Smoking Cessation
GUIDED IMAGERY FOR SMOKING CESSATIONJanuary 2006
SCOPE OF THE PROBLEM
Cigarette smoking is the largest preventable cause of illness, death, and medical expenditures in the U.S.A. (CDC). In 1993, direct medical costs associated with smoking amounted to approximately $50 billion; smoking was responsible for approximately 7 percent of total U.S. health care costs (CDC).
This $50 billion figure is highly conservative, considering that factors not included in this number are: costs of burns from smoking-related fires; perinatal care for low-birth-weight infants whose mothers smoked during pregnancy; and expenses incurred in treating diseases caused by secondhand smoke. Indirect costs include lost productivity and early death (CDC). Another study found that in 1997, smoking-related medical expenditures reached $72.7 billion -- about 11% of total health care costs (McBroom, 1998).
Government estimates put the number of adult American smokers at 45.8 million, half of whom die or become disabled as a direct result. Cigarette smoking kills more than 440,000 people annually and is responsible for one in every five deaths. Direct and indirect costs of smoking-related illness amount to over $155 billion annually (NCCDPHP). It is estimated that in the next 20 years, Medicare will spend $800 billion for care of people with smoking-related illnesses (Rodgers, 1997).
Effectiveness of Smoking Cessation Programs
The cost of smoking-related illness is so high that smoking cessation has been called the “gold standard” of medical cost-effectiveness by Warner (1997), who stated that: “A considered review of the evidence recommends support of all of the major forms of smoking-cessation intervention; even the most expensive are highly cost effective compared with all medical treatments studied.”
For example, simple instructions from a physician to stop smoking resulted in a 2% quit rate at one-year follow-up -- an effect one study’s authors called “modest but highly cost effective. It cost $1500 to save one life” (Law, Tang, 1995). Costs rise as interventions become more intensive, but even moderately effective programs will save far more than they cost (Westmaas, Nath et al., 2000).
Treatment Approaches, including Mind-Body Approaches
Typically, smoking cessation programs achieve 50-60% short-term success rates. However, the relapse rate is often 60-80% at one-year follow-up (Wynd, 1992a). Most widely-used programs have long-term success rates under 35% (Colletti, Supnick, et al., 1982; Hensel, Cavanagh, et al., 1995).
Nonpharmacologic approaches include psychotherapy, support groups, behavioral therapy, providing education/information, hypnosis, telephone monitoring, and rapid-smoking. Medications include nicotine (delivered via patch or chewing gum), buproprion, and fluoxetine. These treatments have long-term success rates varying from 15-32% (West, McNeill, et al, 2000).
The most consistently successful approach is combining nicotine replacement and/or bupropion with behavioral therapy and psychological support. In one study, 35% or more smokers using the multicomponent regimen remained smoke-free for a year (McGhan, Smith, 1996). A recent study combined CBT with community reinforcement and naltrexone to achieve an abstinence rate of 43% at three-month follow-up (Roosen, Van Beers, et al, 2006). In two other studies, 58.5% of those using behavior therapy and nicotine patches were abstinent at five years (Garcia Vera, 2004), while 80% of those in a multicomponent CBT program that also incorporated relaxation training and imagery rehearsal changed their behavior (30% has reduced their cigarette consumption; 50% were abstinent) (Huang, 2005).
In two studies, groups using guided imagery for relaxation and to gain a sense of personal mastery had much higher abstinence rates at 3-months than control groups who had received only counseling (Wynd, 1992a; 1992b). Smokers who practiced imagery at home, and continued using imagery after the training program ended, had abstinence rates over 52% at three months (Wynd, 1992a). In a study of guided imagery, smokers who used an audiotaped imagery program had two times the abstinence rates as the control group (25% versus 12%) at two-year follow-up (Wynd, 2005).
Using self-hypnosis even once resulted in 22% of 226 patients remaining smoke-free after two years. While this is a modest result, it is a better outcome than trying to quit without any assistance (Spiegel, Frischholz, et al, 1993). Hypnosis, which incorporates relaxation, imagery and positive suggestion, has been reported to have significant success rates -- as high at 90% in one study (Klager, 2004). One clinical hypnosis study had an 81% success rate in the three-session hypnosis group, with a 48% success rate at one year post-treatment (Elkins, Rajab, 2004). These studies show that imagery and hypnosis have been as effective as traditional behavioral and psychological approaches. These mind-body techniques were even more effective in smokers who found them pleasant.
References
Centers for Disease Control and Prevention (CDC). Medical-Care Expenditures Attributable to Cigarette Smoking -- United States, 1993. MMWR Morb Mortal Wkly Rep. 1994 43(26);469-472 July 08.
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