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

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.

Acupuncture combined with auricular acupressure for smoking cessation and its effects on tobacco dependence and smoking behavior among Hong Kong smokers: a multicenter pilot clinical study

BACKGROUND

Acupuncture combined with auricular acupressure has been used as a complementary and alternative treatment for smoking cessation in Hong Kong for over 10 years. This study aimed to investigate the success rates of smoking cessation posttreatment, and to evaluate treatment effects on tobacco dependence, smoking behavior, anxiety levels, and sleep disturbances between successful and unsuccessful quit smokers in Hong Kong.

METHODS

This prospective, multicenter clinical study conducted between September 2020 and February 2022 in Hong Kong was part of the Guangdong-Hong Kong-Macau Greater Bay Area project on smoking cessation. Thirty eligible current smokers (mean age 47.10 years; 40% female) were recruited and received a combination of standardized acupuncture and auricular acupressure treatments twice weekly for 8 weeks. The primary outcome was the success rate of smoking cessation at week 24. The secondary outcomes were the success rates of smoking cessation at weeks 8 and 16, exhaled carbon monoxide (CO) levels, and changes in scores on the Fagerström Test for Nicotine Dependence (FTND), Autonomy Over Smoking Scale (AUTOS), Hamilton Anxiety Rating Scale (HAM-A), Self-rating Anxiety Scale (SAS), and Pittsburgh Sleep Quality Index (PSQI). Adverse events were also recorded.

RESULTS

Of 30 eligible participants, 28 completed 6 or more treatment sessions; all completed follow-up assessments. At week 24, the success rate of smoking cessation was 46.67%. The successfully quit rates at weeks 8 and 16 were 36.67% and 43.33%, respectively. The overall change in mean FTND scores from baseline improved significantly from weeks 2 to 24 (P < 0.05), with the successful quit group showing significantly greater improvement between weeks 8 and 24 (P < 0.01). Compared with baseline values, there were significant reductions in mean AUTOS scores from weeks 6 to 24 (P < 0.001), with the successful quit group showing greater improvement at weeks 16 (P = 0.04) and 24 (P < 0.001). No significant changes were detected in exhaled CO levels or HAM-A, SAS, and PSQI scores. No study-related adverse events were observed.

CONCLUSIONS

Acupuncture combined with auricular acupressure could be an effective alternative treatment for smoking cessation and reduction of tobacco dependence among Hong Kong smokers. Trial registration Chinese Clinical Trial Registry, No. ChiCTR2000033650. Registered on June 7, 2020. http://www.chictr.org.cn/showproj.aspx?proj=54866.

Efficacy and safety of acupuncture combined with auricular acupressure for smoking cessation: A study protocol of a multicentre, randomized, controlled clinical trial

Background

Nicotine dependence is an addictive behavioral disease facilitated by habitually smoking cigarettes. In many countries, acupuncture and auricular acupressure have attracted growing attention as complementary or alternative treatments for smoking cessation; however, there is a lack of rigorous randomized, controlled studies evaluating the combination of these two interventions specifically for smoking cessation. The aim of this study is to evaluate the efficacy and safety of using acupuncture combined with auricular acupressure (A&amp;AA) to increase the rates of smoking cessation and ultimately reduce the rates of relapse.

Methods

This is a multicentre, prospective, parallel, randomized, controlled trial. A total of 360 patients with severe nicotine dependence will be randomized into test (A&amp;AA) or control (nicotine replacement therapy, NRT) groups. The test group will be treated with A&amp;AA twice weekly, while the control group will use an NRT patch daily. All treatments will be administered for 8 weeks, with a follow-up period of 4 months. The primary outcome will be the smoking abstinence rate at week 24, with a combined safety assessment. The secondary outcomes will be smoking cessation rates at other timepoints, saliva cortisone test results, and scores on the Fagerstrom Test for Nicotine Dependence, the Autonomy over Tobacco Scale, the Hamilton Anxiety Rating Scale, the Self-rating Anxiety Scale, and the Pittsburgh Sleep Quality Index. The cost of treatment will also be used to evaluate the economic effects of different smoking cessation interventions. Statistical analysis on the data collected from both the intention-to-treat (all randomly assigned patients) and per-protocol (patients who complete the trial without any protocol deviations) patients, will be performed using the statistical software package, IBM SPSS 27.0.

Discussion

This study will provide rigorous clinical evidence evaluating the efficacy and safety of using A&amp;AA as a smoking cessation therapy.

Trial registration

Chinese Clinical Trial Registry (Registration number: ChiCTR1900028371).

Effects of electroacupuncture on pain sensation in a rat model of hyperalgesia with nicotine dependence

Tobacco smoking is considered to be one of the main risk factors in the development of chronic pain. Long-term chronic exposure to nicotine and other forms of tobacco have been shown to be associated with an increased incidence of pain. Studies have shown that acupuncture can help smokers to reduce their desire to smoke, reduce their withdrawal symptoms, and avoid a relapse after treatment. However, little has been reported about the effects of acupuncture on pain sensitivity caused by long-term smoking. Models of hyperalgesia were established in rats exposed to nicotine for 6 weeks. After 6 weeks of continuous nicotine exposure, electroacupuncture at bilateral acupoints Zusanli (ST36) and Taichong (LR3) was performed 20 minutes per day for 6 days at a continuous wave with a frequency of 2 Hz and a stimulus intensity of 1 mA. The results revealed that electroacupuncture treatment increased the mechanical response threshold of hind paw of nicotine-dependent rats with hyperalgesia and up-regulated the protein expression of pain-related factors μ-opioid receptor, β-endorphin and glutamic acid decarboxylase 65 in the spinal cord and midbrain periaqueductal gray and the protein expression of glutamic acid decarboxylase 67 in the spinal cord. These findings suggest that electroacupuncture treatment has positive analgesic effects on pain sensitivity caused by long-term chronic nicotine exposure. One possible mechanism for the improved analgesia is that electroacupuncture increases the expression of pain-related factors in the spinal cord and midbrain periaqueductal gray. This study was approved by Institutional Animal Care and Use Committee (IACUC) of the University of Miami (#18-167) on December 12, 2018.

Mobile chat-based support plus nicotine replacement therapy sampling to promote smoking cessation for community smokers: A randomized controlled trial

INTRODUCTION

Mobile instant messaging could deliver real-time, personalized, interactive smoking cessation support. Nicotine replacement therapy (NRT) is effective in increasing quit attempts and abstinence but is underused. We assessed the feasibility of mobile chat-based intervention combined NRT sampling (NRT-S) on abstinence.

METHODS

In this two-arm, single-blinded, randomized controlled trial, adult (≥18 years) daily cigarette smokers were proactively recruited from Hong Kong community settings using ‘foot-in-the-door’ approach during December 2017 to March 2018. All participants received brief advice on quitting, 1-week of NRT-S, active referral to smoking cessation services, and were individually randomized (1:1) at baseline. The intervention group received two months of chat-based support via instant messaging. The control group received general smoking cessation text messages. The primary outcome was smoking abstinence validated by exhaled carbon monoxide (<4 ppm) and salivary cotinine (<10 ng/mL) at 3 and 6 months using intention-to-treat analysis.

RESULTS

A total of 119 participants (80.7% male, 60.5% aged 30–40 years) were randomized and analyzed. Among the 14 and 13 self-reported quitters at 3 and 6 months respectively, only 3 and 1 had biochemical validation. The 3 months validated abstinence rate was 2/62 (intervention) vs 1/57 (control) (AOR=1.07; 95% CI: 0.08–13.65). At 6 months follow-up (68.9% of participants retained), more participants in the intervention group reported quitting (10/62 vs 3/57; AOR=2.83; 95% CI: 0.70–11.30), smoking reduction (20/62 vs 11/57; AOR=1.74; 95% CI: 0.71–4.26), and quit attempts (56/62 vs 44/57; AOR=2.61; 95% CI: 0.88–7.82). Significantly more NRT-S use (39/62 vs 22/57; AOR=2.27; 95% CI: 1.04–4.96) was observed in the intervention group. Participants engaged in mobile chat support (21/62) reported more NRT-S use (76.2% vs 56.1%), although not statistically significant.

CONCLUSIONS

Mobile chat-based support plus NRT-S was feasible and showed preliminary evidence of increased quitting, smoking reduction, quit attempts, and NRT-S use in proactively recruited community smokers.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT03574077.

Effects of active referral combined with a small financial incentive on smoking cessation: study protocol for a cluster randomised controlled trial

INTRODUCTION

Evidence-based smoking cessation treatments are effective but underutilised, accentuating the need for novel approaches to increase use. This trial investigates the effects of active referral combined with a financial incentive to use smoking cessation services on smoking abstinence among community smokers.

METHODS AND ANALYSIS

This ongoing study is a two-arm, assessor-blinded, pragmatic, cluster randomised controlled trial with follow-ups at 1, 2, 3 and 6 months after randomisation. We aim to enrol 1134 daily smokers from 70 community sites (clusters) in Hong Kong. All participants receive Ask, Warn, Advise, Refer, Do-it-again (AWARD) guided advice and a self-help booklet at baseline. Additionally, participants in the intervention group receive an offer of referral to smoking cessation services at baseline and a small financial incentive (HK$300≈US$38) contingent on using any of such services within 3 months. The primary outcomes are bioverified abstinence (exhaled carbon monoxide <4 ppm and salivary cotinine <10 ng/mL) at 3 and 6 months. Secondary outcomes include self-reported 7-day point prevalence of abstinence, smoking reduction rate, quit attempts and the use of smoking cessation services at 3 and 6 months. Intention-to-treat approach and regression models will be used in primary analyses.

ETHICS AND DISSEMINATION

This protocol has been approved by the Institutional Review Board of the University of Hong Kong/Hospital Authority Hong Kong West Cluster (IRB reference number: UW 18-318). The results of this trial will be submitted for publication in peer-reviewed journals, and the key findings will be presented at national and international conferences.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov Registry NCT03565796.

Effects of simple active referrals of different intensities on smoking abstinence and smoking cessation services attendance: a cluster-randomized clinical trial

BACKGROUND AND AIMS

Proactive brief cessation advice by a lay counsellor combined with a referral to a smoking cessation service (active referral) is effective in increasing service use and quitting in community smokers. We compared the effect of two modified approaches to referrals on the cessation outcomes in community smokers.

DESIGN

Three-arm cluster-randomized trial.

SETTING

General community in Hong Kong.

PARTICIPANTS

Daily cigarette smokers (n = 1163; 77.7% male).

INTERVENTIONS

Participants were randomized to receive on-site active referral (OSR, n = 395), where lay counsellors helped participants make appointments with a smoking cessation service of their choice plus tailored reminders; mobile text messaging referral (TMR, n = 385), where participants were encouraged to use a smoking cessation service via text messages; or brief cessation advice only (control, n = 383).

MEASUREMENTS

The primary outcome was a self-reported 7-day point-prevalence abstinence at 6 months post-treatment initiation. Secondary outcomes included 7-day point-prevalence abstinence at 3 and 18 months, biochemically validated abstinence, smoking reduction and the use of cessation services at 3, 6 and 18 months.

FINDINGS

Using intention-to-treat analysis, the OSR (17.7%) and TMR (17.1%) groups had significantly higher self-reported abstinence than the control (12.0%) group at 6 months [odds ratio (OR) for OSR versus control = 1.58, 95% confidence interval (CI) = 1.06-2.36; OR for TMR versus control = 1.52, 95% CI = 1.01-2.28; both P < 0.05]. The corresponding validated abstinence rates at 6 months were 7.6, 7.8 and 3.9% (OR for TMR versus control = 2.02, 95% CI = 1.07-3.81; OR for TMR versus control = 2.07, 95% CI = 1.10-3.92; both P < 0.05). Self-reported and validated abstinence were similar at 18 months. OSR groups had higher rates of smoking cessation service use than the control group at all follow-ups (all P < 0.001). The smoking reduction rates were similar in continuing smokers.

CONCLUSIONS

Simple active referrals (in person or via text messaging) to smoking cessation services increased abstinence rates among smokers in Hong Kong compared with general brief cessation advice. On-site active referral increased the use of smoking cessation services compared with general brief cessation advice.

Effects of acupuncture on craving after tobacco cessation: a resting-state fMRI study based on the fractional amplitude of low-frequency fluctuation

Background

To explore the immediate effects and mechanism of acupuncture on craving after tobacco cessation based on the fractional amplitude of low-frequency fluctuation (fALFF).

Methods

This was a functional magnetic resonance imaging (fMRI) study. Forty participants were recruited and divided into a smoking group and a non-smoking group, 20 cases in each one. The smoking participants were requested to quit smoking 24 hours before the fMRI scan. The scan process was scan - acupuncture - scan. Between the two scans, acupuncture was applied at Lieque (LU 7), Hegu (LI 4), Baihui (GV 20), Zusanli (ST 36), Sanyinjiao (SP 6) and Taichong (LR 3) in two groups.

Results

After acupuncture, self-made craving for smoking, Minnesota Nicotine Withdrawal Scale (MNWS) and Questionnaire of Smoking Urges (QSU) were all reduced (P<0.05). The fMRI results indicated the immediate effects of acupuncture on smoking craving were significant, and identified salience network (SN) consisted of anterior cingulate cortex and insula, prefrontal cortex, visual cortex and cerebellum as key brains area. Correlation analysis indicated that NWNS scores were positively correlated with the mean fALFF in the ACC (P<0.05) and negatively correlated with the mean fALFF in the insula (P<0.05) in the smoking group.

Conclusions

This was the first study in China to explore the neural mechanisms of acupuncture for smoking craving. The results indicated that the effects of acupuncture on smoking craving were significant, and the SN played a critical role in the process.

Clinical Effectiveness of Traditional and Complementary Medicine Interventions in Combination with Nicotine Replacement Therapy on Smoking Cessation: A Randomized Controlled Pilot Trial

Background: Smoking is associated with many preventable diseases and deaths. Globally, more than 6 million deaths per year are related to smoking. This study aimed to evaluate the pragmatic effectiveness of traditional and complementary medicine (T&CM) interventions for the smoking cessation treatment and to calculate the incremental cost-effectiveness ratio (ICER) of these interventions. Methods: The study design was a pragmatic, open-label randomized trial. The hypothesis of this trial was that the smoking cessation success rate increases with the addition of T&CM methods. The intervention group was provided T&CM interventions in addition to nicotine replacement therapy (NRT) and counseling, whereas the control group was treated with only NRT and counseling. Individuals received treatment for 4 weeks, then follow-up care for 20 weeks. Results: Forty-one participants were enrolled and assigned to either an intervention group or a control group at a ratio of 1:1. The odds ratio values at 4 weeks were 1.96 (0.51-8.51) in intention-to-treat analysis and 3.27 (0.75-17.75) in per-protocol analysis. The amount of smoking (cigarettes) decreased in both groups: from 17.2 ± 10.31 (baseline) to 1.7 ± 3.02 (4 weeks) in the intervention group and from 12.9 ± 5.47 (baseline) to 3.3 ± 5.96 (4 weeks) in the control group. The total medical costs per patient were $212.20 USD in the intervention group and $170.80 in the control group. The adjusted ICER of T&CM interventions was $13,355. Conclusions: This pilot study evaluated the clinical feasibility of T&CM used in conjunction with NRT and counseling for the smoking cessation treatment. However, there was no statistically significant effectiveness of T&CM interventions to raise cessation success rate. This study demonstrates the necessity for further studies based on large-scale randomized controlled trials.

Chat-based instant messaging support combined with brief smoking cessation interventions for Chinese community smokers in Hong Kong: Rationale and study protocol for a pragmatic, cluster-randomized controlled trial

BACKGROUND

Novel approaches to engage community smokers in smoking cessation are needed as smokers typically lack motivation to quit or use evidence-based tobacco dependence treatment. Mobile instant messaging apps (e.g., WhatsApp, Facebook Messenger) are widely used but under-studied as a mobile health modality for delivering smoking cessation support. This paper presents the rationale and study design of a trial which aims to evaluate the effectiveness of a chat-based intervention using mobile instant messaging combined with brief interventions for community smokers.

METHODS

This is a two-arm, parallel, accessor-blinded, pragmatic cluster-randomized controlled trial on an estimated 1172 daily cigarette smokers aged ≥18 years proactively recruited from 68 community sites (cluster) throughout Hong Kong. Subjects in intervention group received three months of chat-based, instant messaging support guided by acceptance and commitment therapy and other behavioural change techniques, integrated with brief advice and active referral to a smoking cessation service using the AWARD (Ask, Warn, Advise, Refer, Do-it-again) intervention model. Control group received brief advice to quit plus a self-help booklet at baseline. Outcomes were assessed at 1-, 2-, 3- and 6-month after baseline. The primary outcome is abstinence validated by exhaled carbon monoxide (<4 ppm) and salivary cotinine (<10 ng/mL) at 6-month after baseline. Primary analyses will be based on intention-to-treat.

COMMENTS

This is the first trial examining the effectiveness of a chat-based cessation support programme combined with brief interventions in promoting abstinence. The intervention model can be adapted for other behavioural change treatments and more advanced digital smoking cessation intervention.

Intervention With Brief Cessation Advice Plus Active Referral for Proactively Recruited Community Smokers: A Pragmatic Cluster Randomized Clinical Trial

IMPORTANCE

Most smoking cessation (SC) clinics are costly, passive, and underused.

OBJECTIVE

To compare the SC effect of a combined intervention involving brief, model-guided SC advice plus active referral to SC services (active referral group) with those of brief, model-guided SC advice only (brief advice group) and general SC advice only (control group).

DESIGN, SETTING, AND PARTICIPANTS

A single-blind, 3-arm, pragmatic cluster randomized clinical trial was conducted including 1226 adult daily smokers in the general Hong Kong community proactively recruited to participate in the Quit-to-Win Contest held in 2015. The study was conducted from June 20 to September 24, 2015. Participants were randomly allocated to the active referral (n = 402), brief advice (n = 416), and control (n = 408) groups. Intention-to-treat analysis was used.

INTERVENTIONS

Brief telephone counseling was offered to the active referral and brief advice groups at 1 and 2 months. Interventions were delivered by SC ambassadors who had undergone a short training period.

MAIN OUTCOMES AND MEASURES

The primary outcome was the self-reported past 7-day point prevalence of abstinence (PPA) at 6 months. The secondary outcomes were carbon monoxide level-validated abstinence, smoking reduction, and SC service use.

RESULTS

Participants included 991 (80.8%) men; mean (SD) age was 42.0 (14.8) years. The response rate was 68.2% at 3 and 72.3% at 6 months. The corresponding PPAs were 18.9% and 17.2% in the active referral group-higher than in the brief advice (8.9% and 9.4%; both P ≤ .001) or control (14.0% and 11.5%; P = .03 at 6 months) groups. Compared with the other 2 groups, the active referral group had significantly higher validated abstinence rates (10.2% at 3 months and 9.0% at 6 months, all P < .05) with odds ratios of 2.84 (95% CI, 1.57-5.15) and 2.61 (95% CI, 1.46-4.68) at 3 months, and 1.85 (95% CI, 1.06-3.23) and 1.81 (95% CI, 1.04-3.16) at 6 months in the brief advice and control groups, respectively. The SC service use rate was significantly higher in the active referral group (25.1%) than in either brief advice (2.4%) or control (3.4%) groups at 6 months (P < .001).

CONCLUSIONS AND RELEVANCE

An intervention involving brief advice and active referral delivered to smokers in the community by volunteers can increase quitting in places where SC services are available but underused.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT02539875.

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.