIS INTERVENTION FOR TOBACCO CESSATION 361

Or it might be that clients enjoy reading the morning paper or e-mail with a cup of
coffee and a cigarette. They can continue to read and have coffee, but the cigarette needs to
be smoked in a different location from enjoying reading and coffee. Only one smoking
activity is eliminated, but one of the more firmly entrenched habits is chosen. Clearly this
requirement gives an opportunity to experience successive approximation and to develop
coping skills. It also serves as ego strengthening when they are successful, even if success
is not 100%. While the first session discusses what to expect with hypnosis, hypnosis is not
incorporated until the second session. Clients already know from the initial phone con-
versation that they will not stop smoking until the third session.
During the initial interview it is important to listen carefully to see whether the
client experiences life with more visual, auditory, or tactile language. And in subse-
quent trance work, does the client relate visual, auditory, or tactile sensory experience?
Was the client passively experiencing or actively doing or interacting with something
while in trance? This information is crucial for building suggestions within a client’s
perceptual frame of referencing life experiences. Indeed, this is the basis of any
individualized trance work, but it is especially helpful for conditions that have
physical, emotional, and behavioral components.
At the second session we begin by discussing what it was like going through the
seven to 14 days between appointments and not smoking in the chosen tobacco-free
zone. Successes are celebrated. Struggles are accepted, and additional behavioral
alternatives and cognitive reframings are discussed. During this appointment clients
are taught a 30-second breathing technique that can help at any time of stress. The
technique is practiced with the provider so clients feel confident doing it before they
leave. They are told to practice this exercise four times every day until their next
appointment. Practicing when they are not stressed develops the skill so that the
technique becomes automatic when needed in times of stress. We also discuss their
vision of themselves as a nonsmoker. Based on their incentives for becoming tobacco
free, this author helps them develop a detailed vision of what being a nonsmoker will
be and will enable them to do. This helps clients focus on what they are becoming and
gaining, rather than focusing on preparing for the battle over tobacco. They are told
they can continue developing their vision during the week and that they will use this
vision in the future to get over nicotine cravings. We discuss the common timeline of
nicotine withdrawal and that having a cigarette once they have stopped starts the
timeline over. This author shares that hypnosis has a strong influence to minimize
cravings, but it does not eliminate all cravings; by using the tools they are learning,
they will able to get beyond cravings and beyond tobacco. It seems prudent to set an
expectation for controllable and diminishing cravings rather than zero cravings.
Most tobacco users have made attempts over the years to stop smoking or chewing
tobacco. Sometimes they have successfully stopped for long periods of time; some-
times cessation was only a day or two. Reviewing prior experiences not only alerts the
362 HERRING

therapist to important content for hypnotic suggestions but also helps the clients
appreciate the importance of planning rather than stopping abruptly without a plan.
In addition to ongoing planning, during the second appointment we do a short
hypnosis session designed for stress reduction. It is constructed to provide ego
strengthening to enhance personal conviction. Some means of trance ratification is
provided and discussed in the posttrance period to help clients unfamiliar with
hypnosis develop confidence that they can successfully “do” hypnosis.
Trance content of a “safe place” lends itself to a good first experience, as it is
flexible and can accommodate individual history, usually provides profound relaxation
sensations, and will provide the therapist with good indication of the client’s hypnotic
skills. During the safe place experience, guiding the individual to reexperience
a success from the past, or providing an opportunity for the client’s “discovery” of
symbols of success, can be incorporated for ego strengthening. Symbols “encountered”
in the safe place might be diplomas, licenses, craft/building projects, children, and so
on. The therapist might be specific and direct using the language of a symbol, or
language can be indirect, such as, “Now as you walk a bit further in this wonderful
place, as you go just a bit further, or maybe you look to your left or right, you discover
something that reminds you of [how much you learned in school; how many wonderful
things you accomplish at that job; what wonderful experiences you had as your
children grew and developed their skills and individual personalities; and so on].”
This author intentionally keeps the language of trance in this second appointment
focused on things other than tobacco cessation. Both in pretrance and trance work the
intent is to reassure the client that we are taking this journey with planning, and there
is time to accomplish each step without rushing or struggling. Therefore, the only
tobacco-related suggestion this provider uses in the later portion of the first trance
experience is “And you can look forward to [date of next appointment] when you will
become a nonsmoker.” This idea will be reinforced two or three more times with
similar but not necessarily identical language: “You can enjoy knowing that you are
making plans and taking steps so you will soon be free from cigarettes.” In addition,
a suggestion can incorporate specific information of what is motivating this particular
individual, such as with this phrasing: “You can look forward to how nice it will be in
just a couple weeks when [you are free or the smell of smoke; you are saving money;
you are improving your health and stamina].” Indeed, whatever the main reason
a client has for becoming tobacco free, a suggestion can be formulated so the
individual enjoys positive anticipation of the change.
Before clients leave this second session, we talk about preparing their home to be
the home of a nonsmoker. Plans are made for any cigarettes remaining on the day of
the next appointment, the “stop date,” as well as washing and putting away ashtrays or
lighters associated with smoking and changing the areas of their home where they
formerly smoked.
 HYPNOSIS INTERVENTION FOR TOBACCO CESSATION 363

The third appointment addresses being a nonsmoker now and going forward. For this
appointment, clients are instructed to get up that morning, modify their routine now as
a nonsmoker, and go about their day tobacco free. During the appointment we discuss what
the day has been like, adjust any plans, review coping strategies, and have a session packed
with suggestions for being tobacco free. Whether suggestions are direct or indirect,
negative and aversive suggestions are never given because they are less effective than
positive suggestions. The session is recorded, and the client is instructed to listen to the
recording at least daily, preferably twice daily, until the next appointment.
Suggestions for this session focus on three areas, and emphasis among the three areas
will shift based on individual needs. First, because nearly all tobacco users approach
cessation with some degree of trepidation, suggestions for ego strength can support clients’
confidence for internalizing the new identity of being a nonsmoker. Suggestions for ego
strength are fundamental to all hypnosis and do not need further elaboration.
Symptoms of nicotine withdrawal will decrease over time, but individuals are
especially vulnerable in the early days and weeks of tobacco cessation. Therefore,
suggestions are given for coping to increase tolerance of cravings, increase awareness
of comfort, and increase likelihood of success. If a client’s language and frame of
reference for life experiences is dominant in a single sensory area, suggestions can be
formulated for that specific sense, or sensory areas can be combined. For example,
cravings can be reduced with suggestions:

And as you approach the waterfall, it looks so inviting. I wonder if you can see how clean the rocks
below the waterfall are? So clean they glisten in the sunlight. And there’s a fresh, cool mist rising
around the waterfall. As you breathe in some of that mist, it is so refreshing and soothing. Notice how
comforting it is as it travels with the breath into your lungs. Soothing, calming, comforting all the way
in, all the way down. And if you like, you can step into the shallow pond. Standing under the waterfall
it gently flows down from the top of your head … and neck, all the way down your body … washing
away not only dust from your journey, but also washing away anything you are better off without. Any
pain, tension, worry, cravings, discomfort of any type—slowly, steadily, calmly washed away.
Anything you are better off without washed away, leaving you feeling wonderful. And when you
first came upon the waterfall it might have sounded like a roar. Now I wonder if you might describe it
as a low hum or maybe you already don’t even notice the sound of the waterfall, as you enjoy more and
more comfort within, and notice the peace and balance of nature all around you.

Suggestions for release from cravings should be based on sensations, activities, or

experiences the clients enjoy. If they like being in nature, detailed descriptions of being
in the setting they enjoy—whether mountains, forests, beaches, and so on—can then
incorporate a suggestion of a soft, fresh breeze blowing away the old habits and
cravings for cigarettes: “I don’t know, and you can just notice, whether the breeze is
cool or warm, and whether it is steady or comes and goes, maybe increasing and then
decreasing when it is of most help and comfort for you.” For those individuals who
enjoy the beach, it offers many sensory and metaphorical opportunities to decrease
364 HERRING

cravings. After several minutes of beach language and sensory experiences, this author
often will suggest the following:
And knowing how you love the beach, and sensing how the beach enjoys your presence and desires to
be supportive, you might want to take this opportunity to pass any cravings you have to your beach, and
ask the beach to dispose of the cravings. And just be surprised to notice what you notice. Perhaps the
cravings wash out to sea, far out to sea, where they dissolve and drift away into nothingness. Perhaps the
sand at your beach takes the cravings and buries them away where they stay away from you, and you
can walk away feeling so free. Maybe there is another way the beach helps rid you of cravings; you can
be surprised to notice what you notice and how you can enjoy feeling comfortable and strong.

Between the third and fourth appointments, clients are also instructed to phone the
provider every day anytime before noon. The provider may be able to answer or callers
might get voicemail. Either way, their call begins with “Hello, this is [client name],
and today I’m a nonsmoker.” They can go on to discuss issues, questions, or concerns,
and to request a return call if they want to talk with this provider. The call serves
a number of purposes. It reinforces their new identity, and the verbalization helps them
own the identity and commitment. It also serves as an early warning system to the
provider. One day may go by without a call from a client; we all get busy from time to
time. But if the afternoon of the second day arrives without a client having called, this
provider will call him or her to ascertain how it is going and provide guidance. If
needed, the fourth appointment can be moved closer.
The fourth session, scheduled seven to 14 days after the third, serves to reinforce
success and shore up any areas presenting challenges for clients. Many people approach
this session feeling minimal need, but it is important to complete. We discuss risks of being
overconfident or too casual if cigarettes are available. The trance incorporates appropriate
suggestions based on their experiences and progress these few weeks.
If they are progressing without major difficulty, it is easy to build a session of
progressive healing from smoking. Sensory language for healing of lungs, clearing of
mind, and calm steadiness and strength to heart are reinforcing. If they are struggling,
a metaphor for overcoming barriers is helpful. This author likes to discuss how water flows
down the stream:
On some days, in some places the water flows effortlessly. Then, from time to time, it may encounter
logs or boulders that make the journey less direct. Rather than stopping, the stream bends and stretches;
it might gather itself up to appreciate its strength, so it can roll over or find a way around the barrier,
soon flowing along smoothly.

If clients report struggle or “failure,” it is important to normalize this challenge and

translate it into a learning experience. Reinforce motivation and expectancy whether in
conversation or trance.
Already you’ve discovered, even in this short time, how you’ve successfully gone from 20
cigarettes per day down to only one or two. You’ve learned how to ignore thoughts about having
a cigarette all those 18 or 19 times. I wonder how powerful you will feel when you go through
 HYPNOSIS INTERVENTION FOR TOBACCO CESSATION 365

a whole 24 hours totally free from smoking even a puff. What might you like to say to the cigarettes
that thought they would always control you? What will you do to celebrate the day of total freedom
from smoking? Each day after that will be special. And then each week and month and year will be
powerful freedom for you.

Sometimes clients indicate that they feel “giving up smoking” is like losing a friend.
Indeed, for many years they received some element of comfort from smoking.
Modified grief work may be appropriate. This author provides trance language and
suggestions about genuine friends and contrasts those friends to people we might have
thought of as friends but who betrayed our friendship:
We do not allow people who betray us or treat us badly to remain a friend; we banish those people
from our lives. And so you thought cigarettes were a comfort; you thought they were a friend. But
they aren’t. It’s all an illusion. Smoking steals our [health, money, beauty, professional image, life
to see our children grow up, etc.].
The object chosen for the previous suggestion is based on client’s primary reasons for
stopping tobacco use.
Whether the client reports little struggle or great struggle, one of the suggestions
this author offers at the fourth and likely final appointment is one for anticipation of
a new norm: “And you can be surprised when you notice how long you go without
even thinking about cigarettes.”
Many hypnotherapists provide tobacco cessation programs as one-session designs.
Certainly people can become tobacco free after a single intervention. This author
believes most smokers feel stress and fear of failure in finally making the decision
to stop tobacco use. A single session might add undue stress or worry. The tobacco
users this provider has worked with welcome the security of having four sessions, in
addition to the preparations for making the important change in their lives prior to the
start of sessions. If additional appointments are desired or needed, they can be
provided, but they are rarely requested. Successfully overcoming a tobacco habit
becomes a rewarding experience for the client and provider alike.

Conclusion

Tobacco use in the United States continues to be a pressing public health problem
that shortens lives and remains a financial burden to individuals and our healthcare
system. It is estimated that smoking costs more than $300 billion a year in direct
medical care for adults and their lost productivity (CDC, Smoking and Tobacco
Use, 2017b). Thus, it is imperative that healthcare professionals remain active
advocates for approaches, products, and interventions that will assist individuals
in their cessation efforts. Hypnosis is an intervention with excellent potential to
support individuals of all ages who are ready to make a commitment to be tobacco
free. Healthcare professionals with training in hypnosis need to promote hypnosis as
366 HERRING

a credible modality to consumers and other health professionals who may be

unaware of the value of hypnosis. While studies show hypnosis to be at least as
effective as other approaches to tobacco cessation, more well-designed outcome
studies are certainly needed to impart a better understanding of how and why
hypnosis can be provided to assist tobacco users to attain the greatest success in
becoming tobacco free. Expanded collaboration between clinicians and researchers
can lead to greater success for consumers and healthcare professionals.

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