A randomized controlled clinical trial of auricular acupuncture in smoking cessation

Effects of acupuncture and nicotine patch on smoking: a multicenter, randomized, controlled, double-blind clinical trial

Aims

To evaluate the effects of acupuncture and/or nicotine patches on smoking cessation.

Methods

Eighty-eight participants were randomly allocated into four groups: acupuncture combined with nicotine patch (ACNP), acupuncture combined with sham nicotine patch (ACSNP), sham acupuncture combined with nicotine patch (SACNP), and sham acupuncture combined with sham nicotine patch (SACSNP). The primary outcome was self-reported smoking abstinence verified with expiratory Carbon Monoxide (CO) after 8 weeks of treatment. The modified Fagerstrom Test for Nicotine Dependence (FTND) score, Minnesota Nicotine Withdrawal Scale (MNWS), and the Brief Questionnaire of Smoking Urge (QSU-Brief) score were used as secondary indicators. SPSS 26.0 and Prism 9 software were used for statistical analyses.

Results

Seventy-eight participants completed the study. There were no significant differences in patient characteristics at baseline across the four groups. At the end of treatment, there was a statistically significant difference (χ2  = 8.492, p = 0.037) in abstaining rates among the four groups. However, there were no significant differences in the reduction in the number of cigarettes smoked daily (p = 0.111), expiratory CO (p = 0.071), FTND score (p = 0.313), and MNWS score (p = 0.088) among the four groups. There was a statistically significant difference in QUS-Brief score changes among the four groups (p = 0.005). There was no statistically significant interaction between acupuncture and nicotine patch.

Conclusion

Acupuncture combined with nicotine replacement patch therapy was more effective for smoking cessation than acupuncture alone or nicotine replacement patch alone. No adverse reactions were found in the acupuncture treatment process.

Clinical trial registration

http://www.chictr.org.cn/showproj.aspx?proj=61969, identifier ChiCTR2100042912.

A multiverse analysis of meta-analyses assessing acupuncture efficacy for smoking cessation evidenced vibration of effects

OBJECTIVE

To explore the impact of methodological choices on the results of meta-analyses (MAs), with acupuncture for smoking cessation as a case study.

STUDY DESIGN AND SETTING

After performing an umbrella review (using MEDLINE, the COCHRANE Library, the Wan Fang database, and the Chinese Journal Full-text Database/March 2018) of MAs exploring the use of acupuncture for smoking cessation, we extracted all randomized controlled trials. Numerous MAs were performed as per every possible combination of various methodological choices (e.g., characteristics of the intervention and control procedures, outcome, publication status, language) to assess their vibration of effects or more precisely the existence of a Janus effect, that is, whether the 10th and 90th percentiles in the distribution of effect sizes were in opposite directions.

RESULTS

After including 7 MAs and 39 randomized controlled trials, we performed 496,528 MAs. The effect size was negative at the 10th percentile (-0.1, favoring controls) and positive at the 90th percentile (1.17, favoring acupuncture). In all, 104,491 MAs showed a statistically significant difference in favor of acupuncture, whereas 392,037 failed to demonstrate the efficacy of acupuncture (including 96 that showed a statistically significant difference in favor of the control).

CONCLUSION

The methodological choices made in performing pairwise MAs can result in substantial vibration of effects, occasionally leading to opposite results.

Effects of auriculotherapy on addiction: a systematic review

Auriculotherapy has been used to reduce withdrawal symptoms during drug detoxication. The purpose of this study was to review the results of the randomized controlled trials (RCTs) that examined the impact of auriculotherapy on addiction. This study aimed to find an effective protocol involving auricular acupuncture points, intervention duration and frequency, and stimulating methods. We searched PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Medline for articles published between January 1, 1994, and March 31, 2021. The keywords used were auricular, acupuncture, addiction, substance misuse, smoking, randomized controlled trial, clinical trial, and human. Each RCT was evaluated for quality applying the risk of bias tool by the Cochrane group. Effect size (Hedges's g) was calculated using the mean values and standard deviation of the experimental and control groups. The risk for bias of these studies was moderate to high and only four studies (11.1%) earned scores of 6, indicating the lowest risk of bias and highest quality RCT. Out of 36 studies, 23 (64%) reported that auriculotherapy was effective for treating addiction such as opioids, cocaine, alcohol, heroin, nicotine, and gambling. The most commonly used combination of acupuncture points (four of 36 studies) was shenmen, sympathetic, liver, lung, and kidney, which are called NADA protocol. The following most frequently used combination of acupressure points (four out of 36 studies) was shenmen, subcortex, heart, lung, and liver. Acupressure could be considered to be used for the treatment of addiction.

Comparison between Acupuncture and Nicotine Replacement Therapies for Smoking Cessation Based on Randomized Controlled Trials: A Systematic Review and Bayesian Network Meta-Analysis

Objectives

To evaluate the efficacy and/or safety of acupuncture therapy (AT) in quitting smoking.

Methods

Randomized controlled trials (RCTs) were searched in PubMed, Cochrane Library, Embase, Web of Science, and Chinese Biomedical Database (CBM). We used Cochrane Collaborative Quality Assessment to assess the risk of bias. Bayesian network meta-analysis was utilized to evaluate the efficacy and safety of different interventions. Data analyses were conducted using WinBUGS 1.4.3, Stata 14, and RevMan 5.3.5 software.

Results

A total of 2706 patients from 23 studies were included, involving 6 treatment arms. Network meta-analysis demonstrated that there was no significant difference in short-term abstinence rates or changes in Fagerstrom test for nicotine dependence (FTND) scores and daily smoking among these groups (AT, sham acupuncture therapy (SAT), auricular acupressure (AA), sham auricular acupressure (SAA), acupuncture plus auricular acupressure (APAA), and nicotine replacement therapy (NRT)). However, there was a significant difference between SAA and AA with risk ratio (RR) of 2.49 (95% CI 1.14, 5.97) in long-term abstinence rate. The probabilistic ranking results showed that APAA and AA were superior to other interventions in the comparison of abstinence rates. There was no obvious inconsistency between the direct comparison and indirect comparison, using the consistency test.

Conclusion

AA was superior to SAA in smoke quitting, but there was no difference among other interventions in long-term truncation rates. There was no difference in short-term abstinence rates among these selected groups. We need large sample RCTs to clarify the advantages of interventions such as APAA and AA. In addition, reporting of adverse events that may occur during treatment also should be enhanced to complement evidence-based medicine. The trial is registered with PROSPERO CRD42020164712.

[Acupuncture and smoking cessation, a review of the literature]

INTRODUCTION

Tobacco smoking represents the main cause of death in industrialised countries. Acupuncture is proposed as an aid to stopping smoking. What are the current studies?

BACKGROUND

We found 23 controlled randomised studies with differing protocols in terms of intensity of treatment and methodology. The meta-analyses undertaken were contradictory. The short-term effect of acupuncture is well documented but the medium term effect is more uncertain.

OUTLOOK

The undertaking of well-standardised, high-intensity protocols is necessary to produce evidence of a medium term effect.

CONCLUSION

Acupuncture can be offered to patients wishing to stop smoking within the framework of a global management programme. The association of acupuncture with classical aids increases the chances of the patient stopping. The conditions of intervention should be defined precisely within the framework of a randomised controlled trial.

Acupuncture for smoking cessation: A systematic review and meta-analysis of 24 randomized controlled trials

INTRODUCTION

We evaluate the effectiveness and safety of transdermal acupuncture by needles for smoking cessation.

METHODS

A literature search for randomized controlled trials (RCTs) was performed in seven electronic databases from inception to February 2017. Meta-analysis was conducted using Revman 5.3.0 software. We used either a random effects model (REM) or a fixed effects model (FEM) for pooling data according to the result of a heterogeneity test (defined as significant if I2>75%). Trial sequential analysis (TSA) was applied by TSA 0.9.5.10 Beta software.

RESULTS

Twenty-four trials involving 3984 participants were included. The methodological quality was generally low. With regard to smoking abstinence, meta-analysis showed acupuncture was more effective compared to no intervention/waiting list for short-term (4 weeks) cessation (1 trial, RR=2.37, 95% 1.41, 3.97) and long-term (longer than 6 months) (2 trials, RR=2.66, 95% CI: 1.50, 4.70). Compared to acupuncture/auricular acupressure alone, acupuncture plus auricular acupressure showed more benefit for short-term cessation (3 trials, RR=1.52, 95% CI: 1.03, 2.25). Acupuncture plus auricular acupressure was more effective compared to sham acupuncture plus sham auricular acupressure for short-term cessation (3 trials, RR=2.50, 95% CI: 1.44, 4.33) and long-term (2 trials, RR=3.61, 95% CI: 1.37, 9.48). Acupuncture in combination with counseling, educational smoking cessation program or moxibustion had more benefit compared to acupuncture for short-term cessation (3 trials, RR=0.75, 95% 0.63, 0.91) and long-term (2 trials, RR=0.77, 95% CI: 0.56, 1.05), and TSA illustrated the cumulative Z-curve of this comparison for long-term across the traditional boundary of 5% significance and monitoring boundaries. No serious adverse events occurred.

CONCLUSIONS

Acupuncture combined with counseling, educational smoking cessation program or moxibustion was more effective than acupuncture as monotherapy with regard to long-term smoking cessation. Further, high quality trials are needed to confirm the result.

Efficacy of acupuncture for lifestyle risk factors for stroke: A systematic review

BACKGROUND

Modifications to lifestyle risk factors for stroke may help prevent stroke events. This systematic review aimed to identify and summarise the evidence of acupuncture interventions for those people with lifestyle risk factors for stroke, including alcohol-dependence, smoking-dependence, hypertension, and obesity.

METHODS

MEDLINE, CINAHL/EBSCO, SCOPUS, and Cochrane Database were searched from January 1996 to December 2016. Only randomised controlled trials (RCTs) with empirical research findings were included. PRISMA guidelines were followed and risk of bias was assessed via the Cochrane Collaboration risk of bias assessment tool. The systematic review reported in this paper has been registered on the PROSPERO (#CRD42017060490).

RESULTS

A total of 59 RCTs (5,650 participants) examining the use of acupuncture in treating lifestyle risk factors for stroke met the inclusion criteria. The seven RCTs focusing on alcohol-dependence showed substantial heterogeneity regarding intervention details. No evidence from meta-analysis has been found regarding post-intervention or long-term effect on blood pressure control for acupuncture compared to sham intervention. Relative to sham acupuncture, individuals receiving auricular acupressure for smoking-dependence reported lower numbers of consumed cigarettes per day (two RCTs, mean difference (MD) = -2.75 cigarettes/day; 95% confidence interval (CI) = -5.33, -0.17; p = 0.04). Compared to sham acupuncture those receiving acupuncture for obesity reported lower waist circumference (five RCTs, MD = -2.79 cm; 95% CI: -4.13, -1.46; p<0.001). Overall, only few trials were considered of low risk of bias for smoking-dependence and obesity, and as such none of the significant effects in favour of acupuncture interventions were robust against potential selection, performance, and detection bias.

CONCLUSIONS

This review found no convincing evidence for effects of acupuncture interventions for improving lifestyle risk factors for stroke.

Effectiveness of auricular acupuncture combined with nicotine replacement therapy for smoking cessation

INTRODUCTION

The aim of this study was to establish if the auricular acupuncture treatment can play a complementary role in enhancing the smoking cessation rate of the smokers receiving conventional therapy, such as NRT and behavioral counseling.

METHODS

This was a retrospective cohort study. Republic of Korea Air Force soldiers who visited the clinic with the intention to quit smoking from September 2016 to March 2017 were reviewed. The smoking cessation program consisted of a 6-weeks treatment period with follow-up at 3 and 6 months from the baseline. Smokers who chose to receive nicotine replacement therapy (NRT) were compared with those who chose to receive auricular acupuncture combined with NRT. Both groups received behavioral counseling.

RESULTS

A total of 148 subjects were reviewed in the study. Of the 86 smokers who received combination therapy, 41 achieved continuous abstinence (47.7%), while 19 out of the 62 smokers stayed abstinent from the NRT group (30.6%). There was a significant difference between the two groups (p=0.037). Minnesota Nicotine Withdrawal Scale scores significantly decreased after the treatment in both groups, but there was no significant difference between the two groups (p=0.681). No serious adverse events were reported from both groups.

CONCLUSIONS

The results of this study indicate that conventional treatments, such as NRT and behavioral counseling, when combined with auricular acupuncture could be a safer and more effective smoking cessation treatment than conventional treatments alone.

Efficacy of Acupuncture Is Noninferior to Nicotine Replacement Therapy for Tobacco Cessation: Results of a Prospective, Randomized, Active-Controlled Open-Label Trial

BACKGROUND

We designed and conducted this multicenter randomized active-controlled open-label trial to evaluate the efficacy of acupuncture, auricular point pressing, and nicotine replacement therapy (NRT) on tobacco cessation in the Chinese population.

METHODS

This randomized controlled trial was conducted in seven hospitals in China between October 2013 and February 2016. Eligible participants were recruited and randomly assigned to receive acupuncture or auricular point pressing or NRT via a central randomization system with a 1:1:1 ratio. All treatment was given for a total of 8 weeks, and follow-up visit was at 16 weeks. The primary outcome measure was carbon monoxide (CO)-confirmed 24-h point abstinence rate (<10 parts per million), 24 weeks after quit day.

RESULTS

A total of 300 participants were recruited and 195 participants finished, with a dropout rate of 35.00%. Two cases of adverse events in the acupuncture group and 2 cases in the NRT group were observed. The CO-confirmed 24-h point abstinence rate was 43.00% at 24 weeks in the acupuncture group, which was similar to 44.00% in the NRT group (P > .05), but significantly higher than the 30.00% in the auricular point group (P < .05). At 24 weeks, the Fagerstrom Nicotine Dependence Test and the Minnesota Nicotine Withdrawal Scale scores in the acupuncture group were significantly lower than those in the auricular point group and in the NRT group (P < .05). Kaplan-Meier analysis showed the time to relapse for acupuncture (44.12 days) was insignificantly longer than NRT (41.18 days), but significantly longer than auricular point pressing (29.53 days).

CONCLUSIONS

We found acupuncture was safe and a possible treatment for tobacco cessation, but it requires further study to establish its role.

TRIAL REGISTRY

Chinese Clinical Trial Registry; No.: ChiCTR-TRC-13003544; URL: http://www.chictr.org.cn/abouten.aspx.

Study protocol of a pragmatic, randomised controlled pilot trial: clinical effectiveness on smoking cessation of traditional and complementary medicine interventions, including acupuncture and aromatherapy, in combination with nicotine replacement therapy

INTRODUCTION

Nicotine dependence is a disease, and tobacco use is related to 6 million deaths annually worldwide. Recently, in many countries, there has been growing interest in the use of traditional and complementary medicine (T&CM) methods, especially acupuncture, as therapeutic interventions for smoking cessation. The aim of this pilot study is to investigate the effectiveness of T&CM interventions on smoking cessation.

METHODS AND ANALYSIS

The STOP (Stop Tobacco Programme using traditional Korean medicine) study is designed to be a pragmatic, open-label, randomised pilot trial. This trial will evaluate whether adding T&CM methods (ie, ear and body acupuncture, aromatherapy) to conventional cessation methods (ie, nicotine replacement therapy (NRT), counselling) increases smoking cessation rates. Forty participants over 19 years old who are capable of communicating in Korean will be recruited. They will be current smokers who meet one of the following criteria: (1) smoke more than 10 cigarettes a day, (2) smoke less than 10 cigarettes a day and previously failed to cease smoking, or (3) smoke fewer than 10 cigarettes a day and have a nicotine dependence score (Fagerstrom Test for Nicotine Dependence) of 4 points or more. The trial will consist of 4 weeks of treatment and a 20 week follow-up period. A statistician will perform the statistical analyses for both the intention-to-treat (all randomly assigned participants) and per-protocol (participants who completed the trial without any protocol deviations) data using SAS 9.1.3.

ETHICS AND DISSEMINATION

This study has been approved by the Institutional Review Board (IRB) of the Dunsan Korean Medicine Hospital of Daejeon University (IRB reference no: DJDSKH-15-BM-11-1, Protocol No. version 4.1.).The protocol will be reapproved by IRB if it requires amendment. The trial will be conducted according to the Declaration of Helsinki, 7th version (2013). This study is designed to minimise the risk to participants, and the investigators will explain the study to the participants in detail. As an ethical clinical trial, the control group will also be given conventional cessation treatments, including NRT and counselling. Participants will be screened and provided with a registration number to protect their personal information. Informed consent will be obtained from the participants prior to enrolling them in the trial. Participants will be allowed to withdraw at anytime without penalty.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov (NCT02768025); pre-results.

Acupuncture for Smoking Cessation in Hong Kong: A Prospective Multicenter Observational Study

This was a prospective multicenter observational study, aiming to explore the effects of acupuncture on smoking cessation in Hong Kong. From March of 2010 to August of 2015, a total of 5202 smokers were recruited based on inclusion criteria and treated with acupuncture for 8 weeks. As a result, 2940 subjects finished the study with a drop-out rate of 43.48%. The self-reported 7-day point abstinence rate was 34.00% in Week 8 and 18.40% in Week 52. The exhaled carbon monoxide level and the number of cigarettes smoked per day were reduced significantly after treatment. The time to relapse was calculated to be 38.71 days. In addition, "cigarettes smoked per day," "Fagerstrom Test for Nicotine Dependence," "total sessions of acupuncture," "whether finished 8 acupuncture treatments in the first month," and "total sessions of acupuncture" were believed to be essential factors for abstinence success. It was concluded that acupuncture was a safe method for smoking cessation and was effective in helping smokers to quit; therefore, acupuncture could be considered as one of the methods to help smokers quit. Further studies regarding the effect differences between acupuncture and medications were needed to clarify the overall benefits of acupuncture.

The History, Mechanism, and Clinical Application of Auricular Therapy in Traditional Chinese Medicine

Auricular therapy includes acupuncture, electroacupuncture, acupressure, lasering, cauterization, moxibustion, and bloodletting in the auricle. For 2500 years, people have employed auricular therapy for treating diseases, but the methods have been limited to bloodletting and cauterization. Only after 1957, the international scientific community became aware that the map of the ear resembles an inverted fetus, its introduction has led to auricular acupuncture (AA) becoming a more systemic approach, and, following the identification and standardization of more precise points, AA has been employed in clinical applications. The mechanisms of AA are considered to have a close relationship with the autonomic nervous system, the neuroendocrine system, neuroimmunological factors, neuroinflammation, and neural reflex, as well as antioxidation. Auricular therapy has been applied, for example, for pain relief, for the treatment of epilepsy, anxiety, and obesity, and for improving sleep quality. However, the mechanisms and evidence for auricular therapy warrant further study.

[Contributions of auriculotherapy in smoking cessation: a pilot study]

OBJECTIVE

To evaluate the contribution of auriculotherapy in smoking cessation.

METHOD

Double-blind randomized controlled trial, conducted with 30 smokers allocated into two groups: Experimental Group (21 participants received 10 sessions of auriculotherapy at specific points for smoking) and Control Group (nine participants received auriculotherapy in points that have no effect on the focus of research).

RESULTS

Auriculotherapy contributed in reducing the number of cigarettes smoked in 61.9% of participants (p=0.002), in reducing the difficult to abstain from smoking in places where it is forbidden by 38% (p=0.050) and in not smoking when ill 23.8% (p=0.025).

CONCLUSION

Given the efficacy only in terms of reducing the number of cigarettes smoked and other parameters, we suggest that future studies consider the use of auriculotherapy combined with other treatment methods, in order to achieve better results in cessation/abstinence.

Adverse events of auricular therapy: a systematic review

The aim of this study was to systematically evaluate the literature on adverse events associated with auricular therapy (AT). Case reports, case series, surveys, and all types of clinical trials reporting adverse events of AT were included. Relevant articles were mainly retrieved from 13 electronic databases and seven Chinese journals on complementary medicine. AT-related adverse events were reported in 32 randomized controlled trials, five uncontrolled clinical trials, four case reports, and two controlled clinical trials. For auricular acupuncture, the most frequently reported adverse events were tenderness or pain at insertion, dizziness, local discomfort, minor bleeding and nausea, and so forth. For auricular acupressure, local skin irritation and discomfort, mild tenderness or pain, and dizziness were commonly reported. Skin irritation, local discomfort, and pain were detected in auricular electroacupuncture, and minor infection was identified in auricular bloodletting therapy. Most of these events were transient, mild, and tolerable, and no serious adverse events were identified. Our findings provide preliminary evidence that AT is a relatively safe approach. Considering the patient's safety, prospective or retrospective surveys are needed in future research to gather practitioner-reported and patient-reported adverse events on AT, and the quality of adverse events reporting in future AT trials should be improved.

A meta-analysis of ear-acupuncture, ear-acupressure and auriculotherapy for cigarette smoking cessation

BACKGROUND

This systematic review evaluated the effects of ear acupuncture, ear acupressure and auriculotherapy for cigarette smoking cessation (SC) at end-of-treatment (EoT), three, six and 12 months follow-up.

METHODS

Searches of six English and Chinese databases located 25 randomized controlled trials (3735 participants). Methodological quality was assessed using Cochrane Risk of Bias. Meta-analyses were conducted in two pools: 1. SC-specific ear acupuncture/acupressure or auriculotherapy (EAP/R) vs. non-specific/inactive control; and 2. SC-specific EAP/R vs. other SC-specific treatment. Sensitivity analyses were conducted based on the validity of interventions as SC-specific treatments or non-specific/inactive interventions; and the use of biochemical SC confirmation.

RESULTS

Pool 1: the 12 valid SC-specific EAP/R interventions were superior to inactive EAP/R controls at EoT (RR=1.77 [1.39, 2.25]), three months follow-up (RR=1.54 [1.14, 2.08]), and six months follow-up (RR=2.01, [1.23, 3.28]) but data were insufficient at 12 months. In Pool 2: there was no superiority or inferiority for EAP/R at EoT or at 3 and 6 month follow-ups compared to SC-specific behavioural therapy or SC-specific body acupuncture.

CONCLUSIONS

Pool 1 data appeared most consistent for studies of ear acupressure (EAPR) vs. non-specific EAPR controls, with confirmed SC rates at 3 months post-treatment of 20.0% for test groups vs. 7.5% for controls. In Pool 2 the EAP/R interventions appeared neither inferior nor superior to the behavioural interventions at 3 and 6 month follow-ups. However, meta-analysis results derived from relatively small-sized trials with no biochemical validation of SC in Pool 2. Larger, well-controlled studies using biochemical confirmation of SC are needed.

Acupuncture and related interventions for smoking cessation

BACKGROUND

Acupuncture and related techniques are promoted as a treatment for smoking cessation in the belief that they may reduce nicotine withdrawal symptoms.

OBJECTIVES

The objectives of this review are to determine the effectiveness of acupuncture and the related interventions of acupressure, laser therapy and electrostimulation in smoking cessation, in comparison with no intervention, sham treatment, or other interventions.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group Specialized Register (which includes trials of smoking cessation interventions identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, and PsycINFO) and AMED in October 2013. We also searched four Chinese databases in September 2013: Sino-Med, China National Knowledge Infrastructure, Wanfang Data and VIP.

SELECTION CRITERIA

Randomized trials comparing a form of acupuncture, acupressure, laser therapy or electrostimulation with either no intervention, sham treatment or another intervention for smoking cessation.

DATA COLLECTION AND ANALYSIS

We extracted data in duplicate on the type of smokers recruited, the nature of the intervention and control procedures, the outcome measures, method of randomization, and completeness of follow-up.We assessed abstinence from smoking at the earliest time-point (before six weeks) and at the last measurement point between six months and one year. We used the most rigorous definition of abstinence for each trial, and biochemically validated rates if available. Those lost to follow-up were counted as continuing smokers. Where appropriate, we performed meta-analysis pooling risk ratios using a fixed-effect model.

MAIN RESULTS

We included 38 studies. Based on three studies, acupuncture was not shown to be more effective than a waiting list control for long-term abstinence, with wide confidence intervals and evidence of heterogeneity (n = 393, risk ratio [RR] 1.79, 95% confidence interval [CI] 0.98 to 3.28, I² = 57%). Compared with sham acupuncture, the RR for the short-term effect of acupuncture was 1.22 (95% CI 1.08 to 1.38), and for the long-term effect was 1.10 (95% CI 0.86 to 1.40). The studies were not judged to be free from bias, and there was evidence of funnel plot asymmetry with larger studies showing smaller effects. The heterogeneity between studies was not explained by the technique used. Acupuncture was less effective than nicotine replacement therapy (NRT). There was no evidence that acupuncture is superior to psychological interventions in the short- or long-term. There is limited evidence that acupressure is superior to sham acupressure for short-term outcomes (3 trials, n = 325, RR 2.54, 95% CI 1.27 to 5.08), but no trials reported long-term effects, The pooled estimate for studies testing an intervention that included continuous auricular stimulation suggested a short-term benefit compared to sham stimulation (14 trials, n = 1155, RR 1.69, 95% CI 1.32 to 2.16); subgroup analysis showed an effect for continuous acupressure (7 studies, n = 496, RR 2.73, 95% CI 1.78 to 4.18) but not acupuncture with indwelling needles (6 studies, n = 659, RR 1.24, 95% CI 0.91 to 1.69). At longer follow-up the CIs did not exclude no effect (5 trials, n = 570, RR 1.47, 95% CI 0.79 to 2.74). The evidence from two trials using laser stimulation was inconsistent and could not be combined. The combined evidence on electrostimulation suggests it is not superior to sham electrostimulation (short-term abstinence: 6 trials, n = 634, RR 1.13, 95% CI 0.87 to 1.46; long-term abstinence: 2 trials, n = 405, RR 0.87, 95% CI 0.61 to 1.23).

AUTHORS' CONCLUSIONS

Although pooled estimates suggest possible short-term effects there is no consistent, bias-free evidence that acupuncture, acupressure, or laser therapy have a sustained benefit on smoking cessation for six months or more. However, lack of evidence and methodological problems mean that no firm conclusions can be drawn. Electrostimulation is not effective for smoking cessation. Well-designed research into acupuncture, acupressure and laser stimulation is justified since these are popular interventions and safe when correctly applied, though these interventions alone are likely to be less effective than evidence-based interventions.

Sham control methods used in ear-acupuncture/ear-acupressure randomized controlled trials: a systematic review

Ear-acupuncture/ear-acupressure (EAP) has been used for a range of health conditions with numerous randomized controlled trials (RCTs) investigating its efficacy and safety. However, the design of sham interventions in these RCTs varied significantly. This study systematically reviewed RCTs on EAP for all clinical conditions involving a number of sham EAPs as a control intervention. The review is guided by the Cochrane Handbook for Systematic Reviews of Interventions 5.1.0 and investigated the types and differences of sham EAP interventions. Four electronic English databases (The Cochrane Library, PubMed, Embase, CINAHL®) and two Chinese databases (CQVIP, CNKI) were searched in December 2012 and 55 published RCTs comparing real and sham EAP for any clinical condition were included. Characteristics of participants, real and sham interventions, and outcomes were extracted. Four types of sham methods were identified. Among the 55 RCTs, 25 studies involved treatment on nonspecific ear acupoints as the sham method; seven studies used nonacupoints on the ear; nine studies selected placebo needles or placebo ear-acupressure on the same ear acupoints for the real treatment; 10 studies employed pseudo-intervention; and five studies combined two of the above methods to be the sham control. Other factors of treatment such as number of points, treatment duration, and frequency also varied greatly. Risk of bias assessment suggests that 32 RCTs were "high risk" in terms of participants blinding, and 45 RCTs were "high risk" in terms of personnel blinding. Meta-analysis was not conducted due to the high clinical heterogeneity across included studies. No relationship was found between the sham designs and efficacy outcomes, or between the sham types and dropout rate. No solid conclusion of which design is the most appropriate sham control of EAP could be drawn in this review.

Ear acupressure for smoking cessation: a randomised controlled trial

This study investigated the efficacy and safety of ear acupressure (EAP) as a stand-alone intervention for smoking cessation and the feasibility of this study design. Adult smokers were randomised to receive EAP specific for smoking cessation (SSEAP) or a nonspecific EAP (NSEAP) intervention which is not typically used for smoking cessation. Participants received 8 weekly treatments and were requested to press the five pellets taped to one ear at least three times daily. Participants were followed up for three months. Primary outcome measures were a 7-day point-prevalence cessation rate confirmed by exhaled carbon monoxide and relief of nicotine withdrawal symptoms (NWS). Intention-to-treat analysis was applied. Forty-three adult smokers were randomly assigned to SSEAP (n = 20) or NSEAP (n = 23) groups. The dropout rate was high with 19 participants completing the treatments and 12 remaining at followup. One participant from the SSEAP group had confirmed cessation at week 8 and end of followup (5%), but there was no difference between groups for confirmed cessation or NWS. Adverse events were few and minor.

Ear acupressure for smoking cessation: study protocol for a randomised controlled trial

BACKGROUND

Smoking is the largest preventable cause of death and disease worldwide but smokers often fail to quit due to nicotine withdrawal symptoms. Current available pharmaceutical therapies may assist with smoking cessation but may have side effects. Ear acupressure (EAP) and ear acupuncture have been used for smoking cessation, and some positive results have been reported. The aim of the study is to assess the efficacy and safety of EAP in assisting individuals to quit smoking and/or support them in the management of nicotine withdrawal symptoms.

METHODS

This study will be a randomised, single-blind, sham-controlled study conducted at RMIT University in Melbourne, Australia. Adult smokers will be randomly assigned to receive EAP specifically for smoking cessation or nonspecific EAP treatments. After a 2-week run-in, participants will be treated once a week for 8 weeks and followed up for 12 weeks. The primary outcome measures will be 7 day point-prevalence cessation rate by self-report validated by expired carbon monoxide and nicotine withdrawal symptoms measured by the Mood and Physical Symptoms Score questionnaire. Secondary outcomes will be self-reported usage of nicotine replacement therapies, cigarette consumption, body weight change and quality of life. The safety end point will be self-reported adverse events associated with EAP. Intention-to-treat analysis will be applied.

DISCUSSION

Findings from this study will determine if this EAP intervention alone can be an effective and safe therapy to assist with smoking cessation and the management of nicotine withdrawal symptoms.

Systematic review and meta-analysis of the effects of acupoint stimulation on smoking cessation

Smoking represents a serious worldwide public health problem because of its close association with the development of chronic disease and cancer. Acupoint stimulation has been used as treatment mode for smoking cessation but its efficacy remains controversial. This systematic review and meta-analysis aimed to determine the effects of acupoint stimulation on smoking cessation rate and daily cigarette consumption. Electronic literature searches in eight electronic databases up to March 2011 were performed to identify acupoint stimulation for smoking cessation. The outcomes assessed were smoking cessation rate and cigarette consumption. We assessed abstinence from smoking at the earliest and last measured time points, and at the 3- and 6-month follow-ups. Meta-analysis was performed using CMA software. A total of 20 RCTs were included in the meta-analysis. A significant effect of acupoint stimulation was found in smoking cessation rates and cigarette consumption at immediate, 3- and 6-month follow-ups, with effect sizes 1.24 (95%CI = 1.07 ~ 1.43, p = 0.003), -2.49 (95%CI = -4.65 ~ -0.34, p = 0.02), 1.70 (95%CI = 1.17 ~ 2.46, p = 0.01), and 1.79 (95%CI = 1.13 ~ 2.82, p = 0.01), respectively. Multi-modality treatments, especially acupuncture combined with smoking cessation education or other interventions, can help smokers to eschew smoking during treatment, and to avoid relapse after treatment.

Alternative smoking cessation aids: a meta-analysis of randomized controlled trials

BACKGROUND

Acupuncture, hypnotherapy, and aversive smoking are the most frequently studied alternative smoking cessation aids. These aids are often used as alternatives to pharmacotherapies for smoking cessation; however, their efficacy is unclear.

METHODS

We carried out a random effect meta-analysis of randomized controlled trials to determine the efficacy of alternative smoking cessation aids. We systematically searched the Cochrane Library, EMBASE, Medline, and PsycINFO databases through December 2010. We only included trials that reported cessation outcomes as point prevalence or continuous abstinence at 6 or 12 months.

RESULTS

Fourteen trials were identified; 6 investigated acupuncture (823 patients); 4 investigated hypnotherapy (273 patients); and 4 investigated aversive smoking (99 patients). The estimated mean treatment effects were acupuncture (odds ratio [OR], 3.53; 95% confidence interval [CI], 1.03-12.07), hypnotherapy (OR, 4.55; 95% CI, 0.98-21.01), and aversive smoking (OR, 4.26; 95% CI, 1.26-14.38).

CONCLUSION

Our results suggest that acupuncture and hypnotherapy may help smokers quit. Aversive smoking also may help smokers quit; however, there are no recent trials investigating this intervention. More evidence is needed to determine whether alternative interventions are as efficacious as pharmacotherapies.

A systematic review of smoking cessation intervention studies in China

INTRODUCTION

China has the highest number of tobacco smokers among the world's nations; however, no systematic review has been conducted of clinical trials on the efficacy of smoking cessation interventions in China. This paper summarizes findings of studies in order to compare the effect of pharmacotherapy, counseling, and Traditional Chinese Medicine (TCM) approaches on the abstinence rate.

METHODS

Clinical trials of smoking cessation interventions published in English or Chinese were extracted from an electronic search of PubMed and WanFang databases. The search yielded 234 studies from the PubMed and 78 studies from the WanFang.

RESULTS

Twenty-nine studies were included in this review. Of these, 11 (37.9%) were randomized controlled trials (RCTs) that assessed the following approaches: counseling (5 studies), TCM (3 studies), pharmacotherapy (1 study), a combination of pharmacotherapy and counseling (1 study), and physician advice (1 study). Pharmacotherapy alone or in combination with counseling generally resulted in a higher abstinence rate than counseling alone. TCM techniques such as acupuncture and ear point seed pressure yielded a much higher abstinence rate than pharmacotherapy and counseling. Findings are inconclusive, however, because most of the TCM studies were noncontrolled trials and did not provide a definition of "abstinence." Findings on the effectiveness of physician advice to quit smoking were also inconclusive.

CONCLUSIONS

A review of smoking cessation studies revealed that pharmacotherapy was effective in China. More RCTs of TCM approaches and physician advice are needed with long-term follow-up assessments and biochemical verification of self-reported abstinence before these approaches are adopted as evidence-based smoking cessation interventions in China.

Acupuncture and related interventions for smoking cessation

BACKGROUND

Acupuncture and related techniques are promoted as a treatment for smoking cessation in the belief that they may reduce nicotine withdrawal symptoms.

OBJECTIVES

The objectives of this review are to determine the effectiveness of acupuncture and the related interventions of acupressure, laser therapy and electrostimulation in smoking cessation, in comparison with no intervention, sham treatment, or other interventions.

SEARCH STRATEGY

We searched the Cochrane Tobacco Addiction Group specialized register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, BIOSIS Previews, PsycINFO, Science Citation Index, AMED, Acubriefs in November 2010; and four Chinese databases: Chinese Biomedical Database, China National Knowledge Infrastructure, Wanfang Data and VIP in November 2010.

SELECTION CRITERIA

Randomized trials comparing a form of acupuncture, acupressure, laser therapy or electrostimulation with either no intervention, sham treatment or another intervention for smoking cessation.

DATA COLLECTION AND ANALYSIS

We extracted data in duplicate on the type of smokers recruited, the nature of the intervention and control procedures, the outcome measures, method of randomization, and completeness of follow up.We assessed abstinence from smoking at the earliest time-point (before six weeks), and at the last measurement point between six months and one year. We used the most rigorous definition of abstinence for each trial, and biochemically validated rates if available. Those lost to follow up were counted as continuing smokers. Where appropriate, we performed meta-analysis using a fixed-effect model.

MAIN RESULTS

We included 33 reports of studies. Compared with sham acupuncture, the fixed-effect risk ratio (RR) for the short-term effect of acupuncture was 1.18 (95% confidence interval 1.03 to 1.34), and for the long-term effect was 1.05 (CI 0.82 to 1.35). The studies were not judged to be free from bias. Acupuncture was less effective than nicotine replacement therapy (NRT). There was no evidence that acupuncture is superior to waiting list, nor to psychological interventions in short- or long-term. The evidence on acupressure and laser stimulation was insufficient and could not be combined. The evidence suggested that electrostimulation is not superior to sham electrostimulation.

AUTHORS' CONCLUSIONS

There is no consistent, bias-free evidence that acupuncture, acupressure, laser therapy or electrostimulation are effective for smoking cessation, but lack of evidence and methodological problems mean that no firm conclusions can be drawn. Further, well designed research into acupuncture, acupressure and laser stimulation is justified since these are popular interventions and safe when correctly applied, though these interventions alone are likely to be less effective than evidence-based interventions.

Photoelectric stimulation of defined ear points (Smokex-Pro method) as an aid for smoking cessation: a prospective observational 2-year study with 156 smokers in a primary care setting

BACKGROUND

Smokex-Pro is a smoking cessation method using a protocol of a standardized consultation and computer-assisted photoelectric stimulation of defined regions in the ear and face.

METHODS

We prospectively enrolled 156 consecutive adult smokers (81 males, 75 females; mean age 43.8 years; body mass index 25.5; daily cigarettes 24.7; Fagerström Test for Nicotine Dependence 5; 30 smoking years). The primary end point was the self-reported continuous abstinence rate.

RESULTS

Participants completed on average only 32% of recommended visits. A total of 76.7% stopped smoking for more than 7 days. Moreover, 53.4% remained free of smoking for more than 90 days. Long-term abstinence rates were 49.3% (1 year) and 47.95% (2 years). Treatment-related side effects were observed in 24.5% of participants. Side effects were mild and resolved within hours.

CONCLUSION

The Smokex-Pro method appears to be an effective aid for smoking cessation. The treatment was well tolerated and showed only mild and temporary side effects. The average cost of treatment is typically less than EUR 90; the total treatment time is typically 60-90 min. These factors make it an attractive alternative compared to traditional smoking cessation methods. Controlled clinical trials will be needed to confirm the results of this study and refine the treatment for maximum efficacy.

Auricular acupressure combined with multimedia instruction or alone for quitting smoking in young adults: A quasi-experimental study

BACKGROUND

Smoking plays a disease-related risk factor and is however the principal cause of preventable death. Many studies support the use of combined rather than single interventions to stop smoking.

OBJECTIVE

This study aimed to evaluate the effects of auricular acupressure combined with multimedia instruction in comparison with auricular acupressure alone on smoking cessation in young adults.

METHOD

A quasi-experimental research design was used and participants were assigned to experimental groups according to their preference. Group 1 received the 10-week program with auricular acupressure plus multimedia instruction; Group 2 received auricular acupressure alone. Thirty-two participants were in each group were recruited from universities in Taiwan. The physical and psychological data were collected right before and after the program.

RESULTS

This study demonstrated the effects of smoking cessation on physical and psychological factors in each group. Statistical between-group differences existed in psychological factors of smoking cessation self-efficacy and nicotine dependence, but not in physical factors of carbon monoxide and cotinine.

CONCLUSIONS

This study adds to the body of research on the benefits of using auricular acupressure combined with or without multimedia instruction for smoking cessation in adolescents. The combined intervention was more effective especially in increasing smoking cessation self-efficacy and decreasing nicotine dependence. Further study is suggested adding control groups such as placebo in order to understand a single effect of smoking cessation.

Auricular acupuncture: a novel treatment for vasomotor symptoms associated with luteinizing-hormone releasing hormone agonist treatment for prostate cancer

OBJECTIVES

To evaluate the role of auricular acupuncture (AA) in men receiving luteinizing-hormone releasing hormone (LHRH) analogues for carcinoma of the prostate, as vasomotor symptoms can affect the quality of life in such men, and similar symptoms in postmenopausal women have been successfully treated with AA.

PATIENTS AND METHODS

In all, 60 consecutive patients with prostate cancer and on LHRH agonist treatment (median age 74 years, range 58-83) consented to weekly AA for 10 weeks. The validated 'Measure Yourself Concerns and Well-Being' questionnaire (a six-point scale to assess symptom severity) was used to assess concerns and well-being before and after treatment.

RESULTS

All men completed the treatment with no adverse events recorded, apart from transient exacerbation of symptoms in two men; 95% of patients reported a decrease in the severity of symptoms, from a mean 5.0 to 2.1 (Student's t-test, P < 0.01).

CONCLUSIONS

The symptomatic improvement was at levels comparable with that from pharmacotherapy, and cost analysis showed AA to be a viable alternative. Larger randomized studies are needed to fully evaluate AA against more conventional treatments, and these are planned.