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MAT-6237; No. of Pages 8 ARTICLE IN PRESS

Maturitas xxx (2014) xxx–xxx

Contents lists available at ScienceDirect

Maturitas
journal homepage: www.elsevier.com/locate/maturitas

Review

Aromatherapy for stress reduction in healthy adults: a systematic

review and meta-analysis of randomized clinical trials
Myung-Haeng Hur a , Ji-Ah Song a , Jeonghee Lee b , Myeong Soo Lee c,∗
a
College of Nursing, Eulji University, Daejeon, South Korea
b
Seoul National University Bundang Hospital, Seongnam, South Korea
c
Korea Institute of Oriental Medicine, Daejeon, South Korea

a r t i c l e i n f o a b s t r a c t

Article history: The aim of this review was to systematically assess the effectiveness of aromatherapy for stress manage-
Received 1 August 2014 ment. Seven databases were searched from their inception through April 2014. RCTs testing aromatherapy
Received in revised form 7 August 2014 against any type of controls in healthy human person that assessed stress level and cortisol level were
Accepted 9 August 2014
considered. Two reviewers independently performed the selection of the studies, data abstraction and
Available online xxx
validations. The risk of bias was assessed using Cochrane criteria. Five RCTs met our inclusion criteria,
and most of them had high risk of bias. Four RCTs tested the effects of aroma inhalation compared with no
Keywords:
treatment, no aroma, and no odour oil. The meta-analysis suggested that aroma inhalation has favourable
Aromatherapy
Essential oil
effects on stress management (n = 80; standard mean difference (SMD), −0.96; 95% CI, −1.44 to −0.48;
Stress P < 0.0001; I2 = 0%). Three of included RCTs tested aroma inhalation on saliva or serum cortisol level com-
Systematic review pared with control and meta-analysis failed to show significant difference between two groups (n = 88,
Cortisol SMDs −0.62; 95% CIs −1.26 to 0.02, P = 0.06, I2 = 46%). In conclusion, there is limited evidence suggesting
Meta-analysis that aroma inhalation may be effective in controlling stress. However, the number, size and quality of
the RCTs are too low to draw firm conclusions.
© 2014 Elsevier Ireland Ltd. All rights reserved.

Contents

1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
2. Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
2.1. Criteria for including studies in this review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
2.1.1. Types of studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
2.1.2. Types of participants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
2.1.3. Types of interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
2.1.4. Types of outcome measures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
2.2. Search methods for identifying the studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
2.2.1. Electronic searches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
2.2.2. Search strategy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
2.3. Data collection and analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
2.3.1. Selection of studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
2.3.2. Data extraction and management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
2.3.3. Assessment of risk of bias in the included studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
2.3.4. Measures of the treatment effect . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
2.3.5. Unit of analysis issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
2.3.6. Assessment of heterogeneity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
2.3.7. Data synthesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00

∗ Corresponding author. Tel.: +82 42 868 9266; fax: +82 42 863 9299.
E-mail addresses: drmslee@gmail.com, mslee@kiom.re.kr (M.S. Lee).

http://dx.doi.org/10.1016/j.maturitas.2014.08.006
0378-5122/© 2014 Elsevier Ireland Ltd. All rights reserved.

Please cite this article in press as: Hur M-H, et al. Aromatherapy for stress reduction in healthy adults: a systematic review and meta-
analysis of randomized clinical trials. Maturitas (2014), http://dx.doi.org/10.1016/j.maturitas.2014.08.006
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3. Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
3.1. Study description . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
3.2. Risk of bias . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
3.3. Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
3.3.1. Self-reported stress . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
3.3.2. Cortisol level . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
4. Discussion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
Competing interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
Provenance and peer review: not commissioned . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00

1. Introduction contain sufficient details for critical evaluation. No language restric-

tion will be imposed.
Stress refers to the state of psychological, physiological and
physical strain that is felt when one is faced with an environ-
ment that is difficult to adapt to [1]. Chronically, it may lead to 2.1.2. Types of participants
physical diseases such as heart disease, stomach ulcers, hyper- The studies evaluated healthy participants were included. The
tension, etc. and psychological maladaptation including insomnia, studies conducted with subjects with chronic or psychological dis-
neurosis, depression, etc [1–5]. Acutely, psychological changes eases; pregnant subjects, children, or animals were excluded.
such as anxiety may appear or physiological changes such as
release of catecholamine, increase in blood pressure due to the 2.1.3. Types of interventions
activation of the sympathetic nervous system, and increase in We included those trials using the aroma inhalation, aromather-
pulse rate may appear [1,6,7]. Particularly from a medical per- apy massage with any types of essential oil alone or as a combined
spective, stress can be the cause of many diseases, and relieving therapy of the aroma inhalation, aromatherapy massage with a
stress is one of the most basic responsibilities of the medical conventional therapy versus the same conventional therapy. Aro-
staff since hospitalizations and surgeries may induce stress [1]. matherapy is defined as the therapeutic use of essential oils from
Particularly in the medical field, efforts to relieve stress are in plants. There were no limitations on the number of essential oils
progress as the number of diseases caused by stress increases used, the dosage, the forms of aromatherapy or the duration of the
while diseases and treatment may be a source of stress themselves treatment.
[1,8].
Aromatherapy is the therapeutic use of essential oils from
plants. Essential oils can be absorbed into the body via the skin 2.1.4. Types of outcome measures
or the olfactory system [9]. Recent systematic review showed The following outcome measures will be assessed based on anal-
that aromatherapy is one of popular complementary and alter- yses of the data obtained in the included trials:
native medicine in UK [10]. Several textbooks have also asserted
the favourable therapeutic effects of aromatherapy for psycholog-
2.1.4.1. Primary outcome. Subjective stress level with visual ana-
ical health including stress management [9,11,12]. One overview
logue scale, numerical rating scale or verified questionnaire for
suggested that aromatherapy, which generally delivered with
measuring stress level was determined.
massage therapy, may induce relaxation which, in turn, might
improve pain and psychological health [13]. There are three
systematic reviews of aromatherapy for psychological health 2.1.4.2. Secondary outcomes.
including anxiety and depression [14–16]. One of them includes
16 RCTs and suggested beneficial effects on reducing anxiety
(1) Cortisol level (saliva or plasma or serum);
[14]. The other systematic review that was based on 13 RCTs
(2) Adverse effects likely to be related to treatment.
showed limited evidence of anxiolytic effects of lavender [15].
Third systematic review included six studies of aromatherapy
for depression and suggested beneficial effects [16]. However, 2.2. Search methods for identifying the studies
no systematic reviews for stress reduction are currently avail-
able. 2.2.1. Electronic searches
The aim of this systematic review was to summarise and crit- The electronic searches were performed using Pubmed, the
ically assess the evidence from randomised clinical trials for or Cumulative Index to Nursing and Allied Health Literature (CINAHL),
against the effectiveness of aromatherapy as an anti-stress treat- EMBASE, and the Cochrane Central Register of Controlled Trials
ment. (CENTRAL). We also searched three Korean databases (the Research
Information Service System (RISS), DBPIA, and the Korean Stud-
ies Information Service System (KISS)). Languages were limited to
2. Methods English and Korean. In addition to electronic databases, grey jour-
nals such as dissertations, news articles, presentation materials, etc.
2.1. Criteria for including studies in this review were searched manually.

2.1.1. Types of studies

Randomized controlled trials (RCTs) and quasi-RCTs were 2.2.2. Search strategy
included. Trials that did not provide detailed results will also be The searching term was (aromatherapy OR aroma* OR (essential
excluded. Dissertations and abstracts will be included if these oil)) AND (stress).

Please cite this article in press as: Hur M-H, et al. Aromatherapy for stress reduction in healthy adults: a systematic review and meta-
analysis of randomized clinical trials. Maturitas (2014), http://dx.doi.org/10.1016/j.maturitas.2014.08.006
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2.3. Data collection and analysis
2.3.1. Selection of studies
Two of the authors independently screened the titles and
abstracts of the searched studies, perform the study selection and
record their decisions on a standard eligibility form. The arbitrator
decided upon the study selection when a consensus could not be
reached.
contacted the authors of eligible trials for clarification. Any dif-
ferences in opinion were resolved by discussion or arbitration
involving a third author.
2.3.4. Measures of the treatment effect
For continuous data, we used the standard mean difference
(SMD) to measure the treatment effect at a 95% confidence interval
(CI) because the studies employed different measurement scale.

2.3.2. Data extraction and management

Two of the authors independently extracted the data using a
standard data extraction form and resolve disagreements through
discussion before analysis. When the reported data were insuffi-
cient or ambiguous, two of the authors contacted the corresponding
authors of the clinical trials by e-mail or telephone to request addi-
tional information or clarification.
2.3.3. Assessment of risk of bias in the included studies
We independently assessed the risk of bias in the eligible stud-
ies according to the criteria described in the Cochrane Handbook
version 5.1.0, which includes random sequence generation, alloca-
tion concealment, blinding of participants and personnel, blinding
of the outcome assessment, incomplete outcome data, selective
reporting, and other sources of bias [17]. The quality of the study
was classified as low, unclear or high risk of bias. If necessary, we
2.3.5. Unit of analysis issues
Data from parallel-group studies were included for meta-
analysis.
2.3.6. Assessment of heterogeneity
Had a meta-analysis been possible, we could have used the I2
statistic to quantify the inconsistencies among the included stud-
ies. An I2 value of >50% was considered indicative of substantial
heterogeneity [18]. If heterogeneity was observed, we conducted a
subgroup analysis to explore its possible causes.
2.3.7. Data synthesis
Data synthesis for comparable trials with comparable outcomes
was performed using Review Manager (RevMan), Version 5.2.6.

Fig. 1. Flow chart of study selection process. RCT: randomized clinical trial; NRS: non randomized controlled study; UOS: uncontrolled observational study.

Please cite this article in press as: Hur M-H, et al. Aromatherapy for stress reduction in healthy adults: a systematic review and meta-
analysis of randomized clinical trials. Maturitas (2014), http://dx.doi.org/10.1016/j.maturitas.2014.08.006
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Table 1
Summary of randomized clinical trials examining aromatherapy and stress in healthy volunteers.

First author Sample size age (sex (M/F)) Intervention group Control Main outcome Intergroup Author’s conclusion
(year) experimental stress (regime) (regime) measures difference

Toda 30 Healthy students 21–26
(2008) years old (23/7) 10 min
serial arithmetic test
(Uchida–Kraepelin test)
Kim (2011) 30 Healthy volunteers (A)
22.3 (7/8); (B) 21.4 (4/11)
Needle insertion for 30 s
Motomura 42 Healthy college
(2001) students (A) 20.7 (7/8); (B)
21.3 (7/7) waiting stress
(20 min)
Toda 21 Healthy female
(2011) university students 21–27
years old (0/21) No
experimental stress
Kim (2009) 37 Healthy soldiers20–24
(37/0) no experimental
stress
(A) Lavender inhalation (B) No (1) Subjective (1) NS ’. . . lavender aroma has a
(5 min, once, n = 16) 10 cm treatment stress (10 cm-VAS) (2) NS stress relief effect.’
from the nose, airborne (n = 14) (2) Saliva cortisol
organic essetial oil (␮g/dL)
(A) Lavender inhalation (B) No aroma Subjective stress P < 0.001 ’Lavender
(facial mask, 5 min, once, (facial mask, (10 cm-VAS) aromatherapy. . .decrease
n = 15) 5 min, n = 15) in the stress . . .’
(A) Lavender (diffused, (B) No Subjective stress NS . . . lavender odorants were
20 min, n = 15) treatment (Stress Arousal associated with reduced
(n = 14) Checklist, SACL) mental stress . . ..
(C) No
experimental
stress and no
treatment
(n = 13)
(A) Lavender inhalation (C) Odorless (1) Subjective (1) A vs. B, NS; ’Peppermint aroma may be
(10 min, once, n = 7) jojoba oil stress (10 cm-VAS) B vs. C, useful for relieving stress.’
(B) Peppermint inhalation (10 min, once, (2) Saliva cortisol P = 0.003; A vs.
(10 min, once, n = 7) n = 7) (␮g/dL) C, NS
(2) A vs. B,
P = 0.01; B vs. C,
P = 0.001; A vs.
C, NS
(A) Aroma inhalation (C) No Serum cortisol A vs. C, P < 0.01; ’. . . aroma inhalation and
(lavender: clary sage: treatment (␮g/dL) B vs. D, P = 0.05 physical treatment might
bergamot = 2: 1: 2, 5 min, (n = 8) reduce initial stress’
once, n = 9) 10 cm from the (D) Oil massage
nose (20 min, n = 10)
(B) Aroma back massage
(lavender: clary sage:
bergamot = 2: 1: 2, 20 min,
once, n = 10)

NS: not significant; VAS: visual analogue scale.

Table 2
Summary of findings.

Aromatherapy for stress management in healthy adults

Patient or population: healthy adults; Settings: Korea, Japana ; intervention: aromatherapy

Outcomes Illustrative comparative risks* Relative effect No. of participants Quality of the evidence Comments
(95% CI) (95% CI) (studies) (GRADE)

Assumed risk Corresponding risk

Control (no Aromatherapy
aromatherapy)
Stress level (VAS, Combined 80 (3 studies) ⊕⊕
−− lowf , g Under experimental stress
SACL)b experimental stress SMD −0.95 (−1.62 to −0.28)
and no experimental No experimental stress
stressd SMD −1.02 (−2.02 to −0.03)
SMD lower (1.44 lower
to 0.48 higher)
Cortisol (Serum, Combined 88 (3 studies) ⊕⊕
−− lowf , g Under experimental stress
saliva)c experimental stress SMD 0.06 (−0.65 to 0.78)
and no experimental No experimental stress
stresse SMD −0.88 (−1.49 to −0.28)
SMD lower (1.26 lower
to 0.02 higher)

GRADE Working Group grades of evidence

High quality: further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.
*
The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is
based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: confidence interval; SACL: stress arousal checklist; SMD:
standard mean difference; VAS: visual analogue scale.
a
Korea: Kim 2009; Kim 2011; Japan: Motomura 2001; Toda 2008; Toda 2011.
b
Stress: Kim 2011: VAS (10 cm, 0 = no pain, 10 = worst pain ever), Motomura: SACL (Stress Arousal Checklist, 18 questionnaire for stress measure, 4-point scoring, high
score means more stress), Toda 2011: VAS (10 cm, 0 = no pain, 10 = worst pain ever).
c
Cortisol: Kim 2009: serum cortisol, Toda 2008: saliva cortisol, Toda 2011: saliva cortisol.
d
Study was done under experimental stress: Kim 2011, Motomura 2001; no experimental stress: Toda 2011.
e
Study was done under experimental stress: Toda 2008; no experimental stress: Kim 2009, Toda 2011.
f
Poorly reported paper (see the ‘Risk of bias’ table).
g
Small sample size.

Please cite this article in press as: Hur M-H, et al. Aromatherapy for stress reduction in healthy adults: a systematic review and meta-
analysis of randomized clinical trials. Maturitas (2014), http://dx.doi.org/10.1016/j.maturitas.2014.08.006
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3. Results
3.1. Study description
The searches identified 629 potentially relevant studies, 5 of
which met our inclusion criteria (Fig. 1). The key data are summa-
rized in Table 1 [19–23]. A total of 147 participants were included
in these trials. Two RCTs originated from Korea [20,23], and other
three studies were conducted in Japan [19,21,22]. All RCTs used
aromatherapy as inhalation [19–23] and one of them used aro-
matherapy with massage in one group [23]. All of the included
studies employed one time intervention and measured the effects
on stress reduction. The session duration was 5 min or 10 min. Two
of the included trials adopted a two-armed parallel-group design
[19,20], two three-armed parallel group designs [21,22] and one
four-armed parallel group designs [23]. Three studies employed
experimental stress [19–21] including 10 min serial arithmetic test
[19], needle insertion for 30 s [20] and 20 min waiting stress [21].
The essential oil used in inhalation included lavender [19–22],
peppermint [22] and blending of several essential oils [23]. The sub-
jective outcomes for stress in these trials were the visual analogue
scale (VAS) [19,20,22] and stress arousal checklist [21] (Table 2).

Fig. 2. (A) Risk of bias graph: review authors’ judgments about each risk of bias item presented as percentages across all included studies; (B) risk of bias summary: review
authors’ judgments about each risk of bias item for each included study.

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analysis of randomized clinical trials. Maturitas (2014), http://dx.doi.org/10.1016/j.maturitas.2014.08.006
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3.2. Risk of bias
All of the included RCTs failed to describe the sequence gen-
eration and allocation concealment (Fig. 2). Four RCTs also had
potential high risk of bias in blinding of aromatherapy because of its
nature [19–21,23]. Only one study employed the assessor blinding
[20].
3.3. Outcomes
3.3.1. Self-reported stress
Four RCTs compared the effect of aroma inhalation on self-
reported stress level as compared with no treatment, no aroma,
or no odor oil [19–22]. One RCT showed significant difference
in stress level compared with no-aroma inhalation in needle
insertion stress [20], while the other two RCTs failed to do so
after arithmetic test and waiting stress [19,21]. Fourth RCT com-
pared two types of aroma inhalation (lavender and peppermint)
with odorless oil control and showed significant stress reduc-
tion in peppermint oil inhalation [22]. The meta-analysis of the
first three trials showed favourable effects of aroma inhalation
on stress reduction (n = 80, SMDs −0.96; 95% confidence inter-
vals (CIs) −1.44 to −0.48, P < 0.0001; heterogeneity: 2 = 1.95,
P = 0.58, I2 = 0%, Fig. 3A) [20–22]. We could not combine the other
together because the authors reported median and interquartile
range [19].
3.3.2. Cortisol level
Three of included RCTs tested aroma inhalation on saliva or
serum cortisol level compared with control [19,22,23]. Three RCTs
showed favourable effects of aroma inhalation on the cortisol level.
However, our meta-analysis failed to show significant difference
between two groups even though moderate heterogeneity (n = 88,
WMDs −0.62; 95% confidence intervals (CIs) −1.26 to 0.02, P = 0.06;
heterogeneity: 2 = 7.42, P = 0.12, I2 = 46%, Fig. 3B).
4. Discussion
The results suggest that aroma inhalation may be effective than
no treatment or odorless inhalation in reducing self-reported stress

Fig. 3. Forest plot of the effects of aromatherapy for self-perceived stress (A) and cortisol level (B) in healthy adults. I: inhalation, M: massage, L: lavender, P: peppermint.

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analysis of randomized clinical trials. Maturitas (2014), http://dx.doi.org/10.1016/j.maturitas.2014.08.006
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and cortisol level. However, the risk of bias was high in all of
the included trials. Collectively, the existing trial evidence shows
limited effectiveness of aromatherapy in reducing stress. Future
studies should be of high quality with a particular emphasis on
designing an adequate control intervention.
Most of the included RCTs did not employ blinding of patients,
practitioners, and assessors. Furthermore, none of them reported
the methods of random sequence generation and allocation
concealment. Trials with inadequate blinding and inadequate
allocation concealment may be subject to selection bias and are
likely to generate exaggerated treatment effects [24,25]. There
were low risks of bias in incomplete outcome data. One trial
showed high risk of bias in selective reporting. Most of the RCTs
had a small sample size, and their results were therefore prone to
a type II error. Small trials may also overestimate treatment effects
by approximately 30% [26].
The mechanisms by which aromatherapy reduces stress may
be related to sympathetic nervous system and parasympathetic
modulation. Aromatherapy may decrease to sympathetic nervous
system activity and increase parasympathetic nervous system [27].
These may promote relaxation and reduce stress level. However,
more basic research is needed to fully understand the mechanisms
underlying the effects of aromatherapy.
One recent systematic review reported that aromatherapy had
possible adverse events [28]. However, none of the reviewed
studies reported any adverse events related with aromatherapy.
Aromatherapy may appear to be generally safe; regardless, the
safety of aromatherapy requires further research.
Our review has a number of important limitations. Although
strong efforts were made to retrieve all RCTs on the subject, we can-
not be absolutely certain that we succeeded. Moreover, selective
publishing and reporting are other major causes for bias [29–31],
which have to be considered. It is conceivable that several neg-
ative RCTs remain unpublished and thus the overall picture may
be distorted. Another possible source of the bias could be the fact
that most of the included trials were carried out in Korea and
Japan, regions which have been shown to produce almost no neg-
ative studies [32]. Further limitations include the paucity and the
often suboptimal methodological quality of the primary data. In
total, these facts limit the conclusiveness of this systematic review
considerably. To establish the role of aromatherapy in the stress
management, adequately designed trials are required.
Collectively, the existing trial evidence is not convincing and
does not show aromatherapy to be an effective modality for manag-
ing stress. Future studies should be of high quality, with a particular
emphasis on designing adequate and appropriate control groups.
In conclusion, these results provide limited evidence for the
effectiveness of aromatherapy in reducing stress level of healthy
subjects. However, the number, size and quality of the RCTs are
too low to draw firm conclusions. Further rigorous RCTs seem war-
ranted but need to overcome the many limitations of the current
evidence.
Contributors
Myung-Haeng Hur, Ji-Ah Song and Myeong Soo Lee designed
the review, performed searches, appraised and selected trials,
extracted data, contacted authors for additional data, carried out
analysis and interpretation of the data, and drafted this report.
Jeonghee Lee reviewed and critiqued on the review protocol and
this report, assisted in designing of the review
Competing interest
None.
Please cite this article in press as: Hur M-H, et al. Aromatherapy for stress reduction in healthy adults: a systematic review and meta-
analysis of randomized clinical trials. Maturitas (2014), http://dx.doi.org/10.1016/j.maturitas.2014.08.006
7
Provenance and peer review: not commissioned
Provenance and peer review: not commissioned; externally
peer reviewed This will need a language edit by Ralph Footring
as scattered grammatical errors and poor English (MR)
Acknowledgements
This work was supported by the National Research Founda-
tion of Korea (NRF) grant funded by the Korean Government
(2012R1A1A3013176).
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analysis of randomized clinical trials. Maturitas (2014), http://dx.doi.org/10.1016/j.maturitas.2014.08.006