- There is currently no clear evidence that mindfulness-based treatments help people to stop smoking or improve their mental health and well-being.
- However, our confidence in the evidence is low or very low, and further evidence is likely to change our conclusions.
What is mindfulness?
Mindfulness involves focusing attention on your thoughts and feelings and observing them without judgment as they arise and pass away. Mindfulness is believed to help people better control their thoughts and feelings, rather than be controlled by them. Stopping smoking gives rise to distressing urges to smoke and low mood, so mindfulness-based treatments could improve people's ability to cope with these.
Types of mindfulness-based therapies include:
- mindfulness training (which involves training in mindfulness-based meditation);
- acceptance and commitment therapy (ACT); which doesn't teach meditation but encourages people to embrace their thoughts and feelings rather than fighting them, while making committed behaviour change);
- distress tolerance training (which provides parts of the ACT therapy, as well as presenting people who smoke with situations that make them want to smoke. This allows them to practise the skills that they have learnt through ACT);
- yoga (which increases awareness of breathing and encourages a connection between mind and body).
What did we want to find out?
We wanted to find out whether mindfulness-based stop-smoking programmes work better than other stop-smoking programmes or no treatment to help people stop smoking.
We wanted to know:
‐ how many people stopped smoking for at least six months;
- whether there were changes in people's mental health and well-being.
What did we do?
We searched for studies that looked at the use of mindfulness to help people stop smoking.
We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods and sizes.
What did we find?
We found 21 studies in 8186 young people and adults who smoked.
The studies tested a range of mindfulness-based treatments, including mindfulness training (8 studies), ACT (8 studies), yoga (3 studies), and distress tolerance training (2 studies). Studies compared these treatments with:
- other stop-smoking treatments that were equally time-intensive (such as counselling);
- other stop-smoking treatments that were less intensive (such as brief advice);
- no treatment.
Most studies took place in the USA (15 studies). Others took place in Hong Kong (2 studies), Brazil (1 study), Ireland (1 study), and Cyprus (1 study). One study did not report the country it took place in.
We did not find clear evidence that mindfulness helped people to stop smoking. When we grouped studies by the type of mindfulness-based intervention people received, we found no evidence that people who received mindfulness training, ACT, distress tolerance training, or yoga were more likely to stop than people who received any other stop-smoking treatments or no support.
Nine studies looked at whether mindfulness-based stop-smoking treatments resulted in positive changes in mental health and well-being, such as reductions in stress or anxiety or improvements in mood. One of these studies found that people who received a mindfulness training programme reported being less stressed than those who received an alternative stop-smoking treatment. However, the other 8 did not find evidence of a difference in mental health and well-being between groups.
What are the limitations of the evidence?
Our confidence in the evidence is low to very low as there were problems with the design of studies, findings of studies were very different from one another, and not enough people took part, making it difficult to tell whether mindfulness helps people to stop smoking or was linked to better mental health and well-being. We need more studies to draw firmer conclusions.
How up to date is this evidence?
We included evidence published to 15 April 2021.
We did not detect a clear benefit of mindfulness-based smoking cessation interventions for increasing smoking quit rates or changing mental health and well-being. This was the case when compared with intensity-matched smoking cessation treatment, less intensive smoking cessation treatment, or no treatment. However, the evidence was of low and very low certainty due to risk of bias, inconsistency, and imprecision, meaning future evidence may very likely change our interpretation of the results. Further RCTs of mindfulness-based interventions for smoking cessation compared with active comparators are needed. There is also a need for more consistent reporting of mental health and well-being outcomes in studies of mindfulness-based interventions for smoking cessation.
Mindfulness-based smoking cessation interventions may aid smoking cessation by teaching individuals to pay attention to, and work mindfully with, negative affective states, cravings, and other symptoms of nicotine withdrawal. Types of mindfulness-based interventions include mindfulness training, which involves training in meditation; acceptance and commitment therapy (ACT); distress tolerance training; and yoga.
To assess the efficacy of mindfulness-based interventions for smoking cessation among people who smoke, and whether these interventions have an effect on mental health outcomes.
We searched the Cochrane Tobacco Addiction Group's specialised register, CENTRAL, MEDLINE, Embase, PsycINFO, and trial registries to 15 April 2021. We also employed an automated search strategy, developed as part of the Human Behaviour Change Project, using Microsoft Academic.
We included randomised controlled trials (RCTs) and cluster‐RCTs that compared a mindfulness-based intervention for smoking cessation with another smoking cessation programme or no treatment, and assessed smoking cessation at six months or longer. We excluded studies that solely recruited pregnant women.
We followed standard Cochrane methods. We measured smoking cessation at the longest time point, using the most rigorous definition available, on an intention‐to‐treat basis. We calculated risk ratios (RRs) and 95% confidence intervals (CIs) for smoking cessation for each study, where possible. We grouped eligible studies according to the type of intervention and type of comparator. We carried out meta‐analyses where appropriate, using Mantel‐Haenszel random‐effects models. We summarised mental health outcomes narratively.
We included 21 studies, with 8186 participants. Most recruited adults from the community, and the majority (15 studies) were conducted in the USA. We judged four of the studies to be at low risk of bias, nine at unclear risk, and eight at high risk. Mindfulness-based interventions varied considerably in design and content, as did comparators, therefore, we pooled small groups of relatively comparable studies.
We did not detect a clear benefit or harm of mindfulness training interventions on quit rates compared with intensity‐matched smoking cessation treatment (RR 0.99, 95% CI 0.67 to 1.46; I2 = 0%; 3 studies, 542 participants; low-certainty evidence), less intensive smoking cessation treatment (RR 1.19, 95% CI 0.65 to 2.19; I2 = 60%; 5 studies, 813 participants; very low-certainty evidence), or no treatment (RR 0.81, 95% CI 0.43 to 1.53; 1 study, 325 participants; low-certainty evidence). In each comparison, the 95% CI encompassed benefit (i.e. higher quit rates), harm (i.e. lower quit rates) and no difference. In one study of mindfulness-based relapse prevention, we did not detect a clear benefit or harm of the intervention over no treatment (RR 1.43, 95% CI 0.56 to 3.67; 86 participants; very low-certainty evidence).
We did not detect a clear benefit or harm of ACT on quit rates compared with less intensive behavioural treatments, including nicotine replacement therapy alone (RR 1.27, 95% CI 0.53 to 3.02; 1 study, 102 participants; low-certainty evidence), brief advice (RR 1.27, 95% CI 0.59 to 2.75; 1 study, 144 participants; very low-certainty evidence), or less intensive ACT (RR 1.00, 95% CI 0.50 to 2.01; 1 study, 100 participants; low-certainty evidence). There was a high level of heterogeneity (I2 = 82%) across studies comparing ACT with intensity-matched smoking cessation treatments, meaning it was not appropriate to report a pooled result.
We did not detect a clear benefit or harm of distress tolerance training on quit rates compared with intensity-matched smoking cessation treatment (RR 0.87, 95% CI 0.26 to 2.98; 1 study, 69 participants; low-certainty evidence) or less intensive smoking cessation treatment (RR 1.63, 95% CI 0.33 to 8.08; 1 study, 49 participants; low-certainty evidence).
We did not detect a clear benefit or harm of yoga on quit rates compared with intensity-matched smoking cessation treatment (RR 1.44, 95% CI 0.40 to 5.16; 1 study, 55 participants; very low-certainty evidence).
Excluding studies at high risk of bias did not substantially alter the results, nor did using complete case data as opposed to using data from all participants randomised.
Nine studies reported on changes in mental health and well-being, including depression, anxiety, perceived stress, and negative and positive affect. Variation in measures and methodological differences between studies meant we could not meta-analyse these data. One study found a greater reduction in perceived stress in participants who received a face-to-face mindfulness training programme versus an intensity-matched programme. However, the remaining eight studies found no clinically meaningful differences in mental health and well-being between participants who received mindfulness-based treatments and participants who received another treatment or no treatment (very low-certainty evidence).