Editor’s Note: This is part 2 of a 2-part series on complementary and alternative approaches to smoking cessation. Find part 1 here.
As stated in part 1 of this series, nicotine is the most used addictive substance with about 1.1 billion individuals who smoke tobacco worldwide. Tobacco smoking is the leading cause of premature mortality.1
Fortunately, many tobacco users would like to quit, and there is growing interest in using complementary and alternative methods (CAM). Again, as mentioned previously a Mayo Clinic survey showed 67% of 1,1175 respondents were interested in the future use of CAM for tobacco cessation, and 27% had already tried some form of CAM. The methods perceived to be most successful among respondents were hypnosis, herbal products, acupuncture, yoga, and massage.2
Part 2 of this review aims to familiarize clinicians with additional CAM methods their patients may be using and the available data on their efficacy.
In a Cochrane database review analyzing 24 trials with more than 7,200 participants, exercise was not found to help patients quit smoking.12 However, some studies have shown beneficial effects when exercise has been combined with other smoking cessation approaches.
Cravings were found to decrease13 when exercise was undertaken in addition to using nicotine lozenges. Abstinence rates increased in sedentary women when exercise was combined with cognitive behavioral therapy (CBT).14 In people with high anxiety who enrolled in a smoking cessation program, the addition of exercise increased rates of quitting.15
Although yoga is generally seen as a form of exercise in the United States, yoga, as an ancient philosophy and a spiritual practice, may also offer benefits other types of physical activity do not.
As there is no standardized approach followed by all yoga practitioners and many different schools exist, it is difficult to gather objective data. However, yoga is generally perceived to be helpful in patients who are motivated to try it. In a study combining CBT with a form of yoga called Iyengar yoga, abstinence rates were 37% higher in the combined modality group.16 Yoga helps to reduce stress and negative emotions associated with smoking cessation and is generally considered safe. Pregnant women and people with certain medical conditions, such as uncontrolled blood pressure, abdominal hernias, glaucoma, or sciatica, should modify some yoga poses.
As an increasing number of people worldwide gain access to the Internet, social media can be used to help patients quit smoking. Interactive websites, smartphone apps, Facebook, WhatsApp, and Twitter groups abound and can help motivated individuals in their smoking cessation efforts. A review of social media interventions suggested that these approaches are feasible, highly acceptable, and may improve outcomes, but more research is needed.17
Acupuncture & Acupressure
A Cochrane database review did not find objective evidence of beneficial effect when using either acupuncture or acupressure.18 However, the authors of the review said that the many ways of performing acupuncture, acupressure, and related modalities made it difficult to make firm conclusions and more research was warranted.
Notably, acupressure focused on the ear—or auricular acupressure—has been considered a viable approach for smoking cessation by many CAM practitioners. A small study from Korea supports this theory. The study had only 55 participants, but researchers found that when auricular acupressure was combined with behavioral therapy, the smoking cessation rate at 1 year was 22% compared to about 5% in those who did not receive auricular acupressure.19
Although there is no evidence that herbal supplements are effective as smoking cessation treatments, cravings may decrease with their use. St John’s wort is commonly used as an herbal antidepressant and, in one small trial, appeared to help with smoking cessation.20 However, some other trials did not find it helpful.21,22
A trial conducted in Thailand randomized 100 smokers between small pieces of lime taken by mouth vs. regular nicotine gum.23 At 9-12 weeks of follow-up, there was no significant difference in abstinence rates. Sixty one percent of individuals in the lime group and 66% in the nicotine group abstained from smoking. Given the small cost and the absence of adverse effects with small pieces of lime, this approach could be considered for people interested in using alternative methods for smoking cessation.
In another small study, 48 participants were randomized between inhaling the vapor from essential oil of black pepper, menthol, or an empty cartridge using an inhalation device. Black pepper essential oil inhalation appeared to decrease cravings.24
Combining CAM approaches with conventional smoking cessation modalities may lead to better outcomes although the literature is not conclusive.25 Research needs to continue. One recent study has combined CBT with psilocybin as a complimentary approach within a structured smoking cessation program. Psilocybin is a mushroom-derived serotonin 2A receptor agonist. When used with CBT and conventional smoking cessation approaches, long-term abstinence (16-57 months) was observed.26
Although there are many CAM practices described in the literature, there is a lack of robust scientific evidence to support their use. Nonetheless, it is important for oncologists and other health providers to encourage their patients to quit smoking using current best practices, in addition to any other modality that the patient perceives as helpful to achieve cessation. This is particularly important for practitioners in low- and middle-income countries where smoking cessation pharmacotherapy may not be readily available.
- 1. Sood A, Ebbert JO, Sood R, Stevens SR. Complementary treatments for tobacco cessation: a survey. Nicotine Tob Res. 2006 Dec;8(6):767-71. doi: 10.1080/14622200601004109. PMID: 17132524
- 2. Wieland LS, Manheimer E, Berman BM. Development and classification of an operational definition of complementary and alternative medicine for the Cochrane collaboration. Altern Ther Health Med. 2011;17(2):50-59.
- 3. National Center for Complementary and Alternative Medicine. https://files.nccih.nih.gov/s3fs-public/nccam_special_report.pdf. Accessed 2 June, 2022
- 4. Lindson-Hawley N, Thompson TP, Begh R. Motivational interviewing for smoking cessation. Cochrane Database Syst Rev. 2015 Mar 2;(3):CD006936. doi: 10.1002/14651858.CD006936.pub3. PMID: 25726920.
- 5. Lindson N, Thompson TP, Ferrey A, Lambert JD, Aveyard P. Motivational interviewing for smoking cessation. Cochrane Database Syst Rev. 2019 Jul 31;7(7):CD006936. doi: 10.1002/14651858.CD006936.pub4. Epub ahead of print. PMID: 31425622; PMCID: PMC6699669.
- 6. Smokefree.gov. “Practice Mindfulness.” https://smokefree.gov/challenges-when-quitting/stress/practice-mindfulness. Accessed 26 May, 2022.
- 7. Charlot M, D’Amico S, Luo M, Gemei A, Kathuria H, Gardiner P. Feasibility and Acceptability of Mindfulness-Based Group Visits for Smoking Cessation in Low-Socioeconomic Status and Minority Smokers with Cancer. J Altern Complement Med. 2019 Jul;25(7):762-769. doi: 10.1089/acm.2019.0016. PMID: 31314565.
- 8. Oikonomou MT, Arvanitis M, Sokolove RL. Mindfulness training for smoking cessation: A meta-analysis of randomized-controlled trials. J Health Psychol. 2017 Dec;22(14):1841-1850. doi: 10.1177/1359105316637667. Epub 2016 Apr 4. PMID: 27044630.
- 9. Vinci C. Cognitive Behavioral and Mindfulness-Based Interventions for Smoking Cessation: a Review of the Recent Literature. Curr Oncol Rep. 2020 May 16;22(6):58. doi: 10.1007/s11912-020-00915-w. PMID: 32415381; PMCID: PMC7874528.
- 10. Barnes J, McRobbie H, Dong CY, Walker N, Hartmann-Boyce J. Hypnotherapy for smoking cessation. Cochrane Database Syst Rev. 2019 Jun 14;6(6):CD001008. doi: 10.1002/14651858.CD001008.pub3. PMID: 31198991; PMCID: PMC6568235.
- 11. Ussher MH, Faulkner GEJ, Angus K, Hartmann-Boyce J, Taylor AH. Exercise interventions for smoking cessation. Cochrane Database Syst Rev. 2019 Oct 30;2019(10):CD002295. doi: 10.1002/14651858.CD002295.pub6. PMID: 31684691; PMCID: PMC6819982.
- 12. Tritter A, Fitzgeorge L, Prapavessis H. The effect of acute exercise on cigarette cravings while using a nicotine lozenge. Psychopharmacology (Berl). 2015 Jul;232(14):2531-9. doi: 10.1007/s00213-015-3887-0. Epub 2015 Feb 22. PMID: 25701265.
- 13. Marcus BH, Lewis BA, Hogan J, King TK, Albrecht AE, Bock B, Parisi AF, Niaura R, Abrams DB. The efficacy of moderate-intensity exercise as an aid for smoking cessation in women: a randomized controlled trial. Nicotine Tob Res. 2005 Dec;7(6):871-80. doi: 10.1080/14622200500266056. PMID: 16298722.
- 14. Zvolensky MJ, Rosenfield D, Garey L, Kauffman BY, Langdon KJ, Powers MB, Otto MW, Davis ML, Marcus BH, Church TS, Frierson GM, Hopkins LB, Paulus DJ, Baird SO, Smits JAJ. Does exercise aid smoking cessation through reductions in anxiety sensitivity and dysphoria? Health Psychol. 2018 Jul;37(7):647-657. doi: 10.1037/hea0000588. Epub 2018 Apr 30. PMID: 29708388; PMCID: PMC6032989.
- 15. Bock BC, Dunsiger SI, Rosen RK, Thind H, Jennings E, Fava JL, Becker BM, Carmody J, Marcus BH. Yoga as a Complementary Therapy for Smoking Cessation: Results From BreathEasy, a Randomized Clinical Trial. Nicotine Tob Res. 2019 Oct 26;21(11):1517-1523. doi: 10.1093/ntr/nty212. PMID: 30295912; PMCID: PMC6821291.
- 16. Naslund JA, Kim SJ, Aschbrenner KA, McCulloch LJ, Brunette MF, Dallery J, Bartels SJ, Marsch LA. Systematic review of social media interventions for smoking cessation. Addict Behav. 2017 Oct;73:81-93. doi: 10.1016/j.addbeh.2017.05.002. Epub 2017 May 2. PMID: 28499259; PMCID: PMC5556947.
- 17. White AR, Rampes H, Campbell JL. Acupuncture and related interventions for smoking cessation. Cochrane Database Syst Rev. 2006 Jan 25;(1):CD000009. doi: 10.1002/14651858.CD000009.pub2. Update in: Cochrane Database Syst Rev.
- 18. Lee EJ. Auricular Acupressure and Positive Group Psychotherapy With Motivational Interviewing for Smoking Cessation. Holist Nurs Pract. 2019 Jul/Aug;33(4):214-221. doi: 10.1097/HNP.0000000000000333. PMID: 31192833.
- 19. Lawvere S, Mahoney MC, Cummings KM, Kepner JL, Hyland A, Lawrence DD, Murphy JM. A Phase II study of St. John’s Wort for smoking cessation. Complement Ther Med. 2006 Sep;14(3):175-84. doi: 10.1016/j.ctim.2006.01.007. Epub 2006 Jun 13. PMID: 16911897.
- 20. Sood A, Ebbert JO, Prasad K, Croghan IT, Bauer B, Schroeder DR. A randomized clinical trial of St. John’s wort for smoking cessation. J Altern Complement Med. 2010 Jul;16(7):761-7. doi: 10.1089/acm.2009.0445. PMID: 20590478; PMCID: PMC3110810.
- 21. Walia N, Gonzalez S, Zoorob R. A Systematic Review of the Use of St. John’s Wort for Smoking Cessation in Adults. Cureus. 2021 Oct 14;13(10):e18769. doi: 10.7759/cureus.18769. PMID: 34796061; PMCID: PMC8590314.
- 22. Rungruanghiranya S, Ekpanyaskul C, Sakulisariyaporn C, Watcharanat P, Akkalakulawas K. Efficacy of fresh lime for smoking cessation. J Med Assoc Thai. 2012 Dec;95 Suppl 12:S76-82. PMID: 23513469.
- 23. Rose JE, Behm FM. Inhalation of vapor from black pepper extract reduces smoking withdrawal symptoms. Drug Alcohol Depend. 1994 Feb;34(3):225-9. doi: 10.1016/0376-8716(94)90160-0. PMID: 8033760.
- 24. Patnode CD, Henderson JT, Coppola EL, Melnikow J, Durbin S, Thomas RG. Interventions for Tobacco Cessation in Adults, Including Pregnant Persons: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA. 2021 Jan 19;325(3):280-298. doi: 10.1001/jama.2020.23541. PMID: 33464342.
- 25. Johnson MW, Garcia-Romeu A, Griffiths RR. Long-term follow-up of psilocybin-facilitated smoking cessation. Am J Drug Alcohol Abuse. 2017 Jan;43(1):55-60. doi: 10.3109/00952990.2016.1170135. Epub 2016 Jul 21. Erratum in: Am J Drug Alcohol Abuse. 2017 Jan;43(1):127. PMID: 27441452; PMCID: PMC5641975.
- Andrew Weil Center for Integrative Medicine, University of Arizona, Tucson, AZ, USA
- Dr. Rajeev Kurapati, Medical Director of Integrative Oncology, St. Elizabeth Healthcare, Florence, Kentucky, USA.
- IASLC Tobacco Control and Smoking Cessation Education Subcommittee