1. Stop Smoking With Hypnotherapy Training Day Ursula James Mark Feldman

2. Who are we?

3. Ursula James Vice principal London college of clinical hypnosis Vice president British society of clinical hypnosis Executive member of the British association of medical hypnosis.

4. Ursula James Lecturing –LCCH –Oxford University medical students Research –Pain control –Dermatology –Heart function

5. Ursula James Expert systems –For hypnotherapy in smoking cessation

6. Mark Feldman Senior partner general practice Trainer in general practice – Regional GP selection –Allocation

7. Mark Feldman Petersfield Screening –Health Screening –Occupational health –Private General practice Stress lecturing –IPD –Corporate clients

8. Mark Feldman Hypnotherapy –BAMH –Research –Practice

9. Who are You? Already experts –Experienced hypnotherapists –Own methadologies Special group –Todays presentation specifically for this audience

10. Aims of the Day

11. Become a Superhero

12. Aims and Objectives Find out about –Stop smoking clinics –Role of Sure-start Understand –Which diseases are due to smoking –Scale of problem –Advantages of Stopping –Theories of addiction

13. Aims and Objectives Discover –How hypnotherapy fits in to EBM –Details of the LCCH study

14. Aims and Objectives Appreciate –Importance of consistent approach reproducibility for research –Acquire A technique which you can ‘ buy in to’

15. Aims and Objectives Learn –formulaic ‘Expert system’ smoking session which will become a research protocol/NHS standard

16. Aims and Objectives Long term aims – Of initial project: To help those in Sure-start project, who wish to use this facility, to stop smoking To produce sufficient initial data on replicability and efficiency of protocol to obtain funding for area then nationwide project

17. Aims and Objectives Long Term Aims –To produce an ‘Expert system’ in the use of clinical hypnosis as effective in smoking cessation in one session’ –To obtain NHS approved status for this method

18. Aims and Objectives Long Term Possibilities for You –To be involved in the research phase – with payment from NHS funds –To become the first practitioners to have this NHS approved status –To become lecturers on the programme

19. Stop smoking clinics Tobacco Advisory Board of the Royal College of Physicians ‘nicotine delivered through tobacco smoke should be regarded as an addictive drug and tobacco use as the means of nicotine self administration’

20. Stop smoking clinics Launched in health action zones in 1999 Cost £60 m over 3 yrs Between April 2000 and March 2001 –127000 smokers set a quit date –48% stop at one month

21. Stop smoking clinics Estimate –£ 600 per life year gain for smokers 35-44 –£750 per life year gain for smokers 45 –54 Compare this with statins for cholesterol –£13000 per life year gained NICE – says < £30,000 per life year is ok for new treatments

22. Stop smoking clinics Local Clinics –2 tiered approach Group clinics One to one sessions through community pharmacists –Validated by carbon monoxide monitor

23. Stop smoking clinics Local Clinics –Patients screened –Offered either Nicotine Zyban

24. Stop smoking clinics Local Clinics –Costs £114 000 per yr –3 full time staff –Consumables / CO monitor –Training –Pharmacists time

25. Stop smoking clinics Local Clinics –From April 2001 – March 2002 836 set quit date 441 ( 51%) successful at 4 weeks from quit date 30% stop at 12 weeks Expected 20% at 52 weeks

26. Sure Start New government initiative –To break the cycle of disadvantage for current generation of young children 10 yr programme £3m budget for 3 yrs

27. Sure Start Brings together –Parents, professionals, community groups Focuses on –Parents, pregnant and children < 4 yrs Works with –Specific postcode areas – patients either ‘in’ or ‘out’

28. Sure Start Objectives Improving social development –Reducing the number of kids < 3 yr on at risk register by 20% Improving health –Supporting parents in caring for their children Target 10% reduction of mothers who smoke whilst pregnant by 2004

29. Sure Start Objectives Improving ability to learn –Better play areas –More libraries for parents Strengthening communities and families –Links with job centres –Accessible childcare for 0-3 yr olds

30. Smoking Stats Introduced from New World in 15 th Century Only a mass habit after 2 nd world war 13 million adults in UK smoke –29% men –25% women In 1974 about 50% of adults smoked

31. Smoking Stats Varying rates throughout country –30% Scotland –26% East Anglia Highest amongst age 20-34 –35% men In the over 60’s –Only 16% smoke

32. Smoking Stats Highest amongst working class –39% men social class 4/5 vs 15% men class 1 80% start as teenagers 450 Children start every day

33. Smoking Stats Smoking kills 120 000 per year in UK That’s 6x more than – the below all together RTA3391 Accidents8933 Poisoning and OD3157 Murder0495 HIV0180 Suicide4485

34. Smoking Stats Half of all smokers are killed by smoking Smoking causes –30% of all cancer deaths [ 80 % of all lung cancer] –17% of all heart disease –80% of all COAD

35. Smoking and Cancer What is Cancer? –Normal contact inhibition –Abnormal proliferation

36. The definitive study Doll and Peto – British Doctors Study 1947- 49 –Established link between smoking and lung cancer –Resulted in most UK doctors stopping almost overnight –Initially thought 1:4 would die due to smoking –Follow up 40 yrs later 1:2.5

37. Smoking and Cancer Result –Local pressure / destruction Nerves Bone Blood vessels Organs Bronchial tree

38. Smoking and Cancer Result –Lymph node spread Eg Breast to axilla –Metastatic spread - typically To bone from –Breast, Bronchus, Kidney, Thyroid, Prostate To Liver from –Colon, Stomach To brain from –Lung

39. Smoking and Cancer Result –Cachexia –Hormonal effects Inappropriate ADH Calcitonin – raised calcium – bones, moans,abdominal groans Neuropathy Acanthosis Nigrans ACTH

40. Smoking and Cancer Lung cancer –90% of all deaths are due to smoking –About 30 000 in UK per year due to smoking –Only 5% will survive 5 yrs

41. Smoking and Cancer Lung cancer

42. Smoking and Cancer Other cancers –Oesophagus 60% of all due to smoking 4500 per yr –Bladder 35% of all due to smoking 2000 per yr

43. Smoking and Cancer Other cancers –Throat and mouth 60% due to smoking 2000 per yr –Kidney 30% due to smoking 800 per yr

44. Smoking and Cancer Other cancers –Stomach30% from smoking – 2000/yr –Pancreas23% from smoking –1500/yr –Leukaemia15% from smoking- 300 /yr

45. Cancer Survival

46. Ischaemic heart disease Smoking –17% of all heart disease deaths – 26000 /yr –If smoke 25 per day  15 x more likely to die –Women who smoke 1-4 / day 2.5x more likely

47. Ischaemic heart disease What is it ? –Angina - chest pain on exertion due to narrowing of coronary arteries –Myocardial infarction - death of a part of heart muscle

48. Ischaemic heart disease What is it ?

49. Ischaemic heart disease What is it ?

50. Ischaemic heart disease Caused by –Raised cholesterol Diet Weight Family history –Raised Blood pressure –Smoking

51. Ischaemic heart disease Smoking –Raises the BP and pulse, makes the heart work harder –Coronary artery spasm –Encourages atherosclerosis –Increases platelet stickiness –Reduces lung function –Carboxyhaemaglobin

52. Other vascular diseases Stroke –11% of stroke deaths due to smoking –Relative risk about 1.5 vs non smokers –If smoke 20 per day 4x risk vs non smokers

53. Other vascular diseases Ruptured aortic aneurism

54. Other vascular diseases Peripheral vascular disease 15 x more common Buergers disease – only in smokers

55. Smoking and Lung Disease Asthma COPD – 27 000 deaths at least 80% due to smoking –Continued decline in lung function Pneumonia 9000 deaths last year

56. Smoking and reproduction Reduced female fertility –Only 72% that of non smokers Increase pill risk –10 yrs older Pregnancy –23% smoke – govt target reduce to 15%

57. Smoking and reproduction Light babies – on average 8 oz lighter Spontaneous abortion Premature detachment of placenta Ectopic pregnancy increased Increased perinatal mortality –420 per year England and Wales

58. Smoking and reproduction Less milk production Lower IQ of children Menopause 2 yrs earlier

59. Smoking and reproduction Reduced sperm counts –Less Y sperm due to toxins Impotence –50% increase in smokers 120 000 men affected

60. Other Illnesses GIT –DU –Colon polyps Eyes –Cataract –Optic neuritis –Macular degeneration –Tobacco amblyobia

61. Other Illnesses Worsening of –Diabetes Retinopathy Arterial problems –Asthma –MS Infections –Cold –Flu –TB

62. Other Illnesses How you look –Tooth loss –2x incidence wrinkles –Psoriasis worse –Bad breath

63. Passive Smoking Passive smoking –Causes 600 deaths from lung cancer each year –Causes 12 000 deaths from heart disease each year

64. Passive Smoking in children Passive smoking –Exacerbation of asthma – Increase frequency of Cot death –Children have 72% increase risk of respiratory problems if both parents smoke

65. Passive Smoking in children Passive smoking –Increase risk of otitis media –17000 children < 5 yrs admitted each year –May affect mental development

66. Stopping Smoking Heart attack risk - after 5 years risk approaches that of non smoker Halves chance of recurrence Stroke risk same as non smokers after 5 yrs

67. Theories of smoking behaviour Peer group Drive for separateness Role Models Mind alteration –Studies show effects on smokers brains equivalent to antidepressants –Withdrawal symptoms

68. Theories of smoking behaviour Weight loss Depression Low self esteem Poor relationships –School –Parents

69. Neurology of smoking Nicotine causes a rise of dopamine in the brain [ due to depressing MAO-a] This leads to addictive behaviour in an attempt to continually reproduce this effect A feeling of high dopamine gives a ‘ high’ cocaine has a very similar effect

70. Neurology of Smoking Normal PET High dopamine after nicotine

71. Neurology of smoking

72. Contents of cigarettes Nicotine –Raises BP, Pulse, –Causes vasocontriction –60 mg will kill you Acetone –Used in nail polish remover

73. Contents of cigarettes Ammonia –Used in fertilisers and cleaning fluids –Increases addictive properties –Lung irritant –Stomach irritant Benzene –Aromatic solvent –Causes cancer cf leukaemia

74. Contents of cigarettes Cadmium –Used in batteries –Liver Kidney and Brain damage Carbon Monoxide –Often associated with deaths from faulty boilers –Carboxyhaemaglobin

75. Contents of cigarettes Formaldehyde –Powerful antiseptic preservative –Causes allergies –Gut problems Hydrogen cyanide –Headaches dizziness vomiting

76. Contents of cigarettes Lead –Heavy metal – –Damages brain, nervous system, kidneys –Red blood cells –Reduces IQ in children

77. Contents of cigarettes Tar –Paralyses cilia –Stains teeth, fingers Shellac –From insect cocoons –Used in wood varnish

78. Bupropion studies 615 smokers – randomised to drug 100mg, 150mg, 300mg or placebo for 7 weeks Try to stop at one week

79. Bupropion studies For 300 mg - at 7 weeks[course end] –10.5% stop with placebo –24.4% stop with drug At one year point prevalence [ no smoking for last week] –12.4% placebo –23.1% drug

80. Bupropion studies 893 smokers one of 4 treatments for 9 weeks – 12 month point prevalence –Placebo oral + placebo patch  15.6% –Bupropion 300mg + placebo patch  30.3% –Nicotine patch + oral placebo  16.4% –Bupropion 300mg + nicotine patch  35.5%

81. Bupropion studies Continuous absence rates = –Bupropion alone  18.4% –Bupropion +patch  22.5% Cost –£86 + counselling – 5 sessions

82. Bupropion studies Problems with Bupropion –11% dry mouth –42% insomnia –6% hypertension { if given with patch} –1:1000 - fitting

83. Bupropion studies Contraindications –Epilepsy –Pregnancy –History of fits –History of head injury –Diabetes on drugs or insulin –Patients on TheophyllineSystemic steroids Antipsychotics Antidepressants

84. Hypnotherapy Studies Hypnotherapy –Safe –Specific Difficult to generalise Few published single session studies

85. Hypnotherapy Studies 226 Smokers [ Spiegel Frishholz Spiegel] –Single session treatment –2 year follow up 53% stop at one week 23% stop at two years

86. Hypnotherapy Studies 40 patients [Berkowitz Townsend Kohberger] –Single session 25% stop at 6/12

87. Hypnotherapy Studies 2810 patients 1997 [ Ahijevych K, Ohio] –Single session group hypnotherapy 22% not smoking one month prior to interview –Telephone interview at 5-15 months

88. Hypnotherapy Studies But –Cochrane review – inadequate data to support hypnotherapy –International Journal Clinical and Experimental Hypnosis [ 2000] – 59 studies  insufficient evidence to support hypnotherapy for smoking

89. Hypnotherapy Studies LCCH method Single sessions Easily learned No side effects Does it work ??

90. Hypnotherapy Studies LCCH study –Single hypnotherapist –LCCH method One hour session only –Follow up one month to one year –Postal Questionnaire

94. LCCH Study Results 59 questionnaires sent { follow up 1/12 to 1 yr } –35 Returned 59.3% Of those returned –30 stopped 85% –1 cut down 2.8% –4 continued unchanged 11..4% At one month –23 stay stopped 65.7% [ 38% if presume all lost to follow up continue ]

95. LCCH Study Results Results beyond this unsatisfactory due to lack of follow up BUT no known restarters after 6 months –Restarters 3 at less than one month 4 at 1-3/12 2 at 4-6/12 –We have a definite 12 stopped at one year { 34% } but as data is incomplete [ Could not be worse than 20% even if all incomplete data showed restarts – some incomplete due to short duration since study started] Could presume 21 stopped at one year which would be 60% stop at one year

96. LCCH Study Results

97. LCCH Study Recently accepted for publication in –European Journal of General Practice

98. The Expert System Criteria –Formulaic process –Fixed selection criteria –Trackable decisions

99. The Expert System - method Fixed selection criteria –Three induction types only –Universal contents to be applied to all patients –Unique contents to be applied dependent on patient responses

100. The Expert System-method Trackable decisions –Each unique selection to be made on the response of patient to specific questions –Session to be written up in ‘tick box’ formula so decisions can be logged at each stage

101. The Expert System-method Introduction session : Questions –Type one question:Identify Behaviours Moods Situations –Purpose To tailor script suggestions

102. The Expert System-method –Type two question:Identify Modality of relaxation Modality of recall –Purpose Ensure rapid trance Tailor feedback modality in trance

103. The Expert System-method –Type three question: Identify Relapse traps –Purpose To stop patient tricking themselves back into smoking

104. The Expert System-method Introduction statements –Binds and double binds –Purpose To prevent patient from having to ask questions which might lead into justification statements for holding onto their habits

105. The Expert System-method Why hypnotherapy will work for them –Willpower –Character –Nicotine Model 3 days –Habits Model 3 weeks - psychocybernetics

106. The Expert System-method Replacements –Selection criteria Behaviours Habits Moods Chemical changes Situations External triggers

107. The Expert System-method 3 induction types only –Visual Focus on the back of your hand –Auditory Listen to the sound of my voice –Kinasthetic Focus your attention on your breathing

108. The Expert System-method Simplification of selection criteria –Select induction based on modality in which patient recalls relaxed state ‘What do you do for relaxation/what do you enjoy doing/what are you good at doing?’

109. The Expert System-method Deepener –Universal contents applied to all patients –Simplification of process 10  1 Now Script formula - Early learning set

110. The Expert System-method –Unique contents to be applied dependent on patient responses Modality of script suggestions Modality of recall Left brain/right brain variances

111. The Expert System-method Therapeutic script suggestions –Behaviours –Moods –Situations Left or right brain dominence –L  logical  feedback in same order as present their habits –R  creative  The garden script

112. The Expert System-method Awakenings –After in a few moments time I’m going to wake you Relapse traps Character re-inforcement

113. The Expert System-method Session closure –Post formal hypnosis direct suggestions –Behavioural binds Remember this is not only about stopping – but it is about not starting again The more other people try to make you… Try hard to tell no-one that you have stopped… The only thing that will come to your lips is a smile…

114. The Expert System-method Session closure –Post formal hypnosis direct suggestions –Behavioural binds Do not discuss the session today Re-emphasis of what are you going to do next – future pace Owning the outcome – hypnosis as amplifier Importance of awareness, ‘if ever you go into a mood, behaviour or situation