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smoking cessation A
meta-analysis of acupuncture techniques
for 1999;8;393-397 ob. !ontrol "dr#an $ %h#te& 'arl-(udw#) $esch
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Tobacco Control 1999; 8 :393C397 393
A meta-analysis of acupuncture
techniques for smoking cessation
Ar ian ! "hite# $arl-%u&ig !esch# '(ar 'r ns
tDepar tment of
Complementar y
Medicine, Postg
raduate Medical
School, Univer sity of
Exeter, Exeter, UK A !
"hite $-% !esch ' 'r
nst
Cor responence to: )epar tment of Complementar y *
eicine# +o stg rauate *eical ,chool# -ni.er sity of
'/eter# 01 2ictor ia +ark !oa# '/eter '30 456;
a7r7&hite8e/eter7ac7uk
!ecei.e 14 *arch 1997 !e.ision recei.e 7 August
1997 Accepte 1 ,eptem9er 1997!stract
Objective "o deter mine the e# ectiveness of
acupuncture for smo$ing cessation and to
examine %hether any
individual aspect of tr
ials is associated %ith
an e# ect& Data
sources ll
randomised
controlled tr ials of
acupuncture for
smo$ing cessation
that %ere listed in
computer ised
data!ases or
reference lists of
relevant ar ticles&
Study selection ll
randomised
single!lind studies
that compared
acupuncture %ith
sham acupuncture&
Data extraction
Methodolog ical data
%ere extracted for
'uality assessment&
(utcome data %ere
extracted for rates of
total smo$ing
cessation at three
inter vals) early after
treatment and after
six and *+ months
follo% up& Data
synthesis,esults
%ere expressed as
odds ratios of success
over f ailure in inter
vention over control g
roups& "he com!ined
odds ratio for all
studies %as
calculated& ,epeated
meta-analyses %ere
su!se'uently perfor
med on su!sets of
studies com!ined
according to de.ned
character istics)
acupuncture
techni'ue, num!er of
attendances, countr y
of or ig in, status of
/our nal, and control
procedure& "he
overall 'uality of
studies %as poor& "he
com!ined odds ratio
for smo$ing cessation
calculated for the
earliest results after
the end of treatment
%as *&+0 1234
con.dence inter vals
1234 C5s6 7 0&28 to *&886& "he com!ined odds
ratio for smo$ing cessation after six months
%as *&+2 1234 C5 7 0&8+ to +&0*6, and after *+
months %as *&09 1234 C5 7 0&:9 to *&8;6&
"here %ere no signi.cant e # ects of
relevance among su!sets of studies g rouped
according to de.ned character istics&
Conclusions cupuncture %as not super ior
to sham acupuncture for smo$ing cessation<
no par ticular aspect of acupuncture
techni'ue %as associated %ith a positive e #
ect& "he conclusions are limited !y
methodolog ical inade'uacies of studies and
!y the a!sence of testa!le hypotheses< design
of future tr ials should avoid these
de.ciencies&
: Tobacco Control 1999; 8 :393C397;
$ey&ors: acupuncture# smoking
cessation
15ntroduction <t has 9een estimate that up
to 1=> of resients in the -nite $ingom
ha.e use acupuncture at some time#an a
recent sur .ey0foun that 11> of the
population &oul consier complementar y
meicine for smoking cessation76he use of
acupuncture for aictions or ig inate from
a chance o9ser .ation that opiate
&ithra&al symptoms &ere relie.e among
?ong $ong aicts &ho recei.e
acupuncture treatment74C73,u9sequent
stuies in animals that ha 9een renere
epenent on r ugs lent some suppor t to
the iea that acupuncture may ha.e an e V
ect on &ithra&al symptoms7
@Acupuncture has 9een consiere for a
role in smoking cessation 9ecause of its e V
ects in releasing neurotransmitter s7 )etails
of these e V ects in humans are still unclear#
as inee are the neurochemical
mechanisms of nicotine aiction an
&ithra&al7 <n aition to e.ience that
acupuncture may release enogenous
opiois#@ 9 there is some e.ience
suggesting a possi9le role for serotonin :1-
?6;# norarenaline :norepinephr ine;# an
cholec ystokinin in acupuncture
analgesia71Aas &ell as in nicotine cra.ing
an &ithra&al7<t seems likely that
increase opamine le.els :through
inhi9ition of monamine o/iase inhi9itor B;
are in.ol.e in nicotine aiction11
@9ut the role of acupuncture in opamine
meta9olism is still uncer tain7
6here is contraictor y e.ience on
&hether acupuncture has a clinically useful
e V ect in smoking cessation7 <n one re.ie&#
%e&ith10
conclue that CDacupuncture is as goo
as nicotine replacement therapy7CE Fn
the other han# ter !iet et al14 1113perfor
me a cr iter ia-9ase# systematic re.ie&
of ranomise controlle tr ials :!C6s;
an conclue that 9etter quality stuies
&ere more likely to 9e negati.e7 6&o fur
ther meta-analysesconclue that there
&as no e.ience that acupuncture ha
an eV ect in smoking cessation7
?o&e.er# these analyses in.ol.e only
eight an si/ stuies respecti.ely# an
may 9e open to 9ias as they inclue
open tr ials7 6he range of techniques
use in these tr ials &as &ie# an the
possi9ility remains that one technique
may 9e more e V ecti.e than another7
6&o 9asic acupuncture techniques are
repor te7 Gir stly# neeles may 9e inser
te &hile the patient rela/es for 1A to 0A
minutes7 6he neeles are then remo.e7
+oints in the ear
are commonly
use in the
'nglish-speaking
&orl# &hereas Grench practitioner s
more commonly use points in the f ace7
Acupuncture points on the 9oy may 9e
neele at the same time# an electr ical
stimulation may 9e applie7 ,econly# an
in&elling neele may 9e inser te into
one or more points in the ear an hel i
n
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394 White, Resch, Er ns
tplace for one or t&o &eeks &ith an ahesi.e ressing7
6he su9Hect is instr ucte to press the neele &hene.er
cra.ings occur7 6he num9er an frequenc y of
treatments .ar y 9et&een practitioner s7
"e conucte a fresh meta-analysis of !C6s# using
a comprehensi.e search strategy# to eter mine the e
V ecti.eness of acupuncture in smoking cessation an
to compare the eV ecti.eness of i V erent techniques7
Methods
)A6A ,F-!C',
13A literature search &as perfor me of computer ise
ata9ases hel 9y *eline :1974C199=;# 'm9ase#
the Br itish %i9rar y# C<,CF* :Centralise <nfor mation
,er .ice for Complementar y *eicine# !oyal College
of Complementar y *eicine# =A Ireat Fr mon
,treet# %onon "C15 3JG;# an ,cience Citation
<ne/# com9ining the ter ms CDclinical tr ialsCE#
CDacupunctureCE# an CDsmokingCE or CDto9accoCE7
+re.ious re.ie&s of acupuncture for aiction &ere
o9taine an their reference lists searche7 6he results
of contacting e/per ts in the Kel an searching for CDg
reyCE literature# perfor me for one recent re.ie&#&ere
inclue# 9ut the proceures &ere not repeate7
Copies of or ig inal ar ticles &ere o9taine an# &here
necessar y# author s &ere contacte to o9tain fur ther
ata or clar ify etails7
,6-)L ,'%'C6<F5
All stuies &ere selecte in &hich su9Hects &ere
ranomise 9y an appropr iate metho to recei.e
acupuncture or a control inter .ention7 Fnly su9Hect-
9lin stuies# in &hich the control g roup recei.e a
sham for m of acupuncture# &ere inclue in the pr
imar y analyses7 ?o&e.er# all stuies &ere inclue
in the compar ison of acupuncture &ith i V erent
control proceures7 6here &ere no restr ictions on
acupuncture technique or length of follo& up# 9ut
only stuies pu9lishe in 'nglish# Grench or Ier
man &ere inclue7)A6A '36!AC6<F5
6he outcome measure use in the analysis &as
complete cessation of smoking at three time points: the
earliest measurement after the inter .ention# an after
si/ an 10 months# follo& up7 +ar ticipantsCM repor ts of
smoking cessation &ere use as 9iochemical conKr
mation &as not a.aila9le in any of the stuies7 "here
necessar y# results &ere recalculate to inclue all
rop-outs# &ho &ere assume to ha.e relapse7
,ustaine cessation rates &ere use &hen a.aila9le in
preference to point pre.alence of a9stinence7
N-A%<6L A,,',,*'56
13'ach paper &as Kr st assesse for appropr iateness
of metho of ranomisation# concealment of
ranomisation# minimisation of practitioner interaction#
an sample si(e calculation7 'ach stuy &as then
score accoring to the metho of ter !iet et alusing a
list of 1@ preeKne cr iter ia &hich inclue .aliation
of outcome an uration of follo& up7 6he ma/imum
possi9le score is 1AA7 6he or ig inal author s allocate
points to each cr iter ion accoring to their estimate of
its impor tance# the highest score 9eing 11 points for
CDIoo quality of acupunctur ist mentione7CE
'/amples of other cr iter ia &ere ranomisation :10;#
aequate escr iption of acupuncture proceure#
su9Hect9lining # an at least 1A su9Hects in each g
roup :1A points each;7
)A6A ,L56?',<,
6he ata &ere analyse using custom-&r itten
soft&are kno&n as !e.*an 071a7 6his prog ramme
&as e.elope an pu9lishe 9y the Cochrane
Colla9oration to pro.ie accessi9le an
stanarise methos of perfor ming meta-analyses
for the Cochrane ata9ase of systematic re.ie&s7 <t
pro.ies the f acility of perfor ming repeate meta-
analyses on .ar ious com9inations of stuies &hich
ha.e 9een selecte accoring to eKne cr iter ia7 <n
the present stuy# total num9er s of su9Hects
inclue in each g roup# an the num9er s &h
oTable 1 Details of random controlled trails of acupuncture for smoking cessation
Author n
Treatment
Sustained
treatment C
ontrol
procedure(sDuration of follo! u
t*ar tin09
+arker3A
,teiner31
17
Cottrau/134 :a; Aur iculo i7n7 :a; ,ham = months 10= :9; Aur iculo O 'A :9; ,ham
01 :a; Aur iculo i7n7 :a; ,ham = &eeks 0A :9; Aur iculo O 'A :9; ,ham
30
==1 Gacial 5A :a; 5icotine gum 13 months :9; 6 ime cigarette cas
e00 Boy O aur iculo i7n7 ,ham 4 &eeks 2ane.enne0AA Gace O 9oy 5A ,ham 10 months RCTs using other controls Cla.el
0A1 1@ Aur iculo O f acial 5A :a; Beha.iour 10 months :9; + lace9o :c; "aiting list
7
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Acupuncture techni"ues for smoking cessation 39
12ane.enne Cla.el
Iillams Iil9ey
,teiner
%acroi/ %amontagne
*artin :a; *artin :9;
%agrue
+arker :a; +arker :9;
F.erall0AA n
99=
14 90
00
117 71
10= 134 114
03 0A
0A13
1A1A7A1 A71
Fs ratio :log scale
;#$%igure 1 &dds ratios and $'( con)dence inter
*als for smoking cessation at )rst assessment after
inter *ention for indi*idual and o*erall odds ratio+
Tr ials in descending order of "ualit,+ n - .umber
of sub/ects+ 0ar tin and Waite,and 1arker23included
separate tr ials in the repor ts, labelled (a and (b
in the )gure +
ha stoppe smoking
at speciKe time inter
.als :Kr st measure#
si/ months# 10
months; &ere entere
into ta9les for compar
ison7 ,u9sequently all
stuies &ere allocate
to su9g roups
accoring to the
follo&ing character
istics: acupuncture
technique# num9er of
attenances# countr y
of or ig in# status of
1974 = O O Cla.el01=0 4 O Iil9ey0019 1 Iillams3117 4
O ,teiner0=10 4 %amontagne041A 0 O %acroi/0947 0
A096here &ere 1A repor ts of stuies in &hich the control
g roup recei.e some for m of sham acupuncture# as
set out in ta9le 17 ?o&e.er# *ar tin an "aitean
+arker an *ok3A
repor te t&o compar
isons :t&o g roups
recei.ing i V erent
acupuncture
proceures# each &ith
its o&n control g roup;7
)ata from each of these
stuies &ere entere
separately7 6hus the%irst
author 4ualit, score
302ane.enneEar liest inter *al
(!eeks 5 0 onths 1 # 0 onth
s
on 23 March 2005
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39= White, Resch, Er ns
tComparison n :a; Acupuncture technique:04
auriculo
in&elling neele facial points
1 or 0 :9; 5um9er of attenances:
3 or more
Grance :c; Country of origin:
5orth America Fther
*eline liste :; ,tatus of Hournal:
not *eline liste
9eha.iour therapy :e; .s Fther
inter.ention:
nicotine gum &aiting list @ 7 4
1 7
4 1
3
7 1
3 0 3
A71 1
Fs
ratio
:log
scale;1
A%igure # &dds ratios and $'( con)dence inter *als for smoking
cessation at )rst assessment after inter *ention for subg roups of sham6
controlled random controlled tr ials of acupuncture + Compar isons (a
to (d include sham6controlled studies7 compar ison (e includes all
randomised studies+ n - .umber of sub/ects+
colleagues# none of &hom &ere
acupunctur ists7 6his stuy ha
9een uner score 9y 01 points7
:"e &oul argue that the opinion of
a specialist in the area shoul 9e
consulte &hen assessing the
quality of e/per ience or technique7;
F6?'! CF*+A! <,F5,
Gigure 0 sho&s that no par ticular
aspect of the stuies &as ientiKe
&hich le to a result in &hich
acupuncture &as super ior to sham#
&hether com9ining stuies &ith i V
erent acupuncture techniques#
num9er of attenances# countr y of
or ig in# or status of Hour nal7 6he
compar isons &ith other control g
roups &ere limite 9y small num9er
s of stuies7 Acupuncture appear s
to 9e as eV ecti.e for smoking
cessation as 9eha.iour therapy#0A 0=
1@5o stuy &as 9ase on a hypothesis that acupuncture
might ha.e par ticular 9eha.ioural e V ects that might
assist smoking cessation# for e/ample# 9y reucing
&ithra&al symptoms# 9y inucing euphor ia or 9y
increasing moti.ation an there9y reucing the relapse
rate7 )ata on cra.ing &ere only presente in one repor tin
&hich 31@ out of the total of 99= su9Hects assesse their
nee for a cigarette after the inter .ention as a seconar y
outcome measure7 6he results o not suggest any
inPuence of either nicotine che&ing gum or acupuncture
on le.els of cra.ing7 6here remains the question &hether
all potential contr i9utions of acupuncture in nicotine
epenence ha.e 9een e/plore7 6his stuy i not
unco.er e.ience that any par ticular technique of
acupuncture &as more promising than any other#
although the strength of this conclusion is limite 9y the
small num9er of stuies7 6here &ere trens in f a.our of
using f acial points an of repeating treatment on three or
more occasions7 6hese trens harly amount to a
hypothesis for the action of acupuncture on either the
neurochemical or the 9eha.ioural le.el &hich &oul Hustify
fur ther research at the present time7 <t is a/iomatic that# if
fur ther research into acupuncture for smoking cessation
is conucte# this shoul 9e to a much highersingle stu
y
on 23 March 2005
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Acupuncture techni"ues for smoking cessation 39
7stanar of quality than pre.iously7 <n aition to the
nee for a clear hypothesis# the maHor methoolog ical
requirements ientiKe are: calculation an recr
uitment of aequate sample si(e# appropr iate metho
of ranomisation of su9Hects# concealment of
ranomisation# minimisation of therapist 9ias#
9iochemical .aliation of smoking cessation# an long-
ter m follo& up for at least si/ months an prefera9ly
10 months7
<n conclusion# e.en the most r igorous tr ials pro.ie
no e.ience that acupuncture is super ior to sham in
smoking cessation7 6here is also no e.ience that one
acupuncture technique is super ior to another7
1 G isher +# "ar A7 Complementar y m eicine in 'urope7 809
1994;902:1A7C117
0 * intel Complementar , 0 edicines+ 0 arket intelligence repor t, 1$$:+
%onon: *intel# 19977
3 "en ?%# Cheung ,LC7 6reatment of r ug aiction 9y acupuncture
an electr ical stimulation7 Asian 9 0ed 1973; 2:13@C417
4 5g %$L# )outhitt 6C# 6hoa 5B# et al+ *oiKcation of mor phine-
&ithra&al synrome in rats follo&ing transaur icular stimulation: an
e/per imental paraigm for aur icular acupuncture7 8iol 1s,chiatr
1971;*0 :171C@A7
1 Choy L*# 6so "-"# Gung $+# et al+ ,uppression of narcotic
&ithra&als an p lasma AC6? 9y aur icular electroacupuncture7
8iochem 8ioph,s Res C ommun 197@; 8+:3A1C97
= Cheng !,,# +omeran( B# Lu I7 'lectroacupuncture treatment o f
mor phine-epenent mice reuces signs o f &ithra&al# &ithout
sho& ing cross-tolerance7 Eur 9 1har macol 19@A;;8 :477C@17
7 ?an J,# Qhang !%7 ,uppression of mor phine a9stinence synrome
9y 9oy electroacupuncture of iVerent frequencies in rats7 Dr ug
Alcohol Depend 1993;9* :1=9C717
@ ? an J# 6erenius % 7 5 eurochemical 9asis of acupuncture
analgesia7 Annu Re* 1har macol To;icol 19@0;++:190C00A7
9 ? an J,# ) ing 3Q# Gan , I7 Cholec ystokinin octapeptie :CC$-@;:
antagonism to electroacupuncture analgesia an a possi9le role in
electroacupuncture tolerance7 1a i n 19@=;+::1A1C117
1A 5utt ) J7 Aiction: 9rain mechanisms an their treatment
implications7 <ancet 199=;98::31C=7
11 Go&ler J,# 2olko& 5 )# "ang I-J# et al+ <nhi9ition o f monoamine
o/iase B in the 9rains of smoker s7 .ature 199=;9:2:733C=7
10 %e&ith I67 6he treatment o f to9acco aiction7 Comp Ther 0ed
1991;9:140C17
13 ter !iet I# $leiHnen J# $nipschil +7 A m eta-analysis of stuies into
the e V ect of acupuncture on aiction7 8r 9 =en 1 ra ct
199A;80:379C@0714 %a& *# 6ang J%7 An analysis of the eVecti.eness
of inter .entions intene to h elp people stop smoking7 Arch >nter n 0
ed 1991;*33:1933C417
11 Giore *C# Bailey "C# Cohen ,J# et al7 Smoking cessation+ Clinical
+ractice Iuieline 5 o 1@7 !ock.ille# *ar ylan: -, )epar tment of
?ealth an ?uman , er .ices# +u9lic ?ealth ,er .ice# Agenc y for ?
ealth Care +o lic y an !esearch# Apr il 199=7 :A?C+! +u9lication 5o
9=A=907;7
1= Lusuf ,# +eto !# %e&is J# et al+ Beta 9lockae ur ing an after
myocarial inf arction: an o.er .ie& of the ranomi(e tr ials7 1rog
Cardio*asc Dis 19@1;+: :331C717
17 Cla.el-Chapelon G# Benhamou ,# Company-?uer tas A# et al+
?elping p eople to stop smoking: ranomise compar ison o f g roups
9eing treate &ith acupuncture an n icotine gum & ith control g roup7
809 19@1;+2* :113@C97
1@ Cla.el G# +aoletti C7 -ne Rtue e iVRrents prog rammes e
Rsinto/ication ta9ag ique por tant sur prs e 1AAA .olontaires recr
utRs ans la population gRnRrale: rRsultats S 1 mois7 Re* E pid?@miol
Sant?@ 1ubli"ue 199A;98:133C@7
19 Cla.el G# +aoletti C# Benhamou ,7 A ranomise 0CS0 f actor ial
esign to e.aluate iV erent smoking cessation methos7 Re* E
pid?@miol Sant?@ 1ubli"ue 1990;80 :1@7C9A7
0A Cottrau/ JA# ?arf !# Boissel J-+# et al+ ,moking cessation &ith
9eha.iour therapy o r acupunctureCTa controlle stuy7 8eha* R es Ther
19@3;+* :417C047
01 Iil9ey 2# 5eumann B7 Aur icular acupuncture for smoking
&ithra&al7 Am 9 Acupunct 1977;3:039C477
00 Iillams J# % e&ith I6# * achin )7 Acupuncture an g roup therapy
in stopping smoking7 The 1 ra ctitioner :%onon; 19@4;++8:341C47
03 %a9aie J-C# )ones J-+# I achie J-+# et al+ )Rsinto/ication ta9ag
ique: acupuncture et traitement m Rical7 =aA 0 ?@d %rance
19@3;20:0741C77
04 %acroi/ J-C# B esancon G7 % e se.rage u ta9ac7 'Y cacitR e
lCMacupuncture ans un essai comparatif 7 Ann 0?@d >nter n
1977;*+8:4A1C@7
01 %ag r ue I# +oupy J%# Ir illot A# et al+ Acupuncture anti-ta9ag ique7
.ou*elle 1resse 0?@dicale 1977;2:9==7
0= %amontagne L# Anna9le %# Iagnon *-A7 Acupuncture for smoker s:
lack of long-ter m therapeutic e V ect in a controlle stuy7 Can 0ed A
ssoc 9 19@A;3:7@7C9A7
07 %eung J-+7 ,moking cessation 9 y aur icular acupuncture an
9eha.ioral therapy7 1s,cholog ia 1991;98 :177C@77
0@ *acho.ec GJ# *an ,C7 Acupuncture an hypnosis compare: K fty-
eight cases7 Am 9 C lin B,pn 197@;+*:41C77
09 *ar tin I+# "ai te +*'7 6he eYcac y o f acupuncture as
an ai to stoppi ng smoki ng7 .C0ed919@1;29:401C37
3A +arker %5# *ok *,7 6he use of acupuncture for smoking
&ithra&al7 Am 9 Acupunct 1977;3:3=3C=7
31 ,teiner !+# ?ay )%# )a.is A"7 Acupuncture therapy for the
treatment o f to9acco smoking aiction7 Am 9 Chin 0ed 19@0;*0 :
1A7C017
30 2ane.enne A# !empp *# Burghar I7 'tue e lCMaction
spRciKque e lCMacupuncture ans la cure e se.rage ta9agique7 Sem
B Dp 1a r is 19@1;;*:0111C=A7
33 Clement-Jones 2# *c%oughlin %# %o&r y +J# et al+ Acupuncture in
heroin aicts: changes in met-enkephalin an 9eta-enor phin in
9loo an cere9rospinal Pui7 <ancet 1979;+:3@AC37