July, 2006


According to the Centers for Disease Control, cigarette smoking is the largest preventable cause of illness, death, and medical expenditures in the U.S.A. In 1993, direct medical costs associated with smoking totaled an estimated $50 billion, and smoking was responsible for approximately 7 percent of total U.S. health care costs (CDC, 1994).

This $50 billion figure is highly conservative. Many factors were not included in the total medical costs: smoking-related burns from fires; perinatal care for low birth weight infants whose mothers smoked; and the costs of treating diseases in others caused by secondhand smoke.

Also not included were the indirect costs of lost productivity and early death (CDC, 1994). A more recent study found that annual smoking-related medical expenditures for California alone reached $72.7 billion in 1997, about 11% of total health care costs (Miller, Zhang et al, 1998).

The CDC estimates that 44.5 million adults in the United States smoke cigarettes, resulting in death or disability for half of all regular users. Cigarette smoking is responsible for more than 440,000 deaths each year, or one in every five deaths; counting direct and indirect costs, smoking related illness costs the nation more than $167 billion each year (NCCDPHP, 2006).

It is estimated that Medicare will spend $800 billion over the next 20 years caring for people with smoking-related illnesses (Rodgers, 1997).

Effectiveness and Cost-effectiveness of Smoking Cessation Programs

Smoking-related illness consumes so many health resources that smoking cessation has been called the “gold standard” of medical cost-effectiveness (Warner, 1997). His report from the University of Michigan School of Public Health found 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, a simple instruction from a physician to stop smoking resulted in a 2% quit rate one year later, an effect study authors called “modest but highly cost effective. It cost $1500 to save one life (Law, Tang, 1995).” As interventions become more intensive, costs go up. However, even modestly effective programs will save far more than they cost (Westmaas, Nath & Brandon, 2000).

Issues in Smoking Cessation

While it is typical for stop-smoking programs to achieve short-term success rates of 50-60%, the rate of relapse is often 60-80% in the year following the program (Wynd, 1992a). Most widely-used programs have long-term success rates under 35% (Colletti, Supnick & Rizzo, 1982; Hensel, Cavanagh et al, 1995).

Non-drug programs include psychotherapy, behavioral therapy, providing information, support groups, hypnosis, telephone monitoring, and rapid-smoking. The most commonly used medication is nicotine, given as a patch or in chewing gum. The prescription drugs bupropion and fluoxetine are also used. All these treatments have similar long-term success rates, varying from 15-32% in different studies (Sykes & Marks , 2001; West, McNeill & Raw, 2000).

Combining nicotine replacement and/or bupropion with behavioral therapy and psychological support has consistently shown itself more effective than a single treatment alone, with 35% or more of patients remaining 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).

Imagery and self-hypnosis in smoking cessation

In two studies, groups who used guided imagery to relax and gain a sense of personal power had much higher 3-month abstinence rates than a control group which received only counseling (Wynd, 1992a; Wynd, 1992b. Smokers who practiced imagery at home and continued practicing after the training program ended had abstinence rates over 52% at three months (Wynd, a). In a 2005 study of guided imagery, smokers using an audio-taped imagery program had twice the abstinence rates as the control group (25% versus 12%) at 24-month follow-up (Wynd, 1995).

Using self-hypnosis even once resulted in 22% of 226 patients remaining smoke-free after two years. Similar success rates also occurred in a group single-session hypnosis program (Ahijevych, Yerardi, et al, 2000). While the results are modest, it is better than trying to quit without any help (Spiegel, Frischholtz et al, 1993). However, hypnosis, which incorporates relaxation, imagery and positive suggestion, has been reported to have a success rate as high at 90% (Klager, 2004).

A clinical hypnosis study at the College of Medicine at Texas A&M University had an 81% success rate in the three-session hypnosis group, with a 48% success rate at 12 months post-treatment (Elkins & Rajab, 2004). Thus, imagery and self-hypnosis have been as effective as other behavioral and psychological approaches. The techniques were even more effective in patients who found them pleasant.


A low-cost, guided imagery based, self-care program is likely to be at least as effective as other behavioral or psychological treatments. It should help at least 20-32% of users stop smoking in the long term. The results may be even better if nicotine replacement is used at the same time. The benefits of smoking cessation in terms of patient outcomes and lower need of medical services make this program highly cost-effective.


Ahijevych K, Yerardi R, Nedilsky N. Descriptive outcomes of the American Lung Association of Ohio hypnotherapy smoking cessation program. International Journal of Clinical and Experimental Hypnosis. 2000 Oct; 48 (4):374-87.

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.

Colletti G, Supnick JA, Rizzo AA. Long-term follow-up (3-4 years) of treatment for smoking reduction. Addict Behav. 1982;7(4):429-33.

Elkins GR, Rajab MH. Clinical hypnosis for smoking cessation: preliminary results of a three-session intervention. Int J Clin Exp Hypn. 2004 Jan;52(1):73-81.

Garcia Vera MP. Clinical utility of the combination of cognitive-behavioral techniques with nicotine patches as a smoking-cessation treatment: five-year results of the "Ex-Moker" program. J Subst Abuse Treat. 2004 Dec;27(4):325-33.

Hensel MR, Cavanagh T, Lanier AP, Gleason T, Bouwens B, Tanttila H, Reimer A, Dinwiddie RL, Hayes JC. Quit rates at one year follow-up of Alaska Native Medical Center Tobacco Cessation Program. Alaska Med. 1995 Apr-Jun;37(2):43-7.

Huang CL. Evaluating the program of a smoking cessation support group for adult smokers: a longitudinal pilot study. J Nurs Res. 2005 Sep;13(3):197-205.

Klager R. [Smoking cessation. With hypnosis success in over 90%] [Article in German] MMW Fortschr Med. 2004 May 13;146(20):16.

Law M, Tang JL. An analysis of the effectiveness of interventions intended to help people stop smoking. Arch Intern Med. 1995 Oct 9;155(18):1933-41.

McGhan, W.F, Smith MD. Pharmacoeconomic analysis of smoking-cessation interventions. Am J Health Syst Pharm. 1996 Jan 1;53(1):45-52.

Miller L, Zhang X, Rice D, Max W. State Estimates of Total Expenditures Attributable to Cigarette Smoking, 1993. Public Health Reports 1998 113: 447-458. Quoted on:
Accessed June, 2006.

Rodgers K. The hazards of secondhand smoke. Business & Health Special Report. Vol. 15, No. 8, summer, 1997, p. 6.

Roozen HG, Van Beers SE, Weevers HJ, Breteler MH, Willemsen MC, Postmus PE, Kerkhof AJ. Effects on smoking cessation: naltrexone combined with a cognitive behavioral treatment based on the community reinforcement approach. Subst Use Misuse. 2006;41(1):45-60.

Sykes CM, Marks DF. Effectiveness of a cognitive behaviour therapy self-help programme for smokers in London, UK. Health Promot Int. 2001 Sep;16(3):255-60.

Spiegel D, Frischholz EJ, Fleiss JL, Spiegel H. Predictors of smoking abstinence following a single-session restructuring intervention with self-hypnosis. Am J Psychiatry. 1993 Jul;150(7):1090-7.

Targeting Tobacco Use: The Nation's Leading Cause of Death. At a Glance 2006. National Center for Chronic Disease Prevention and Health Promotion. http://www.cdc.gov/nccdphp/aag/aag_osh.htm
Accessed June, 2006.

Warner KE. Cost effectiveness of smoking-cessation therapies. Interpretation of the evidence-and implications for coverage. Pharmacoeconomics. 1997 Jun;11(6):538-49.

West R, McNeill A, Raw M. Smoking cessation guidelines for health professionals: an update. Health Education Authority. Thorax. 2000 Dec;55(12):987-99.

Westmaas JL, Nath V, Brandon TH. Contemporary smoking cessation. Cancer Control. 2000 Jan-Feb;7(1):56-62.

Wynd, CA. Relaxation imagery used for stress reduction in the prevention of smoking relapse. J Adv Nurs. 1992a Mar;17(3):294-302.

Wynd CA. Personal power imagery and relaxation techniques used in smoking cessation programs. Am J Health Promot. 1992b Jan-Feb;6(3):184-9.

Wynd CA. Guided health imagery for smoking cessation and long-term abstinence. J Nurs Scholarsh. 2005;37(3):245-50.