Summary: A systematic review and meta-analysis indicates that controlled breathing interventions produce statistically significant reductions in substance cravings across alcohol, nicotine, opioid, stimulant, and polysubstance use disorders.
The review synthesized data across 20 studies encompassing 1,249 participants to evaluate the efficacy of various breathwork modalities. The analysis demonstrated that non-heart rate variability biofeedback (HRVB) breathing practices provide immediate, single-session craving relief, whereas HRVB techniques demonstrate stronger efficacy in multi-session protocols targeting sustained, long-term craving attenuation.
While evidence regarding substance dependence and withdrawal remains preliminary due to limited trial numbers, the preliminary effect size for dependence was large, positioning accessible breathwork practices as a high-scalability adjunct to standard addiction therapeutics.
Key Facts
- Efficacy in Craving Attenuation: Systematic analysis of 20 empirical trials (N = 1,249) demonstrated small but statistically significant reductions in acute and sustained substance cravings.
- Protocol Dynamics (HRVB vs. Non-HRVB): Non-HRVB breathwork techniques (such as slow-paced or resonant breathing) yielded robust evidence for acute, single-session craving relief. HRVB protocols—requiring real-time heart rate sensors—proved superior for long-term craving reduction across multi-session regimens.
- Broad Substance Applicability: Craving suppression effects were consistent across all evaluated substance categories, including nicotine, alcohol, opioids, central nervous system stimulants, and polysubstance patterns.
- Preliminary Impact on Dependence and Withdrawal: Data regarding withdrawal (4 studies) and dependence (2 studies) showed variable consistency; however, the observed effect size on substance dependence was large, highlighting a priority area for future pre-registered clinical trials.
- High Scalability via mHealth: Given global smartphone penetration exceeding 75%, digital health-guided controlled breathing represents a low-cost, accessible intervention capable of augmenting primary substance use disorder treatment protocols.
Source: Society for the Study of Addiction
Controlled breathing interventions can reduce cravings in people who use substances, including alcohol, tobacco, and other drugs, according to a new review published in the scientific journal Addiction.
The review combined results from 20 studies (1,249 participants overall) that looked at how controlled breathing can help people using substances to reduce craving, withdrawal symptoms, or dependence.
The breathing-based interventions included several types of controlled breathing: heart rate variability biofeedback (HRVB), resonant breathing, yogic breathing, rhemercise, mimicking smoking, and three-part breathing. See details below.
The review found that breathing-based interventions appear promising for improving substance use-related outcomes, with the strongest evidence showing small but statistically significant reductions in craving. While there was no difference in the effect of HRVB breathing vs non-HRVB breathing, the evidence for HRVB was concentrated in multi-session interventions targeting long-term craving reduction and thus had stronger evidence for these longer-term changes. Conversely, non-HRVB breathing studies spanned both formats, yielding stronger evidence for immediate, single-session craving relief.
The positive effects of controlled breathing were consistent across nicotine, alcohol, opiates, stimulants, other substances, and poly-substance use.
Evidence for the effect of controlled breathing on dependence and withdrawal was more limited, as these outcomes were based on fewer studies (two studies examining dependence and four examining withdrawal symptoms) that showed less consistent effects; however, the effect of controlled breathing on dependence was large and warrants further investigation.
According to lead author Dr Ariel Dart Roxburgh, of Monash University, “Our review suggests that breathing interventions can be an effective and low-cost add-on to addiction treatment. With more than three quarters of the world’s population owning a mobile phone, the potential benefits of low-cost smartphone-assisted breathing interventions are substantial. What we need next is larger, pre-registered trials with standardised measures and longer follow-up, so we can improve our understanding of how these interventions work.”
- Heart-rate variability biofeedback (HRVB) uses real-time biofeedback (a sensor that tracks heart rate) to help people learn to pace their breathing to match their heart rhythm.
- Resonant breathing is like HRVB but can be done without biofeedback by approximating the pace of breathing to resemble what would be achieved with HRVB. This is usually 6 breaths per minute.
- Yogic breathing uses controlled patterns of inhalation, exhalation and sometimes breath retention. One example is Sudarashana Kriya Yoga breathing where participants are taught to follow three distinct breathing patterns that vary in speed, depth of breath, and breath hold length.
- Rhemercise is slow-paced breathing that incorporates additional behavioural components such as Duchenne smiling, yawning, and positive verbalisation coordinated with breathing.
- Mimicking smoking involves controlled deep breaths at set intervals to mimic the action of smoking (e.g. inhale for 5 seconds, hold for 2 seconds, exhale for 5 seconds).
- Three-part breathing is a set of three breathing techniques, each involving breathing in deeply and focusing on expanding a different portion of the body (e.g. abdomen, lower chest, upper chest).
Primary funding: This work was not funded directly. Dan Lubman and Shalini Arunogiri are supported by NHMRC Fellowships (GNT1196892 and GNT2008193).
Declaration of interests: The authors have no competing interests to declare and have no financial or non-financial competing interests relating to this project.
Key Questions Answered:
A: HRVB utilizes real-time heart rate sensor feedback to help individuals sync their breathing rate directly with their heart rhythm. Non-HRVB breathing (such as fixed 6-breath-per-minute resonant breathing) relies on fixed counting without sensor feedback. Non-HRVB methods excel at immediate, single-session craving relief, while HRVB exhibits stronger evidence for sustained craving reduction across multi-session programs.
A: No. The systematic review confirmed that the positive effects of controlled breathing on craving reduction were consistent across all evaluated substances, including nicotine, alcohol, opioids, stimulants, and polysubstance use.
A: Because controlled breathing requires no specialized pharmaceuticals and minimal cost, integrating these protocols into smartphone applications allows evidence-based addiction coping mechanisms to reach billions of people globally as a low-cost adjunct to traditional treatment.
Editorial Notes:
- This article was edited by a Neuroscience News editor.
- Journal paper reviewed in full.
- Additional context added by our staff.
About this addiction research news
Author: Jean O’Reilly
Source: Society for the Study of Addiction
Contact: Jean O’Reilly – Society for the Study of Addiction
Image: The image is credited to Neuroscience News
Original Research: Open access.
“Controlled breathing and heart rate variability biofeedback for substance use-related outcomes: A systematic review and meta-analysis” by Ariel Dart Roxburgh, Bosco Rowland, Dan I. Lubman, Sukhjit Kaur Bains, May Anne Pek, Bernard Tso, Victoria Manning, Shalini Arunogiri. Addiction
DOI:10.1111/add.70542
Abstract
Controlled breathing and heart rate variability biofeedback for substance use-related outcomes: A systematic review and meta-analysis
Background and aim
Substance use disorders (SUDs) contribute significantly to global social and economic burden. Breathing-based interventions offer a low-cost, scalable adjunct or alternative to traditional treatment, yet their effects on substance use-related outcomes has not been systematically evaluated. This study aimed to systematically review and meta-analyse the effectiveness of controlled breathing and heart rate variability biofeedback (HRVB) interventions in improving substance use-related outcomes among people using alcohol and other drugs, including nicotine.
Methods
Web of Science, PsycINFO, MEDLINE, CINAHL, EMBASE, PubMed, Scopus and Cochrane were searched, with the final search conducted on 14 November 2025. The protocol was prospectively registered with the International Prospective Register of Systematic Reviews.
Eligible studies were quantitative, with repeated-measure designs, with at least one substance use-related outcome; interventions were required to have controlled breathing as the primary mechanism and were categorised by inclusion of HRVB. The review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A random-effects model was used to estimate pooled effects.
Results
Of 3502 studies identified, 20 met the inclusion criteria, of which 15 were eligible for meta-analyses. Breathing-based interventions produced lower craving than controls, with a small but statistically significant and consistent effect [Hedge’s g = 0.30, 95% confidence interval (CI) = 0.12–0.48, heterogeneity (I2) = 23.5%, 12 studies, 696 participants].
Effects on withdrawal symptoms were uncertain compared with controls (g = 0.46, 95% CI = −0.28 to 1.19, I2 = 89.7%, 4 studies, 289 participants), while larger effects were observed for substance dependence compared with control (g = 0.85, 95% CI = 0.21–1.48, I2 = 70.9%, 2 studies, 144 participants). For the craving outcome, no difference between type of breathing intervention (HRVB vs. other) was identified [Q between (1) = 0.17, P = 0.68].
Conclusions
In people who use substances, breathing-based interventions appear to lead to statistically significant reductions in craving compared with controls, supporting their potential as a low-cost and scalable strategy for managing craving in substance use disorders.
