Detrimental effects

All of us working in dentistry are well versed in the effects of smoking on the mouth. Studies have shown current and long term smoking in young adults is detrimental to periodontal health, but smoking cessation may be associated with a relatively rapid improvement in the periodontium.1 As a dental hygienist practising since 1991 I have consistently advised my patients on issues of oral health, and one of my most regular mantras has been ‘give up smoking’.

Trying to find ways to improve the oral health of my patients left me frustrated as I was only equipped with basic methods of tackling the problem of smoking: discussing the probability of tooth loss due to gum disease; quoting statistics; maybe showing patients horrendous pictures; and in some cases making them aware of soft tissue changes signalling an increased probability of cancer in their own mouths. Despite my best efforts, there were still many patients who continued to smoke. The most baffling thing of all was that a high proportion of these patients professed a desire to be non-smokers. What is it that made these rational and intelligent patients choose to be so irrational about their habit?

Intervention

The Public Health Intervention Guidance states that health professionals, including dentists, should refer smokers to an intensive support service such as NHS Stop Smoking Services.2 The NHS initiative and website enables smokers to look into different ways of getting support and advice; they also provide comprehensive information about the various Nicotine Replacement Therapies (NRT) available over the counter and through GP surgeries. Advising patients to use this facility made total sense. Despite referral to this network of support, information and advice, there seemed no logic in my patients returning every three months with actively destructive periodontal disease and a continued smoking habit. I wanted to know what it was that made these patients make an informed decision to continue smoking – surely it couldn't be, as they often professed, just to keep me working! I wanted to see if there was a different approach to smoking cessation advice that could change the outcome for these patients.

Smokers' choices

  • Nicotine Replacement Therapies (NRT). These therapies help the smoker quit by slowly reducing the nicotine levels over a period of time. NRT varies from chewing gum to patches, inhalers, and even gels that can be rubbed into the skin!

  • Medication. Drugs such as Zyban can be recommended in appropriate cases and prescribed by the doctor, though there are limitations depending on health. This method requires the strict supervision of a prescribing practitioner.

  • One to One or Group Support. The NHS offers information about local support groups to help smokers quit through willpower alone or alongside other methods. Details can be found at www.gosmokefree.nhs.uk.

  • Self Help Literature. Any popular book shop or online book retailer will produce a long list of publications dedicated to smoking cessation; many of these include DVDs or CDs.

  • Hypnotherapy. Using the state of hypnosis to resource the subconscious, hypnotherapy tailored to the psychological background of a smoking habit offers long term change, avoiding withdrawal effects and addressing the fear of living without cigarettes.

My choices

The systems in place to help people quit smoking are numerous and the NHS initiative seemed very robust and had been successful for a few of my patients. However, I was drawn to hypnotherapy because of its potential to facilitate long term change. I cannot deny a curiosity about the peripheral benefits of gaining such a skill; maybe I could also help those more anxious patients? I decided that this would be an interesting route to explore.

I chose to look for a course that would give me a thorough knowledge of clinical hypnotherapy and also provide some background into the psychological basis that lay behind a nicotine addiction and smoking habits. I already had some knowledge of Neuro-Linguistic Programming (NLP) and its use in helping promote change in behaviour and perception, so when I found a course that included all these elements I was keen to get started. The Contemporary College of Therapeutic Studies (CCTS) at Birkbeck College in London offered a year-long Diploma of professional training in Clinical Hypnosis, NLP Hypnotherapy and Psychotherapy. The syllabus looked daunting and full of many things I had no initial desire to learn, though I remember modules of my hygienist training looking distinctly uninteresting at first, only to later find they were essential in practice. Most important was the fact that this Diploma would qualify me to practise as a registered hypnotherapist with the General Hypnotherapy Council (GHR), and qualify me for the Central Register of Smoking Cessation Therapists. Thus I began the course in October 2007.

What did I learn?

An individual approach to smoking

The psychology of a smoking habit is apparently unique to each smoker; it is not just about having a cigarette – people use smoking in different ways. Excuses we hear from our patients give us clues to the way they view their addiction, reasons why they think they need to smoke. Smokers believe that smoking benefits them.

  • Stress – I can't give up yet, I am under a lot of stress

  • Boredom – It gives me something to do with my hands

  • Concentration – They help me concentrate whilst I am studying

  • Relaxation – I get home and just need to light up and relax

  • Socialising – I only smoke when I am out

  • Confidence – I smoke because I want to, I enjoy it.

The main obstacle to becoming a non-smoker is addictive thinking such as ‘I can't … I must … I've got to … I need”. Every smoker would rather be a non-smoker, but this is not an easy admission; each smoker justifies the habit in ways that excuse them responsibility for the choice they are forced to make to feed the addiction to nicotine. Counselling skills and individually tailored hypnotherapy scripting can develop the smoker's insight into these excuses. It isn't simply a case of telling a client, it's about helping them listen and be enlightened so they can achieve the cognitive shift that creates long term change. The aim of therapy is to help the client remove the smoke coloured glasses that have been clouding their vision. Once the client realises that smoking is completely pointless, the right choice becomes clear; only then hypnotherapy and positive suggestion can support them through nicotine withdrawal.

Identifying a valid set of reasons to quit and the ways in which the client validates the need to smoke is like defining the rope in a tug of war. We then set about creating the winning team by letting the client explore the futility of smoking, recognise their individual take on how they have justified the habit and then discuss the addiction in terms of a thing that feeds on this strategy – like a parasite that demands control. After all, our most defiant clients do not like to be told what to do. Reframing the addiction in this way turns the client's defiance into a strong motivational drive toward giving up smoking.

Cognitive shift

A cognitive shift can be best described as a smoker to non-smoker tug of war.

Reasons to quit Reasons to smoke

Health Relaxation

Money Concentration

Control Handling stress

Social pressure Enjoyment

Distasteful Addiction

Looking at the two teams it isn't going to take much to weaken the reasons to smoke. For instance, do we really think that wilfully inhaling toxins and damaging our health is a relaxing pastime? Concentration is much the same story – if you are going to concentrate, you don't need distractions. So to keep the nicotine parasite inside you from interrupting while you are trying to concentrate, you feed it before you start the task and you keep on feeding it. If you didn't have the parasite to cope with, there would be nothing to wreck your concentration.

Fear and guilt keep the individual smoking

Hypnotherapy allows them to take the message deeper, reprogramming the subconscious reactions to situations that have triggered the desire to smoke.

Smoking occupies such a central part of the smoker's life and daily routine that they believe it benefits them – defining key moments in the day. But the benefit is no more than the avoidance of discomfort, so the benefit can only exist if the discomfort exists. It is the fear and anticipation of the discomfort (of not smoking) that needs to be reduced in size. Once you've had a cigarette you create the feeling that a non-smoker has all the time – you get back to normal. But relieving discomfort ensures that it will come back again. Its appetite is insatiable – nicotine lasts in the body for about 48 hours and then the parasite begins to wither. This is where hypnosis comes in – it helps the client get through the withdrawal phase. Here are some typical fears and easy ways to navigate them without criticising the client:

  • Fear of Failure. Don't tell people you are quitting

  • Fear of Change. What will it be like to be a non-smoker? What will happen if I can't have a cigarette?

  • Fear of Catastrophic Expectations. Some clients will fear that they will put on weight as a side-effect of stopping smoking – there is no need to replace smoking with eating as smoking is not a treat

  • Guilt. This feeling is associated with continued smoking. If you, as a rational and intelligent adult, know and understand the dangers associated with smoking, then to continue is clearly irrational behaviour. How would it make you feel?

Reprogramming the subconscious

After going through this process with the client, a session of hypnotherapy allows them to take the message deeper, reprogramming the subconscious reactions to situations that have triggered the desire to smoke. Without exploring the client's individual smoking habit hypnotherapy alone would be much less effective. Using language the client volunteers during counselling makes the script congruent with the way they see their habit. During hypnosis, positive suggestion gives the client a stronger sense of resolve, reinforcing the achievement of giving up. They no longer feel like they cannot have a cigarette; instead they celebrate the fact that they no longer have to smoke, enjoying their control over the withering parasite – that surely has to be a feeling worth keeping.

Producing results

My assistant has also asked me to warn her when I intend to use a relaxing hypnotic tone with a patient as she will need to pinch herself awake from time to time!

It is autumn 2008 and what have I achieved? I have become a very effective hypnotherapist and I have also become a much better all round communicator. Knowledge of the psychological aspects of patients' decisions have improved the way my advice is both received and delivered. I have developed techniques in my use of language during treatment to help relax patients, some of whom have previously required treatment under sedation but now receive regular dental care without. Since starting to use visualisation techniques anxiety in my surgery has reduced. My assistant has also asked me to warn her when I intend to use a relaxing hypnotic tone with a patient as she will need to pinch herself awake from time to time!

I now work in Enhance, a new dental spa in the beautiful little city of Ely. As well as routine private dental care, we offer facial rejuvenation and tooth whitening procedures. Smoking is still an issue we tackle daily with patients, but the advanced periodontal treatment procedures I provide produce results in my non-smoking patients ensuring they can take full advantage of all the treatment options we have. I am aware that not all my patients are the best candidates for hypnotherapy; like all therapies and procedures success is often in selection. I still recommend some of my patients consider NRT and I will often advise them to discuss smoking cessation with their GP. I understand much more about the habit of smoking thanks to the course at CCTS and the expert guidance of my tutors Sandra Westland, Tom Barber and Tanya Colley. I know for those who feel they wish to work on changing their minds, nicotine replacement is clearly not the answer – I now feel equipped to offer them a therapy that could result in the long term change they desire.

Teaching material from J. Trimmer, 2002, has also been adapted for this article.