Controlled breathing interventions may reduce substance craving among patients with substance use disorders involving alcohol, nicotine, and other substances, although evidence for withdrawal symptoms and substance dependence was less certain.
Investigators searched eight databases through November 14, 2025, and identified 20 studies that met the inclusion criteria, 15 of which were included in the meta-analysis. They enrolled patients across alcohol, nicotine, opioid, stimulant, or polysubstance use disorders in community and inpatient settings. Interventions included controlled breathing techniques such as heart rate variability biofeedback (HRVB), resonant breathing, yogic breathing, and other approaches in which breathing was the primary therapeutic mechanism. The investigators examined substance use–related outcomes such as substance craving, withdrawal symptoms, and substance dependence. A prespecified subgroup analysis compared HRVB with other breathing interventions.
Across 12 studies, controlled breathing was associated with a small reduction in craving compared with control conditions. Heterogeneity was low, indicating that the effect was generally consistent across the studies. Publication bias analyses, including funnel plot assessment and Egger's regression, did not identify evidence of small-study effects.
Four studies evaluating withdrawal symptoms did not demonstrate a statistically significant benefit compared with controls. Two randomized trials evaluating substance dependence showed a significant pooled improvement, although the investigators noted that the analysis was based on few studies and showed substantial heterogeneity.
The subgroup analysis found no statistically significant difference between HRVB and other controlled breathing interventions in reducing craving. The investigators noted that HRVB studies generally evaluated interventions delivered over multiple sessions, whereas several non-HRVB studies assessed the immediate effects following a single breathing session, limiting direct comparisons of sustained treatment effects.
The investigators cautioned that the evidence was strongest for craving and more limited for the other outcomes. Although most studies included in the craving analysis had a low risk of bias, the certainty of evidence remained low because the pooled analysis included quasi-experimental studies alongside randomized trials. The investigators also cited the small number of studies evaluating dependence and withdrawal, variability in intervention protocols and duration, the lack of long-term follow-up in many studies, and reliance on subjective outcome measures as important limitations.
The findings supported controlled breathing as a potential low-cost, scalable adjunct to addiction treatment, while additional high-quality randomized trials are needed to clarify its effects on other substance use-related outcomes.
"Breathing-based interventions demonstrated consistent and significant effects in reducing craving among individuals with substance and nicotine use disorders," wrote lead study author Ariel Dart Roxburgh, of the Monash Addiction Research Centre at the Eastern Health Clinical School at Monash University in Australia, and colleagues.
The study received no direct funding. Full disclosures of the study authors can be found in the study.
Source: Addiction
