Ninety Five Posts in 2007

Sunday, December 30, 2007

Jonathan Foulds, MA, MAppSci, PhD

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Almost Time To Quit

Sunday, December 30, 2007

Jonathan Foulds, MA, MAppSci, PhD

For those of you planning to quit smoking from January first, there’s just one more day of smoking before you become smoke-free. If you don’t have a clear plan for your quit yet, then now is the time to make it. Are you going to use nicotine replacement therapy (and if so, which ones)? Are you going to quit from the stroke of midnight? Are you going to be sober or intoxicated at that moment? What are you going to do with any remaining cigarettes? Who have you told about quitting and who might be helpful? These are all issues that should be considered now, and the answers written down for clarity (just in case you are not very clear headed in the morning).

If you are going to use NRT but don’t have any yet, you’d better buy some tomorrow.

For many smokers the very thought of quitting, “for ever” can seem very scary. Some will have barely had a day of life as an adult without smoking. So it can feel like stepping off a ledge without knowing how far it is to the bottom. Don’t worry…its not so far. And a little bit of preparation is analogous to putting a few cushions down on the other side of the ledge, so that even if you fall it won’t be such a hard landing. For those who find it scary, it may help to think about it one hour at a time. Some find it easier at first to consider themselves as still smokers, who have simply decided not to smoke for that hour. And they continue to think of it that way hour after hour. Somehow breaking it down into shorter time units feels less daunting than “forever”.

Once you have your quit smoking plan sorted out, you may want to consider what other “resolutions” you want to make for 2008. When I look back at my previous years’ resolutions I see that most still apply: try to exercise every day, keep my office tidy (ha!), lose a pound a week for 20 weeks and keep it off, and try to get to bed on time to have enough sleep. I just read a nice post on healthline about the sleep issue at:
http://www.healthline.com/blogs/healthline_connects/2007/12/five-signs-you-need-more-sleep-in-2008.html
One of the points that struck home with me is that when we’re sleep deprived we’re not so good at sorting out life’s other challenges. This issue is particularly relevant to stopping smoking at New Year. Many of us stay up later than usual on December 31, and you may not have the option of a lie in the next day. Either way, your normal sleep cycle is already disturbed, and sometimes quitting smoking can affect that as well. So its important to get back to a normal regular sleep cycle as soon as you can in the new year so you can feel more refreshed and ready to stick to your resolutions.

Best of luck, and have a great one.

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Ready, Steady…..

Wednesday, December 26, 2007

Jonathan Foulds, MA, MAppSci, PhD

OK, here we are coming to the end of another year. If you are still smoking have you ever said to yourself things like, “I’ll quit when I go to college”, or “I’ll quit when I graduate from college”, or “I’ll quit when I start my new job” or “I’ll quit by the time I’m 30” or “I’ll quit for New Year 2000” etc etc? Well, now its time to stop putting it off. Cigarettes are more expensive than ever before. If you try to buy them tax-free on the internet you risk getting a large bill from your state finance department, you now can’t smoke in most public places, and the evidence about the bad health effects is stronger and clearer than ever before. We also now have more methods if stopping smoking that have been shown to increase your chances of success.

So here we are approaching the end of 2007 and the beginning of 2008. Wouldn’t it be great to reach this time next year having gone the whole year without smoking? So now is the time to really get yourself ready to quit. One of the first things to do is to choose a Quit Date. Many people at this time of year will choose January 1, and that is as good a time as any. Some may choose to put it off a little for good reasons. One reason might be “I’m going to be drinking and smoking on New Year’s eve and I want to start my quit day with a clear head and without having smoked at all after midnight the night before.” In that case why not pick January 2 as your quit day?

Another reason to delay a little bit might be because you intend to use Chantix or Zyban and havn’t got your prescription yet, and so won’t have time to get it and take it for 7 days (as advised on the labeling) prior to the quit day by January 1. In that case see your doctor and get started on your medicine as soon as possible.

But regardless of which individual day you choose to quit on, don’t delay it for too long. I’d suggest that any date that is more than two weeks into the year is delaying too long unless you have an exceptionally good reason. And once you have chosen your date, its immediately time to start getting ready.

You may want to review my post on the health effects of smoking to remind yourself of some of the main reasons for quitting:
How bad is smoking for your health? 2/18/07
http://www.healthline.com/blogs/smoking_cessation/2007/02/how-bad-is-smoking-for-health.html

You may want to plan how you might cope with nicotine withdrawal symptoms, as suggested in this post:
Ten tips for coping with nicotine withdrawal. 3/7/07
http://www.healthline.com/blogs/smoking_cessation/2007/03/ten-tips-on-coping-with-tobacco.html

You will certainly want to make a plan to get rid of all your tobacco:
Get rid of all your tobacco. 6/16/07
http://www.healthline.com/blogs/smoking_cessation/2007/06/get-rid-of-all-your-tobacco.html

…and you should consider whether you are going to use a pharmacological aid to smoking cessation, like nicotine replacement therapy:
Which nicotine replacement therapy? 6/19/07
http://www.healthline.com/blogs/smoking_cessation/2007/06/which-nicotine-replacement-therapy.html

Its also a good idea to be thinking about what has tripped you up on any prior quit attempts, and what you can do differently this time in order to succeed. In particular, its worth anticipating specific things coming up in your life in the next week or two that may be a risk for relapse. Make a plan of how you will manage these situations without smoking.

I’d be interested to hear from anyone out there who is currently planning to quit smoking at New Year. Use the “comment” option on the blog to tell us how you are planning to quit, and let us know of your progress.

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Have a happy, healthy holiday

Sunday, December 23, 2007

Jonathan Foulds, MA, MAppSci, PhD

I’d like to take this opportunity to wish everyone at Healthline and all the readers out there in cyberspace, a happy, healthy holiday season. It is about this time of year that people often reflect on the year gone past and start thinking of plans or “resolutions” for the year ahead. So my posts over the next few weeks will focus on quitting smoking for the new year. The holiday season has potential for relapse (sometimes linked to the stresses associated with large family gatherings!), but more so the potential for renewed quit attempts on January 1 and in the month thereafter. This is also a time of year when people tend to overeat more and drink more alcohol. Unfortunately the happy holiday news stories are frequently interspersed with tragedy. Lets try to avoid some of the preventable tragedies by ensuring that we and our family members do not drink and drive, are careful in the way we place and dispose of candles and lit cigarettes (common causes of fires this time of year) and generally don’t overdo it when it comes to food and drink! Most of all, lets try to appreciate and enjoy time spent celebrating with family and friends, and preparing new year resolutions that will ensure we can enjoy many more.
Have a great one.

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Planning to quit smoking with Chantix

Wednesday, December 19, 2007

Jonathan Foulds, MA, MAppSci, PhD

We are currently approaching the peak “New Year” season for quitting smoking – also a time when people are very busy finishing off their year-end work and participating in the holiday season. As Chantix is the newest medication designed to help people quit, and will likely be heavily advertised by Pfizer – its manufacturer, I expect hundreds of thousand of people will use it for the first time over the coming months.

However, as we have discussed at length on this forum, some concerns have emerged regarding potential adverse events relating to use of this medicine: depressive or suicidal thoughts, aggressive or erratic behavior and drowsiness.
See link for prior discussions: http://www.healthline.com/blogs/smoking_cessation/2007/11/chantix-varenicline-safety-being.html

So is this a good drug that may help save your life or a dangerous drug that may harm you? As we’ve discussed before, the evidence is clear that Chantix is effective at helping smokers quit and is typically accompanied by fairly mild side-effects (e.g. mild nausea). The concerns are over the possibility that a very small minority of Chantix users (perhaps between 0.1 and 1%) may experience the more serious side-effects mentioned above. At the moment the FDA is investigating this, but so far there is no conclusive evidence that these side effects are caused by Chantix (rather than being rarely occurring effects of stopping smoking). I therefore recommend that smokers interested in quitting should not be scared to try Chantix as the drug really does help smokers quit. But I strongly recommend that smokers planning to use Chantix should ensure that they have organized a proper quit plan, utilizing a number of support networks (e.g. telephone quitline, family etc) but very much involving the family doctor also. By this I mean that rather than simply calling in to the doctor for a prescription (or ordering it on a website), you arrange an appointment with your doctor to discuss the use of the medicine, and its potential side-effects, and that you also arrange at least one follow-up appointment with him/her within the first two weeks of starting on the medicine. If a doctor who knows you and your medical history is supporting your quit attempt and monitoring your progress it is far less likely you will be seriously affected by these potential side effects, and more likely you will succeed in quitting.

This model of quitting smoking is also precisely what is recommended by the Clinical Pratice Guideline your doctor should be following (advising doctors on the “5 As”: Ask, Advise, Assess, Assist, Arrange)
http://www.tobaccoteacher.com/5As.html

So my recommendation for people thinking of trying Chantix in the near future is that you should start planning now. This would involve making an initial appointment to see your doctor, planning a target quit date (just over a week after your doctors appointment) AND arranging an additional follow-up appointment shortly after your quit date, so your doctor can monitor progress and give advice. These steps should be taken in addition to using other assistance such as telephone quitlines and internet sites for smoking cessation, enlisting the support of family and friends, and taking other sensible behavioral steps (e.g. throwing out all your remaining tobacco the night before your quit date).

Best of luck, and have a great holiday season.

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Allen Carr's Easy Way To Quit -2

Thursday, December 13, 2007

Jonathan Foulds, MA, MAppSci, PhD

The Allen Carr method of stopping smoking is widely used throughout the world, and over 10 million of his books, DVDs and videos have reportedly been sold. The method has been associated with some very bold claims. You can find out more about it at:
http://www.allencarrseasyway.com/
Back in the 1990s when I worked in London near the original Allen Carr clinic, I was asked to do a mini evaluation. Here is a copy of the report. It basically shows that although the treatment appears to help get people motivated to quit, it doesn’t contain any “magic” ingredient capable of getting quit rates anything like those often claimed.

Brief Evaluation of the "Easy Way To Stop Smoking" Clinic, Raynes Park

INTRODUCTION

The charity, QUIT, which aims to help and encourage smoking cessation, provides a Quitline service. As part of this service, smokers can phone the Quitline and be informed of smoking cessation treatment services in their local area. However, QUIT quite correctly do not feel it appropriate to direct clients to centres which make excessive and unsubstantiated claims as to their treatment's efficacy. As the name suggests, Allen Carr's "Easy Way" treatment does make some strong claims, such as the following claims on the promotional leaflet:

1 - "It is equally effective for long-term, heavy smokers and casual smokers.
2 - It is instantaneous and permanent.
3 - It requires little or no willpower.
4 - There are no bad withdrawal pangs.
4 - You won't even put on weight."
5 - The clinic also claims, "We would emphasize that 80% of clients succeed with one sessions only, and that, of those that require extra sessions, 80% succeed after the second session."

In addition to making these impressive claims for the effectiveness of his treatment, Allen Carr has been critical of other agencies purporting to help smokers. For example, in his 1995 book entitled, "The Only Way To Stop Smoking Permanently" Mr Carr states (p24)

"My great mistake was in underestimating the sheer incompetence, apathy, ignorance ineptitude and plain stupidity of the very institutions that purport to care, like the BMA, QUIT, THE GOVERNMENT, THE CIVIL SERVICE, THE MEDIA and all their so-called experts who, far from assisting the poor smokers to get free, merely persists in giving them advice which is almost guaranteed to ensure their slavery for life! They merely perpetuate the myths that smoking is a habit, a pleasure or a crutch, that smokers smoke because they choose to smoke and because they enjoy it and the greatest myth of them all: THAT IT IS DIFFICULT TO STOP!"

On p20 of the same book he asks, "Why havn't organisations like the BMA, ASH and QUIT bothered to check me out?

Partly in response to this, Mr Peter McCabe, Chief Executive of QUIT, asked me to look into the treatment and report on whether or not the claims made about the effectiveness of Allen Carr's treatment are reasonable and accurate.

During a meeting with Allen Carr and Robin Hayley (Managing Director, Allen Carr's Easyway [International] Ltd) it was agreed that they were happy to have their service evaluated and would be keen to hear the results. In the first instance the plan was for 20 smokers with a serious desire to quit to receive the treatment at the Raynes Park clinic, and be monitored for three months to assess their success in stopping smoking.

In addition, it was agreed with Mr Roy Sheehan (Therapist at the Raynes Park Clinic) that I would be able to do a brief audit of previous clients from their client register in order to hear their views on the treatment.

AIM : To evaluate the likelihood that the claims made by the "Allen Carr Easy Way to Stop Smoking" Clinic are accurate.

METHOD: 19 volunteer smokers with a strong desire to quit and a willingness to attend the Raynes Park Clinic for treatment were recruited at St George's Hospital, Tooting. All the participants were first of all interviewed by Jonathan Foulds or Carol Mills (Clinical Nurse Specialist) in order to check that they were appropriate to refer to the clinic (ie smokers who were highly motivated to quit and who would be willing to attend for treatment and be followed up).

PARTICIPANTS: The main characteristics of the volunteers are presented in the table. Almost all the participants stated that their desire to stop smoking was "very strong", and all but one of them had tried to stop before. As indicated by the range of cigarettes per day and expired carbon monoxide, the sample were mainly quite heavy smokers. Generally, they were a fairly typical group of smokers' clinic clients.

Main Participant Characteristics
No. male/ female: 8/11
Mean Age (range): 43 (27-59)
Mean number of cigarettes per day (range): 24 (10-50)
Mean expired carbon monoxide (range): 25 (9-44)
Mean number of years of smoking (range): 26 (9-43)
Strength of desire to quit (0-4, 4=very strong): 3.8 (3-4)

PROCEDURE: Once the participants agreed to participate, they were referred to the Easy-way Clinic and given details to enable them to arrange an appointment. One additional person was assessed but did not attend any appointments (due to difficulty getting time off work) and so his data are not discussed here. It was arranged that in addition to attending the clinic, the clients would be contacted one week after their "quit date" and again at various time-points in order to monitor progress. Participants who claimed to be abstinent at the 4 week telephone follow-up were asked to attend St George's to validate this by providing a measure of expired carbon-monoxide with a concentration of less than 10 parts per million.

RESULTS:
Participation: 19 participants attended the Raynes Park clinic at least once. Two clients who relapsed within the first 3 months returned to the clinic for booster sessions.

Smoking Cessation: At one week follow-up 13 of the 19 participants (68%) claimed to have stopped smoking and not had a puff during the previous week. Of the other six participants, two managed three days without a cigarette, one managed two days and three were not able to abstain for one day.

These three participants who were unable to quit for even a day were particularly heavy smokers, averaging 38 cigarettes per day, and having an average expired carbon-monoxide concentration of 38 parts per million.

At one month follow-up, nine participants (47%) claimed to be abstinent. However, only five of these (26%) attended a follow-up and validated their abstinence by providing an expired carbon monoxide measurement of less than 10 ppm (average = 5ppm). One attended and had two separate measurements above 10 ppm (one as high as 39). Two (a husband and wife pair) claimed to be abstinent on the telephone but failed to attend three separate validation appointments. One other participant couldn't attend due to pressure of work. The true one-month success rate therefore lies somewhere between the validated rate (26%) and the self-reported rate (47%). One participant claimed to be abstinent on the phone but when she attended had an expired carbon monoxide level of 26 ppm and admitted that she has been smoking, but did not want her friend to know.

At 3 month follow-up 6 participants (32%) claimed to be abstinent. 5 of these (26%) claimed to have been abstinent from their first appointment, and one had lapsed, but managed to abstain again after a booster session.

An attempt was made to follow-up these 6 participants again approximately 8 months after their quit date. Two confirmed that they had returned to smoking, two confirmed that they continued to be abstinent and three were consistently unavailable and a family member who answered the phone volunteered that they thought they were still abstinent. This suggests long term (unvalidated) abstinence rate of around 26%.

Withdrawal Symptoms: Several of the participants reported that they had experienced nicotine withdrawal symptoms and craving during the first weeks. Seven participants reported that five or more symptoms (mainly irritability, feeling miserable, restlessness, sleep disturbance and craving for a cigarette) were experienced more or much more than usual, and so fulfilled standard diagnostic criteria for the nicotine withdrawal syndrome (4 of these were abstinent for the first week). For example, one man became so depressed that he was tearful during the first week.

General Comments by Participants: The participants described the format of the treatment in the following terms:

"A small group of about 8 people... we were allowed to smoke during the session ...that was good... he talked very quickly for a long period - about 3 hours...virtually a verbal monologue, a harangue...a high speed intense lecture about smoking, full of sympathy and understanding...a lot of repetition..discussed reasons why we smoke with some quotations from the book... there was a break for coffee, there was a group chat and then 10 minutes of hypnotherapy at the end."

Some of the positive comments were as follows:
"It was helpful to be brainwashed, very positive.....24 hour support is available...he positively reframed the withdrawal experience..it rang true...not nagging..a relaxed atmosphere."

Some of the negative comments were as follows:
"He spoke very quickly, I felt I missed a lot...not enough backup, a tape could have been included...good-but one-off session no good, would like intensive support during first weeks of quitting...stuff about not needing willpower was crap - a lie...too long and boring...the 90% success rate is not backed up by stats - based on people asking for their money back."

15 (79%) felt that the content of the treatment was properly explained beforehand. Of the 4 who did not, one commented that they had not expected hypnosis to be part of the treatment and one claimed to have been unaware that the session would last for 4 hours.

17 (89%) recalled that during the session there was criticism of other methods as being ineffective gimmicks or even dangerous. Nicotine replacement therapy in particular was mentioned by the therapist and the clients recalled it being said that "patches cause cardiac arrest...a con...horror stories about patches...very negative about nicotine substitutes..very bad side effects...gum causes cancer of the mouth...addictive."

14 (74%) said that they would recommend the clinic to friends who wanted help to stop.

Brief Follow-up of Previous Clients at the Raynes Park Clinic
One possibly important difference between the clients we referred to the clinic and the clinic's usual clientele is that they did not have to pay the usual £95 fee. It may well be that this serves to ensure that clients are highly motivated and may make them more likely to attend further free booster sessions. We therefore tried to contact a number of previous clients on the phone to assess how successful they had been. Quite correctly, the clinic did not want an "outsider" cold-calling ex-clients, and so the procedure was that the clinic secretary (who knew the clients) called the number in the registration card and asked if they were happy to speak to me. We selected the letter "F" and went through the registration forms in order, calling those with a London phone number. After a while we decided to only call those attending the clinic since 1993, as so many earlier clients were no longer at the same number.

After making 50 calls, it turned out that 36 were not in, or had changed number, 4 said they did not wish to answer any questions (2 admitted they were smoking to the receptionist, one just said "no" and the other said she was working to a deadline and didn't have the time at the moment). 10 agreed to answer some questions about their treatment at the clinic.

Results: As shown in below, these 10 clients had first attended the clinic an average of 21 months previously. 70% of them were currently smoking (and another who had returned to smoking after attending the clinic had just stopped again a week ago on her own). The 8 clients who went back to smoking lasted an average of about 6 weeks before relapsing.
Five of the clients who had managed to abstain for at least 8 weeks were asked if they had put on any weight. Four said yes and one said no. The average weight gain was 10.8 lbs and even the person who said "no" commented that in fact he had only put on about 5 lbs. There were some signs that the amount of weight gain was related to the length of time off cigarettes, for example, the person who had remained off cigarettes for the longest period (23 months) reported the largest weight gain (21 lbs).

Participant Characteristics and Outcome
No male/female: 4/6
Mean age (range): 42 (29-52)
Previous daily cigarettes (range): 28 (15-40)
Average time since first attended the clinic, in months (range): 21 (2-32)
No (%) currently smoking: 7 (70%)
No (%) not smoked since clinic attendance: 2 (20%)
Mean length of time from clinic attendance to starting smoking, in weeks (range), based on the 8 who restarted smoking: 5.5 (0-16)
No (%) who said the first week was quite easy: 6 (60%)

Five of these ten clients had more than one contact with the clinic. One had gone back for a booster session and bought the book and video but was still unable to quit. She did not enquire about the money back as she felt the clinic had "done their best". Another had telephone contact and arranged two further appointments and had to cancel both of these. She then realised that she was not eligible for her money back due to the cancellations. Another went back for a free appointment but was smoking again within a week. She said that she enquired about the money back and was asked to come along for another appointment. At that point she said she no longer wanted to attend the clinic again. She commented, "I felt they weren't particularly interested - it's a bit grudging if you go back." Another has arranged a booster session and has still to attend. Another client said she had attended the clinic about 5 times and found it "exhilarating" but had returned to smoking each time. She had never asked for her money back because she was either out of the time schedule (described in the guarantee, attached) or did not want to ask as she blamed herself for her failure. Another who was smoking said she did not know she could claim her money back (although it is clearly stated) and another did not ask for it because she relapsed after the 3 month time limit.

DISCUSSION: Although the number of clients studied here is too small to make any definitive statements about success rates, they suggest that around two thirds of the clients manage to achieve initial abstinence for the first week, about a third remain abstinent in the short term (1-3 months), and about 20-25% remain abstinent in the longer term (over 6 months). If anything, these are likely to be overestimates as they do not include biochemical verification of abstinence.

It is clear that a reasonable proportion of the clients (around 40%) experience marked withdrawal symptoms in the early stages and that weight gain is the norm for those abstaining in the longer term. There was also some evidence that heavy smokers found it particularly difficult to abstain (eg of the 5 clients smoking at least 40 per day, only one [20%] managed to abstain for a week).

All in all, these figures are fairly typical of those seen in other smokers' clinics. The initial one-week abstinence rate is very respectable, and suggests that the initial 4-hour treatment session probably does contain an active ingredient, in the sense that it boosts clients' motivation, clarifies their thinking and helps them to reach a state in which they are determined to quit. To quote one of the clients, "it was helpful to be brainwashed". The fact that 70-80% of the clients said that they would recommend the clinic to friends also shows that, regardless of whether or not they actually succeeded in stopping smoking, most felt that the treatment served to increase their chances.

On the whole, most of the information given as part of the treatment appeared to be reasonably accurate. The main exceptions to this are (1) the specific claims about the treatment's efficacy and (2) the information given about the efficacy and safety of nicotine replacement therapy.

The money back guarantee is clearly stated (copy attached) and is a positive aspect of the service. However, as shown above, it is clearly inaccurate to claim success rates based on the proportion of clients who are successful in obtaining their money back. The majority of clients do not succeed in stopping smoking permanently but do not succeed in getting their money back for a range of reasons (eg they feel the clinic provided a service and are embarrassed about asking for the money back, or they did not feel it provided much help and so are not prepared to spend another four hours (plus travelling) of their time just to get the money back). There may also be an effect whereby those people who do not succeed with this method are particularly prone to blame themselves. On p24 of Allen Car's 1995 book he states, "I know that all smokers feel stupid". There is a great risk that they might feel even more so if they do not succeed with this method, after all, they have been told that this is the "easy way" and over 90% of people succeed. There may also be some risk that they will be put off trying again.

CONCLUSION: This brief evaluation found no evidence to substantiate the claims made by Allen Carr's Easyway To Stop Smoking that:

- it is equally effective for heavy smokers and casual smokers,
- it is instantaneous and permanent,
- it requires little or no willpower,
- there are no bad withdrawal pangs,
- it will avoid weight gain,
- it is successful in doing this in at least 80% of clients.

The evidence is more consistent with the view that less than 30% of clients remain abstinent in the long term, and weight gain and withdrawal symptoms are common. On the other hand it seems that the treatment helps boost motivation in the early stages and achieves respectable initial quit rates (about two thirds abstinent in the first week). Overall the treatment was positively evaluated by the clients and the vast majority would recommend it to friends.

My main recommendation would be that the clinic and those associated with it should immediately cease to make excessive and unsubstantiated claims about the effectiveness of the treatment and should withdraw any material which makes such claims. I'd also suggest that the information provided about nicotine replacement is checked and presented in a more balanced fashion. I'd be happy to provide Mr Carr with copies of published research reports evaluating the safety and efficacy of these treatments.

I have little doubt that this treatment will have helped many smokers to quit. If the information provided on treatment efficacy and nicotine replacement is corrected, then it will reduce the risk of clients feeling that they have been misinformed.

Jonathan Foulds
Chartered Clinical Psychologist
Lecturer in Tobacco Addiction, St George's Hospital Medical School (1996?)

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The Allen Carr “Easy Way” to quit smoking -1

Thursday, December 13, 2007

Jonathan Foulds, MA, MAppSci, PhD

A colleague in Mexico recently asked me to explain the popularity of the Allen Carr method of quitting smoking, and I thought this might be of wider interest. It just so happens that Allen Carr’s original clinic in Raynes Park in London was about 500 yards from my old home in London and so I had the chance to meet him and discuss his methods.

Allen Carr was an accountant by profession, who became a 100-cigarettes per day smoker. After numerous attempts to quit, he finally succeeded at the age of 49. In doing so he felt that he’d finally figured out how to quit smoking, and wrote a book to tell others how to do it as well: “The Easy Way To Stop Smoking”. He started a smokers clinic in Raynes Park in south west London. The method used there was a little unusual. Basically about 6 people would sit in a room in comfortable chairs, each with their own ashtray, and sit smoking while listening to Allen (or later one of his many other therpists) talk pretty much constantly for 4-6 hours. The general message here is that although it is an addiction, it is also a deadly poison, and in fully understanding that and in fully committing ones mind to quitting, anyone can succeed. Obviously there’s more to it than that in the book and in the 6 hour session, but its main characteristic is a single-mindedness and a focus on quitting, that you can succeed, that you are not really giving up anything valuable. Many who have sat through the session or even watched the video have described it as “a bit like being brainwashed”. Although he was not a trained psychologist, Allen Carr clearly had an intuitive grasp of some of the key principals of behavior change and his method is similar to cognitive therapy (a psychological treatment based on changing the way a person thinks – in this case about smoking). At his clinic he would have an enormous pile of discarded cigarette packs in one corner of the room, an enormous pile of lighters in another. He explained that these were left by people who had succeeded with this method, and that towards the end of the session the participants would be expected to throw their own packs onto the piles and never smoke again. Its clever psychology as it gives tangible visual evidence of many others having succeeded this way before. He was able to give a very clear message, often rather critical of other efforts to help people stop smoking, and unburdened by the need to back his views or opinions up with hard scientific evidence. It was rather unfortunate and unnecessary that he chose to speak against other methods that are supported as effective by solid evidence, but that was part of the rather evangelical, single-minded approach that many found appealing.

I won’t go on and spend too much time describing his other products and achievements. You can find out more about these at the website: http://allencarr.com/central/
But in summary, Allen Carr’s original book went on to be very successful, being translated and published in many languages and reportedly selling over 7 million worldwide. He subsequently wrote a number of other similar books, and then videos, DVDs etc, and established a network of clinics and seminars around the world. He died of lung cancer in November 2006 at the age of 72.

There is no doubt that a great many smokers quit smoking with the help of his method – mainly by reading one of his books. I believe that other kinds of therapists can learn something from it also. In terms of research evidence, two published studies reported very good quit rates (40% and 51% at one year) from use of his method in a workplace context. These were simply descriptions of treatment and outcomes, with no comparison group, and so it is hard to draw any firm conclusions, other than to not that the quit rates, while not being the 90% often claimed, are very good. When I worked in London I was asked to do a mini evaluation of quit rates at the Allen Carr clinic there. Basically I found that although the treatment appeared to boost people's motivation to quit, and some succeeded, the quit rates (under 30%) did not match the claims. A copy of my full report on that evaluation will be provided in my next post. On the basis of that evaluation, I don’t believe the Allen Carr method is all its cracked up to be, and if someone had a few hundred dollars to spend on quitting smoking there are treatments with much better evidence supporting them. However, if you, or someone you know, is thinking about quitting, not ready to try medication (e.g. nicotine patch, Zyban or Chantix), but willing to read a book, then Allen Carr’s might be worth a try.

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Does laser therapy or acupuncture help smokers quit?

Monday, December 10, 2007

Jonathan Foulds, MA, MAppSci, PhD

I’m frequently asked about the effectiveness of acupuncture for stopping smoking, and more recently these questions have been about “laser therapy”. “Laser therapy” uses “cold lasers” instead of needles in an acupuncture-like treatment.

Unfortunately the existing evidence does not support the effectiveness of either of these treatments. The conclusion of the most recent Cochrane review was that:
“There is no consistent evidence that acupuncture, acupressure, laser therapy or electrostimulation are effective for smoking cessation”.
If you want to read the details of that review, click on
http://www.cochrane.org/reviews/en/ab000009.html

If you would like to view a Fox news item on this topic click on:
http://www.freedomlasertherapy.com/video/foxnews.htm

Over 10 years ago, when I was running a tobacco treatment clinic at St George’s Hospital Medical School in London, UK, we did a mini evaluation of a local laser therapy clinic. The clinic claimed very high quit rates, but that didn’t turn out to be the case. Basically I’d advise people wanting to quit smoking not to waste their time and money on laser therapy, but rather to make use of treatments that have been demonstrated to increase your chances of quitting smoking (counseling from a trained professional, NRT, Zyban or Chantix).

My report is reproduced below:

Brief Evaluation of the Laser Therapy Stop Smoking Centre (205 St John's Hill, Battersea).

INTRODUCTION

The charity QUIT, which aims to help and encourage smoking cessation provides a Quitline service. As part of this service smokers can phone the Quitline and be informed of smoking cessation treatment services in their local area. However, QUIT quite correctly do not feel it appropriate to direct customers to centres which make excessive and unsubstantiated claims as to their treatment's efficacy. This issue arose when the Battersea Laser Therapy Centre asked to be included on the QUIT register. QUIT was asked to use its good offices to persuade the Department of Health that Laser Therapy should be available in every NHS and Trust Hospital. The Battersea Clinic's Chief Executive, Mr Barry Murphy claimed that their treatment is about 90% successful and that this had been substantiated by a Department of Trade and Industry consultant. In addition he claimed that the treatment is quick, painless and that there are no withdrawal symptoms. Mr Peter McCabe, Director of QUIT, asked me to look into the treatment and decide whether or not these claims are likely to be accurate.

On discussing this with Mr Murphy he was very willing to be of help and suggested that I send along ten smokers with a serious desire to quit, and that I monitor their success. He also confirmed that the treatment is 90% successful, and that by this he meant that 90% of smokers who attend the clinic stop smoking completely and don't have another puff of tobacco for at least the following year. He admitted that they do not have any hard evidence to back up this claim. Although I was aware that ten subjects is not enough to prove anything, there is ample evidence in the scientific and medical literature suggesting that smoking cessation treatments rarely achieve one year success rates above 30% and therefore if even 6 or 7 of the subjects I sent to the clinic succeeded then that might warrant further investigation.

AIM

To evaluate the likelihood that the Battersea Laser Therapy Clinic achieves 90% one-year smoking cessation success rates.

METHOD

10 volunteer smokers with a strong desire to quit and a willingness to attend the Laser Therapy clinic for treatment were recruited by advertisement at St George's Hospital, Tooting. All the subjects were first of all interviewed by Jonathan Foulds in order to check that they were appropriate to refer to the Laser Therapy Clinic (ie highly motivated healthy smokers who would be willing to attend follow-up appointments).

SUBJECTS

A main subject characteristics are presented in the table. All the subjects stated that their desire to stop smoking was "quite strong" or "very strong", and every one of them had tried before. None of them had any serious concurrent medical problems. As indicated by the range of cigarettes per day and expired carbon monoxide, the sample included both light and quite heavy smokers. Generally, they were a fairly typical group of smokers' clinic clients.

Main Subject Characteristics

Number male/ female: 4/6
Mean Age (range): 34 (18-60)
Mean number of cigarettes per day (range): 20 (7-35)
Mean expired carbon monoxide (range): 16 (5-26)
Mean number of years of smoking (range): 17 (3-40)
Strength of desire to quit (0-4, 4=very strong): 3.6 (3-4)
Mean number of previous attempts to quit (range): 5 (1-20)

PROCEDURE

Once the subjects agreed to participate, an appointment was made for them to attend the Laser Therapy Clinic. It was arranged that in addition to attending the clinic they would be contacted by Jonathan Foulds one week after their "quit date" and then again in 2-3 months time in order to monitor progress. Subjects who claimed to be abstinent were asked to validate this by providing a measure of expired carbon-monoxide with a concentration of less than 10 parts per million.

RESULTS

Participation: All of the subjects attended the clinic at least once (range = 1-4 visits).

Smoking Cessation: At one week follow-up 3 of the 10 subjects had stopped smoking and not had a puff during the previous week. All had appropriately low expired carbon monoxide levels (6, 6 and 4 ppm). Of the other seven subjects one managed four days without a cigarette, three managed two days and three only managed to abstain for one day.
At 2-3 month follow-up only two subjects continued to abstain. All of the other subjects were smoking on a daily basis. Interestingly, the two who managed to abstain were by far the lightest smokers in the group. They had been smoking only 7 and 10 cigarettes per day over the past few years, and had expired carbon-monoxide levels of only 5 and 6 ppm at the pre-quit assessment interview.

Withdrawal Symptoms: Several of the subjects reported that they had experienced nicotine withdrawal symptoms and craving during the first week. For example, one subject said "I had a lot of craving, I was in a foul mood, felt miserable and restless. I had poor sleep and dreamt about smoking." Another commented, "They claimed I'd have no craving or irritability. I was disappointed because I was craving for a cigarette as soon as I left the clinic and felt very irritable... no different to previous times".

General Comments by Subjects: The subjects were generally appreciative of the clinic staff's positive attitude and the encouragement they received from the clinic. They did not find the laser treatment uncomfortable and a number commented on how relaxed they felt during the procedure. Three reported headaches after the first session and wondered whether this might have been caused by the laser. Some felt that the clinic made excessive claims about the treatment, eg one commented, "They claimed to be able to help loose weight, stop taking drugs, stress management, depression etc and gave the impression that the laser would take care of it....it can't be true".

DISCUSSION

The success rates found in this small group (30% at one week and 20% at around 10 weeks) are roughly what one would expect to find in a group of smokers who make a serious attempt to stop smoking on their own without any formal help. The fact that only the two lighter smokers stopped smoking suggests that the treatment lacks any ingredient which treats nicotine dependence. This sample is really far too small to come to any conclusions about the clinic's success rates. However, there is no indication or sign that it contains any unusually therapeutic ingredient and it is clear that the claim of 90% success is completely inaccurate. Similarly, the claim that the treatment eradicates craving and withdrawal symptoms would seem to be inaccurate.

One could argue that anything which encourages people to try to stop smoking is not such a bad thing. However, where this involves conning people into parting with large sums of money (eg £100) on the basis of false claims of high success rates this is clearly not in the public interest. Such individuals may consequently fail to obtain effective help to stop smoking, and deserve the right to make decisions about their treatment on the basis of accurate information.

A review of the effectiveness of acupuncture for smoking cessation (Schwartz, 1988) found only one study which attempted to biochemically validate claimed successes. This study found a success rate of 8% at 13 months. The review also commented, "There is no evidence from this review that acupuncture may relieve withdrawal symptoms. It has not been demonstrated that acupuncture is able to promote smoking cessation". Nothing from this small evaluation suggests that laser therapy is able to promote smoking cessation either.

CONCLUSION

This brief evaluation found no evidence to substantiate the claim that Laser Therapy is 90% effective in helping smokers to quit, or in relieving withdrawal symptoms and craving. In fact the short term success rate was only 20%, and a number of subjects experienced strong craving and withdrawal symptoms.

The Laser Therapy Centre and those who are associated with it should immediately cease to make excessive and unsubstantiated claims about the effectiveness of the treatment and should withdraw any material which makes such claims.

Jonathan Foulds
Chartered Clinical Psychologist
Lecturer in Tobacco Addiction, St George's Hospital Medical School
December 1996

Labels: acupuncture, foulds, laser therapy, nicotine nasal spray smoking cessation

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