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Laughter prescription

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Laughter is the tonic, the relief, the surcease for pain. produces laughter and the concomitant physiologic bene-
Charlie Chaplin fits without the use of humour; humour without laughter
might not produce those benefits and potentially could

I
t has been more than 30 years since Norman Cousins have adverse effects on the therapeutic relationship.
published an article in the New England Journal of When considering new pharmacologic interventions
Medicine1 extolling the potential medicinal benefits or invasive procedures, it is quite appropriate to place the
of laughter and humour. Yet the study of laughter still onus of proof of efficacy on the creator of the protocol.
occupies a rather modest place in scientific inquiry. 2 This mind-set is driven by appropriate concerns for false-
It was not until 1995 that laughter as an exercise, or positive errors. Given the side effects and inherent risks
laughter yoga, emerged systematically through laugh- associated with pharmaceuticals, one exercises caution
ter clubs. The popularity of such laughter programs has to be clear that the intended effect is achieved beyond
grown markedly during the past decade. With increasing reasonably considered chance factors. Thus recommen-
recognition, one might expect that there would be grow- dations suggest P values be set conservatively and tech-
ing application of laughter and humour for their comple- niques employed to avoid a “false discovery rate.”11
mentary and alternative medical benefits. (It should be Similar thinking seems to have been applied to the
noted that laughter is an adjunct to and not a replace- consideration of laughter’s potential medicinal effects.
ment for accepted therapies.) They are easy to prescribe Although proponents of laughter and humour can be
and there are no substantial concerns with respect to traced back to the Bible (“A merry heart doeth good
dose, side effects, or allergies. It seems, however, that like a medicine, but a broken spirit drieth the bones”
the medical community has been reluctant to embrace [Proverbs 17:22]), and a variety of medical benefits of
and support laughter for health. laughter have been supported through research, the
scales seem to remain tipped markedly in the direction
History and importance of the of caution.
role of humour in medicine The most positive claim that researchers seem will-
Humour researchers3-8 have reported shortcomings of ing to make is that “current research indicates that using
studies on the physiologic effects of laughter. For example, humor is well accepted by the public and is frequently
“Taken together, the empirical studies reviewed ... provide used as a coping mechanism. However, the scien-
little evidence for unique positive effects of humor and tific evidence of the benefits of using humor on vari-
laughter on health-related variables.”4 Other commenta- ous health related outcomes still leaves many questions
tors have cautioned practitioners about advocating the unanswered.”12
benefits of laughter, fashioning themselves as self-styled
laughter police. “For practitioners to implement credible Biology of laughter and humour
programs and effectively teach self-management tech- There are, however, several good reasons to conclude
niques, further empirical research on the physical, psycho- that laughter is effective as an intervention. Although
social, debonafide [sic], and placebo effects of humor and the evidence (detailed below) demonstrating laughter’s
laughter needs to be conducted.”9 Furthermore, Bennett10 benefits could be stronger, virtually all studies of laugh-
argued that although humour and laughter have been the ter and health indicate positive results. Similarly, there
focus of attention in the popular media and medical lit- are almost no negative side effects or undesirable rami-
erature, and despite statements about the health benefits fications associated with laughter as an intervention.
of humour, current research was insufficient to validate This is a case in which the appropriate logic might be
such claims. He identified support for the role of humour more akin to the legal perspective of “innocent until
and laughter in other areas, including patient-physician proven guilty.”
communication, psychological aspects of patient care, Yet, given the prevailing orientation toward laughter
medical education, and reducing stress among med- as an intervention, an exhaustive review of the medical
ical professionals. It is also important to note that while literature to assess demonstrated benefits of laughter
humour and laughter are often connected, there are
some important distinctions. For example, laughter yoga La traduction en français de cet article se trouve
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Can Fam Physician 2009;55:965-7 (Eng), CFPlus (Fr)

Vol 55: october • octobre 2009 Canadian Family Physician • Le Médecin de famille canadien 965
Commentary
was completed. Several databases were searched for laughter and humour can illuminate what cancer patients
all occurrences of laughter, and reviews of laughter already know; studies have shown that 50% of cancer
and humour2,4,13,14 were examined. The intent was to patients used humour20 and 21% of a group of breast can-
find studies related to benefits of laughter and laugh- cer patients used humour or laughter therapy.21
ter effects. Although the literature contains “an abun-
dance of non–evidence-based opinion”14 exploring how Clinical evidence
laughter and humour should or should not be applied in As Rosner22 reported, randomized controlled clinical
medical settings, there is also a substantial body of well- trials have not been conducted validating the thera-
researched information demonstrating many benefits peutic efficacy of laughter. Benefits, however, have
and potential benefits of laughter and humour. Future been reported in geriatrics,23 oncology,24-26 critical care,27
studies might enhance the literature by considering psychiatry, 28,29 rehabilitation, 30 rheumatology, 1 home
that laughter is highly social and examining laughter in care,31 palliative care,32 hospice care,33 terminal care,34
social settings. Furthermore, careful descriptive work and general patient care. 35 These and other reports
linking physiologic systems with types, kinds, and con- constitute sufficient substantiation to support what is
texts of laughter will be valuable.2 experientially evident—laughter and humour are thera-
Morse’s conclusion about laughter and humour in peutic allies in healing.
the dental setting summarized the literature to date: One area where questions remain is the effect of
“Laughter and humor are not beneficial for everyone, but laughter on the so-called stress hormones: epinephrine,
since there are no negative side effects, they should be norepinephrine, and cortisol. This is important because
used ... to help reduce stress and pain and to improve it is theorized that if laughter does, in fact, decrease
healing.15 Findings range from suggesting that, in addi- stress hormones, this would be one mechanism that
tion to a stress-relief effect, laughter can bring about might explain the proposed connection between laugh-
feelings of being uplifted or fulfilled16 to showing that the ter and immune function, and from there to improved
act of laughter can lead to immediate increases in heart health outcomes.17
rate, respiratory rate, respiratory depth, and oxygen con- “The relationship between humor and health is a com-
sumption.17 These increases are then followed by a per- plex one. Groucho Marx once noted that ‘A clown is like
iod of muscle relaxation, with a corresponding decrease an aspirin, only he works twice as fast.’ Patch Adams,
in heart rate, respiratory rate, and blood pressure. the founder of the Gesundheit community, where laugh-
Overall, the arguments against using laughter as ter therapy is a daily medical routine, would no doubt
an intervention appear to be both unduly cautious and agree. Both men, to do their work, require a commun-
based on the desire for more evidence. The arguments ity—the former as an audience and the latter to mag-
in favour of laughter as an intervention are grounded in nify the power of the healing response. After all, half of
the virtually universal positive results associated with the fun in laughter, as well as healing, is sharing it.”36
existing studies of laughter. Although scholars and prac- Yet, research might not be ready and able to measure
titioners recognize the value of further study, more rep- and understand the complexities of how laughter works,
lication, and identification of specifics, the call for more particularly when laughter occurs in a group environ-
application of laughter as an intervention seems war- ment, such as laughter clubs. “The prevailing medical
ranted. Perhaps it is time to usher in a new era in which paradigm has no capacity to incorporate the concept
we reverse our concerns about errors. that a relationship is a physiologic process, as real and
It might be time to start giving more credence to posi- as potent as any pill or surgical procedure.”37
tive views about laughter, such as that laughter might
reduce stress and improve natural killer cell activity. Clinical bottom line
As low natural killer cell activity is linked to decreased As Robert Provine, the noted laughter researcher, com-
disease resistance and increased morbidity in those mented in the documentary Laugh Out Loud, “Until the
with cancer or HIV disease, laughter might be a useful scientists work out all the details, get in all the laugh-
cognitive-behavioural intervention.18 ter that you can!”38 Medical practitioners could begin to
The many voices of cancer survivors and of those who help patients get more laughter in their lives. Following
have employed laughter in their recoveries supply fur- the announcement of a study of the benefits of laughter
ther promising support. One such person, Scott Burton, on endothelial function,39 Dr Michael Miller, one of the
said, “The other reactions; anger, depression, suppres- study’s authors, said he envisioned a time when phys-
sion, denial, took a little piece of me with them. Each icians might recommend that everyone get 15 to 20
made me feel just a little less human. Yet laughter made minutes of laughter in a day in the same way they rec-
me more open to ideas, more inviting to others, and ommend at least 30 minutes of exercise. Although phys-
even a little stronger inside. It proved to me that, even icians’ advice about health-promoting behaviour might
as my body was devastated and my spirit challenged, I have a limited effect in some cases,40 it can certainly be
was still a vital human.”19 Perhaps medical prescription of a catalyst for change.41 Specifically, medical practitioners

966  Canadian Family Physician • Le Médecin de famille canadien  Vol 55:  october • octobre 2009
 Commentary
might acquaint themselves with opportunities such as 18. Bennett MP, Zeller JM, Rosenberg L, McCann J. The effect of mirthful
laughter on stress and natural killer cell activity. Altern Ther Health Med
laughter clubs, which are available for their patients and 2003;9(2):38-45.
provide information and endorsements. Let us begin to 19. Burton S. Why not laugh? Minneapolis, MN: Inconvenience Productions; 2003.
consider that, along with eating your vegetables and Available from: www.sburton.com/whynotlaugh.htm. Accessed 2008 Feb 11.
20. Bennett M, Lengacher C. Use of complementary therapies in a rural cancer
getting enough sleep, laughter is a sound prescription as
population. Oncol Nurs Forum 1999;26(8):1287-94.
a wonderful way to enhance health.  21. Lengacher CA, Bennett MP, Kip KE, Keller R, La Vance MS, Smith LS, et al.
Dr Strean is an Associate Professor in the Faculty of Physical Education and Frequency of use of complementary and alternative medicine in women with
Recreation at the University of Alberta in Edmonton. breast cancer. Oncol Nurs Forum 2002;29(10):1445-52.
22. Rosner F. Therapeutic efficacy of laughter in medicine. Cancer Invest
Competing interests
None declared 2002;20(3):434-6.
23. Williams H. Humor and healing: therapeutic effects in geriatrics. Gerontion
Correspondence
1986;1(3):14-7.
Dr William B. Strean, University of Alberta, Physical Education and Recreation,
P-408 VVC, Edmonton, AB T6R 1L5; telephone 780 492-3890; fax 780 492-2364; 24. Bellert JL. Humor. A therapeutic approach in oncology nursing. Cancer Nurs
e-mail billy.strean@ualberta.ca 1989;12(2):65-70.
25. Erdman L. Laughter therapy for patients with cancer. Oncol Nurs Forum
The opinions expressed in commentaries are those of the authors. Publication
1991;18(8):1359-63.
does not imply endorsement by the College of Family Physicians of Canada.
26. Trent B. Ottawa lodges add humour to armamentarium in fight against can-
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