7.18 Alternative therapies and emerging treatments

Last updated: January 2023

Suggested citation: Jenkins, S., Greenhalgh, EM., & Ford, C. 7.18 Alternative therapies and emerging treatments. In Greenhalgh, EM, Scollo, MM and Winstanley, MH [editors]. Tobacco in Australia: Facts and issues. Melbourne: Cancer Council Victoria; 2023. Available from: http://www.tobaccoinaustralia.org.au/chapter-7-cessation/7-18-unproven-methods 

The most successful approach to smoking cessation is behavioural support combined with first-line pharmacotherapy and follow-up1 (see 7.16.5.2). However, many people trying to quit smoking take an interest in alternative and emerging treatments, such as acupuncture, yoga or hypnotherapy, as a primary treatment or to complement evidence-based treatment modalities. The evidence to-date does not indicate that these alternative treatments are as effective for smoking cessation as first-line treatment.

7.18.1 Acupuncture

Acupuncture involves applying needles or surgical staples to the skin of the ear or other parts of the body. Related treatments include acupressure, laser therapy, and electrostimulation, all of which aim to stimulate acupuncture points on the body. A Cochrane review published in 2014 concluded that, although there is weak evidence for short-term effects, there is no consistent, bias-free evidence that acupuncture, acupressure, or laser therapy are effective for long-term smoking cessation. It also concluded that electrostimulation is not effective for smoking cessation. Due to the popularity of these interventions, the authors suggest that more robust research is justified; however, they are not likely to be more effective than existing evidence-based strategies.2

Since the 2014 Cochrane review, further studies have been published which provide mixed support for the efficacy of acupuncture and ear acupressure for smoking cessation. A 2019 systematic review found one trial indicating  that acupuncture was effective compared to no intervention/waiting list for short-term cessation and another two trials indicating it was effective for long-term cessation. Further meta-analyses found that acupuncture in combination with ear acupressure was more effective than sham treatment for short-term and long-term cessation. Acupuncture in combination with counselling, an educational smoking cessation program or moxibustion (a traditional Chinese medicine) was also found to be more effective than acupuncture as monotherapy.3 A 2021 meta-analysis concluded that the current evidence did not indicate that acupuncture or ear acupressure was more effective than sham treatment or nicotine replacement therapy (NRT) for short-term cessation. For long term cessation, there was evidence that ear acupressure was more effective than sham treatment.4 Overall, meta-analyses of acupuncture for smoking cessation have produced divergent results which may be due to differences in methodologies.5  

7.18.2 Hypnotherapy

Hypnotherapy is often purported to assist with quitting smoking, and aims to act on underlying impulses to weaken the desire to smoke or strengthen the will to stop. A 2019 Cochrane review of hypnotherapy for smoking cessation found that existing studies did not provide reliable evidence that it had a greater effect on sustained quit rates than other interventions or no treatment.6

7.18.3 Exercise

Regular exercise has been suggested as a strategy for managing nicotine withdrawal and weight gain, and it does appear to be effective for reducing cravings.7 A small study in Canada found that an acute bout of exercise provided additional craving relief to the nicotine lozenge in recently quit smokers, suggesting exercise may complement existing therapies and maximise reductions in cravings.8

Despite their promise, a 2019 Cochrane review found there was no evidence that adding exercise to smoking cessation support improved long-term abstinence compared to cessation support alone. The quality of evidence was judged to be of low certainty, due to concerns about bias, imprecision and publication bias in trials, and as such the possibility of a modest benefit of exercise could not be ruled out.9 A 2021 meta-analysis of randomised controlled trials comparing aerobic exercise (e.g. running, walking, cycling), with or without NRT, to usual care found moderate-quality evidence that aerobic exercise increased smoking cessation in the short-term, but not at medium- or long-term follow-ups.10

7.18.3.1 Yoga

Yoga is one of the most widely used complementary and alternative therapies. Despite suffering from some methodological limitations, a growing body of research suggests that practising yoga is beneficial for both mental and physical health.11-14 A 2014 review of yoga interventions for smoking cessation concluded that such interventions hold promise for smoking cessation, with the majority of studies showing that it increased quitting rates.15

Subsequent research has found further evidence that yoga interventions increase smoking abstinence and reduce cravings compared to general wellness activities. 16,17 A small study comparing yoga and aerobic exercise found both activities were associated with reduced negative affect, though only yoga was associated with a reduction in cigarette cravings.18 Though more high quality research is needed to draw firm conclusions.

7.18.4 Biofeedback

Biofeedback aims to increase control over involuntary body processes though recording respective bodily functions (e.g., skin temperature, electrodermal activity, muscle tension) and training patients to self-regulate these functions. Neurofeedback is a form biofeedback targeting self-regulation of brain activity using techniques such as function magnetic resonance imaging (fMRI) and electroencephalogram (EEG). Biofeedback and neurofeedback methods for smoking cessation aim to address factors that trigger relapse, such as stress and craving. Early research suggests that biofeedback and neurofeedback techniques may be promising for supporting smoking cessation, however, further high-quality research is needed to be able to draw conclusions about their efficacy. 19,20  

7.18.5 Aversive conditioning

Aversive conditioning or aversion therapy, involves pairing an unwanted behaviour (e.g., smoking) with an unpleasant stimulus, with the objective of reducing the undesired behaviour (e.g. the urge to smoke). Aversion methods for smoking cessation include rapid smoking, covert sensitisation (smoking while imagining unpleasant associations), smoke holding (holding smoke in mouth while breathing through nose), or pairing smoking with electric shocks, silver acetate (a chemical producing an unpleasant taste) or other unpleasant methods or products. Most of these methods are not supported by evidence. 31,32 A 2001 Cochrane review of aversive smoking concluded that rapid smoking (which requires smokers to take a puff every few seconds to make smoking unpleasant) may be effective, but noted the poor quality of many of the studies.32

One study found that a single night of olfactory aversive conditioning during sleep (i.e., pairing cigarette odour and profoundly unpleasant odours) significantly reduced cigarette-smoking behaviour, and this effect persisted for several days.33 Another study pairing smoking-related images with aversive images of long-term health consequences of smoking (e.g., lung cancer) found that cigarette craving reduced and activation in control-associated brain regions (e.g., dorsal anterior cingulate cortex) increased. Further research is needed to investigate the efficacy of this method as a smoking cessation therapy.34

7.18.6 Transcranial magnetic stimulation

Targeting the brain reward circuitry that underlies addiction with artificial stimulation appears to be a promising treatment for tobacco use.35 Building on research showing that repetitive transcranial magnetic stimulation (rTMS) affects cigarette consumption, general craving, and cue-induced craving, 36,37 meta-analyses have found evidence that combining non-invasive brain stimulation (NIBS) techniques [rTMS and transcranial direct current stimulation (tDCS)] with smoking-related cues is associated with higher rates of smoking abstinence and greater smoking reduction compared to sham treatment. Due to high risk of bias in several studies, higher quality research is needed to determine the effectiveness of these techniques. 38,39  

7.18.7 E-cigarettes

See Section 18B.6 for a detailed discussion of the effectiveness of e-cigarettes for smoking cessation and the other effects of e-cigarette use on smoking.

7.18.8 Other types of cessation interventions

Approach bias retraining (ABR) aims to retrain people who smoke to avoid smoking-related cues rather than approach them. A pilot study found higher rates of abstinence among those who were treated with cognitive behavioural therapy (CBT) and ABR than those who received CBT and sham retraining three months later.40

 

Relevant news and research

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References

 

1.   The Royal Australian College of General Practitioners. Chapter 2. Pharmacotherapy for smoking cessation. Supporting smoking cessation: A guide for health professionals. East Melbourne, Vic: RACGP, 2021. Last update: Viewed 1st October 2021. Available from: https://www.racgp.org.au/clinical-resources/clinical-guidelines/key-racgp-guidelines/view-all-racgp-guidelines/supporting-smoking-cessation/pharmacotherapy-for-smoking-cessation.

2.   White AR, Rampes H, Liu JP, Stead LF, and Campbell J. Acupuncture and related interventions for smoking cessation. Cochrane Database of Systematic Reviews, 2014; 1:CD000009. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24459016

3.   Wang JH, van Haselen R, Wang M, Yang GL, Zhang Z, et al. Acupuncture for smoking cessation: A systematic review and meta-analysis of 24 randomized controlled trials. Tob Induc Dis, 2019; 17:48. Available from: https://www.ncbi.nlm.nih.gov/pubmed/31516491

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8.   Tritter A, Fitzgeorge L, and Prapavessis H. The effect of acute exercise on cigarette cravings while using a nicotine lozenge. Psychopharmacology, 2015. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25701265

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https://academic.oup.com/ntr/advance-article-abstract/doi/10.1093/ntr/nty212/5122859?redirectedFrom=fulltext

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