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Kicking Butts!
Alternative Adjunct Treatment for Smoking Cessation

By Shirley Vanderbilt

Originally published in Massage Bodywork magazine, October/November 2001.
Copyright 2003. Associated Bodywork and Massage Professionals. All rights reserved.



Cigarette smoking, once a symbol of glamour, sophistication and power, is now recognized as a harbinger of disease and death. According to the American Lung Association (ALA), "Smoking-related diseases claim an estimated 430,700 American lives each year, including those affected indirectly, such as babies born prematurely due to prenatal maternal smoking and victims of secondhand exposure to tobacco carcinogens." The ALA states, "Smoking is directly responsible for 87 percent of lung cancer cases."1 Of the thousands of chemicals found in smoke from a burning cigarette, including carbon monoxide, radon and benzene,2 at least 60 are known human carcinogens.3 A recent Surgeons General report stated smoking is "the leading known cause of preventable death and disease among women," with lung disease claiming more women's lives than breast cancer in the year 2000.4

Despite warnings from the medical field, the smoking habit continues to be a serious health problem for many Americans, especially women. Nicotine is highly addictive, reaching the brain through smoke inhalation faster than narcotics administered intravenously.5 But quitting requires more than treatment for addiction; most smokers also have a psychological attachment to the habit, linking it with other activities in their lives.

Many smokers claim their habit as a coping mechanism for stress, while in fact smoking creates a cycle of stress throughout the day. Nicotine depletion between periods of smoking leads to increased feelings of stress that are assuaged once nicotine is again inhaled. Smoking then becomes a conditioned response to acute nicotine depletion, a "fix" for the frequent episodes of withdrawal symptoms throughout the day. Long-term cessation actually reduces stress levels for the ex-smoker.6

Anxiety and depression are common symptoms for both men and women trying to quit. However, a woman's hormonal changes can add to emotional stress and this, combined with fear of weight gain, makes quitting more difficult for females. It has also been noted that nicotine replacement therapy (NRT) may not be as effective for women as for men.7


Putting Out the Fire
Emotional side effects (anxiety, tension, irritability and depression) constitute a major portion of the smoking-cessation challenge, therefore a multi-treatment approach is recommended. What works for some may not work for others. Medical research has shown the most effective methods include behavioral modification, counseling, support groups and drug treatment, such as nicotine replacement and the antidepressant bupropion.8

While NRT can ease withdrawal symptoms, it does not address psychological and behavioral addiction. Antidepressants (such as nortriptyline and bupropion) have been somewhat successful, but they have different mechanisms of action and no singular chemical mechanism has been identified as a trigger point for drug intervention.9 Smoking-cessation programs abound in behavior modification clinics and on the Internet, including those offered by NRT products. Despite the availability of these approaches, smoking-cessation rates remain disappointingly low with new generations of young smokers continuing to take up the habit.

Without a magic bullet, many smokers find themselves enduring the rigors of nicotine withdrawal for days or weeks, only to eventually succumb to anxiety and habit by lighting up again. So, the search goes on to find the perfect mix of magic tricks to carry smokers beyond both physiological and psychological dependency.

Complementary and alternative treatments are also taking a shot at busting the nicotine habit. But what works and what doesn't? We now take a look at two approaches in the research bank. The first, acupuncture, appears to have failed the research test thus far. The second, self-administered massage, is but an infant in scientific study. Although results in both fields indicate a need for further study, massage shows promise of emerging as the more expedient (and perhaps more successful) adjunct therapy for smoking cessation.


Acupuncture Misses the Mark
Although acupuncture is widely offered as a treatment for smoking cessation, more than a decade of scientific research has yet to establish clear evidence of its effectiveness. A systematic review published by The Cochrane Library evaluated results of 18 randomized trials comparing acupuncture with sham acupuncture, another intervention or no intervention for smoking cessation. Early uncontrolled studies of the 1980s claimed rates as high as 95 percent for short-term success, but long-term results were either not stated or showed a significant decrease in subjects continuing to abstain from smoking. In reviewing randomized controlled studies, the Cochrane team found no evidence to substantiate these earlier claims.10

Studies included in the review varied in acupuncture technique, with no specific approach emerging as more effective than another. In comparing acupuncture to sham acupuncture and other anti-smoking interventions, there were no differences in outcome. As compared to no intervention, acupuncture initially appeared to be superior, but the results were not sustained. Limitations of the studies included insufficient information to establish correct randomization and blinding, absence of biochemical testing to verify cessation (with the exception of four trials), and lack of long-term data.

Three studies comparing acupuncture to sham acupuncture showed positive results with a combination of techniques; however, results were not sustained. Techniques included electroacupuncture, ear acupuncture and prolonged ear acupressure. Based on these findings, reviewers concluded, "It is possible acupuncture stimulation that is both intensive and continuous may have an effect which is not seen with more limited treatment, and this deserves further research."11


Craving Relief
"I need a cigarette." That's the brain talking when stress and anxiety hit, whether withdrawal symptoms are physical or psychological. The University of Miami's Touch Research Institute (TRI) has zeroed in on a simple approach for reducing this craving using self-massage administered to the ears and hands. As with other smoking-cessation treatments, it may not work for everyone, but the results of TRI's pilot study are encouraging. Similar to many acupuncture studies, the TRI pilot was limited by lack of long-term follow-up and absence of biochemical testing. However, the focus of the project was to evaluate effectiveness of self-massage for reducing "anxiety and withdrawal symptoms (e.g., craving intensity) related to attempts at smoking cessation." Measurements were applied for these effects and reduction in number of cigarettes smoked, rather than for complete abstinence.12

Building their proposal on previous research showing the effectiveness of massage in reducing anxiety and stress hormones, the team surmised "massage therapy might help reduce smoking or at least smoking cravings." As a self-administered technique, it would be a practical approach immediately available, and by keeping the hands busy might "help reduce the anxious behaviors that typically accompany nicotine cravings."13

Ten males and 10 females, ranging in age from 18 to 45 years, were recruited from a medical campus and assigned to a self-massage or control group. Both groups were instructed to refrain from smoking during one craving occurring in the morning, one in the afternoon and one in the evening. In the control group, subjects were instructed to use, at that time, whatever behavior (such as gum chewing) they usually rely on when smoking is not an option. The massage group received demonstration and written instructions for a 5-minute hand or ear massage, and were requested to use the technique at each of the three craving times.14

Over the four-week study, self-report measures were used for data collection. Immediate changes in anxiety, mood and withdrawal symptoms were reported on the first and last day of the study, before and after the treatment or control period. Measurements included the State of Anxiety Inventory, the Profile of Mood States and the Withdrawal Symptoms Visual Analog Scale. A smoking profile questionnaire was also administered on the first and last day of the study to evaluate long-term results.15

The massage group clearly fared better, both following the first day and at the end of the study period, with lower scores on anxiety, depressed mood, and craving and intensity. Additionally, the subjects reported smoking fewer cigarettes per day in the fourth week than on the first day of the study. The only improvement noted in the control group was a reduction in craving intensity, although not as significant a reduction as the massage group; nor was there a concomitant reduction in number of cigarettes smoked per day.16

In conclusion, researchers stated the findings suggest "self-massage may be a convenient and cost-effective adjunct therapy for reducing smoking-related anxiety." The authors added, "The underlying mechanism for the reported effects of self-massage are not clear. One interpretation might be that massage reduces anxiety (as has been shown in many studies). Another interpretation is that keeping the smoker's hand busy might reduce smoking-related anxiety and thereby assist in achieving smoking reduction and potentially smoking cessation."17

Continued research in the application of massage and bodywork for cessation-related symptoms is vital to providing drug-free alternatives as a component of smoking-cessation programs. The results of the above mentioned studies, both acupuncture and massage, warrant further investigation. It is important to keep in mind the complexities of nicotine addiction and the need for a combination of approaches to address all levels of dependency -- physical, psychological and behavioral. While adjunct treatments can help, research has shown for the majority of smokers, no single approach can address all of the issues involved. Clients requesting massage or other bodywork for smoking cessation should be urged to also pursue use of counseling, support groups, classes and online programs, and, if needed and desired, consult a physician for pharmacological help.

Shirley Vanderbilt is a staff writer for Massage Bodywork magazine.


References
1. American Lung Association. www.lungusa.org/tobacco/smoking_factsheet99.html.
2. QuitNet. Boston University School of Public Health. www.quitnet.com.
3. ALA.
4. National Center for Chronic Disease Prevention and Health Promotion. "Women and Smoking: A Report of the Surgeon General -- 2001." www.cdc.gov/tobacco/sgr_forwomen.htm.
5. ALA.
6. Parrott, A.C., "Stress modulation over the day in cigarette smokers," Addiction 90, 2 (Feb. 1995): 240-242.
7. Eisner, Robin. "Women's Unique Smoking Cessation Needs." ABCNEWS.com. http://more.abcnews.go.com/sections/living/DailyNews/quitting01622.html.7/05/01.
8. Ibid.
9. Gambassi, G. and Bernabei, R., "Antidepressants and Smoking Cessation," Archives of Internal Medicine 159 (June 14, 1999):1257.
10. White, A.R., Rampes, H. and Ernst, E., "Acupuncture for Smoking Cessation (Cochrane Review)," The Cochrane Library 3 (2001).
11. Ibid.
12. Hernandez-Reif, M., Field, T. and Hart, S., "Smoking Cravings Are Reduced by Self-Massage," Preventive Medicine 28, 1 (Jan. 1999): 29, 31.
13. Ibid., 29.
14. Ibid.
15. Ibid.
16. Ibid., 30-31.
17. Ibid., 31.




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