Acupuncture for smoking cessation

White AR, Rampes H, Ernst E
Cover sheet - Background - Methods - Results - Discussion - References - Tables & Graphs

A substantive amendment to this systematic review was last made on 17 June 1999. Cochrane reviews are regularly checked and updated if necessary. Background and objectives: Acupuncture is promoted as a treatment for smoking cessation, and is believed to reduce withdrawal symptoms. The objective of this review is to determine the effectiveness of acupuncture in smoking cessation in comparison with: a) sham acupuncture b) other interventions c) no intervention. Search strategy: We searched the Cochrane Tobacco Addiction Group trials register, Medline, Psyclit, Dissertation Abstracts, Health Planning and Administration, Social SciSearch, Smoking & Health, Embase, Biological Abstracts and DRUG. Selection criteria: Randomised trials comparing a form of acupuncture with either sham acupuncture, another intervention or no intervention for smoking cessation. Data collection and analysis: We extracted data in duplicate on the type of subjects, the nature of the acupuncture and control procedures, the outcome measures, method of randomisation, and completeness of follow-up. We assessed abstinence from smoking at the earliest time-point (before 6 weeks), at six months and at one year follow-up in patients smoking at baseline. 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 to smoke. Where appropriate, we performed meta-analysis using a fixed effects model. Main results: We identified 18 publications involving 20 comparisons. Acupuncture was not superior to sham acupuncture in smoking cessation at any time point. The odds ratio (OR) for early outcomes was 1.22 (95% confidence interval 0.99 to 1.49); the OR after 6 months was 1.38 (95% confidence interval 0.90 to 2.11) and after 12 months 1.02 (95% confidence interval 0.72 to 1.43). Similarly, when acupuncture was compared with other anti-smoking interventions, there were no differences in outcome at any time point. Acupuncture appeared to be superior to no intervention in the early results, but this difference was not sustained. The results with different acupuncture techniques do not show any one particular method (i.e. auricular acupuncture or non-auricular acupuncture) to be superior to control intervention. Reviewers' conclusions: There is no clear evidence that acupuncture is effective for smoking cessation.

Acupuncture has been used in the treatment of nicotine dependence in the West since an incidental observation in Hong Kong (Wen 1973). Opium smokers who had been given electroacupuncture for pain relief claimed that their opiate withdrawal symptoms were less

Law & Tang performed a limited meta-analysis of the Medline-listed trials. Uncontrolled studies have suggested that acupuncture might also reduce the symptoms of nicotine withdrawal and some remarkably high rates of initial success have been claimed. This includes points on the ear. and held in position with surgical tape for several days. or a surgical suture may be inserted and knotted with a bead attached. known as electroacupuncture. Alternatively. Types of intervention Any treatment involving needle puncture of areas of the body described by the study’s author as acupuncture points.severe than they expected. falling to 34% after twelve months (Fuller 1982). Schwartz found no evidence of a specific effect (Schwartz 1988). usually in ear points. Ter Riet (Ter Riet 1990) performed a criteria-based systematic review of randomised controlled trials and found that the better the quality of the study the more likely it was to be negative. Clearly only randomised controlled studies can determine whether this is more than a placebo effect. For example Fuller claimed that 95% of 194 subjects were not smoking after three treatments in one week. or in addition. As alternatives to indwelling needles. Patients are instructed to press the indwelling needles when they become aware of withdrawal symptoms. were also included. Studies in which an electrical stimulation was applied to the needles. Vincent & Richardson found that acupuncture appeared to be as effective as other methods in the initial stages of nicotine withdrawal. Ashenden & Silagy (1997) included 10 studies in a systematic review looking at the long-term success of acupuncture in smoking cessation: 9 of the studies could be combined in a meta-analysis which concluded that. Choy claimed 88% success in a large study of 514 subjects but did not state the long-term results (Choy 1983). Brewington et al (Brewington 1994) concluded that acupuncture might be of limited assistance in withdrawal. Several literature reviews of controlled trials of acupuncture for smoking cessation have been published yet the conclusions are not uniform. face and body.20 minutes). He concluded that on balance there was no evidence that acupuncture was efficacious in the treatment of nicotine addiction. Objectives To evaluate whether acupuncture a) has a specific effect in smoking cessation beyond placebo effects b) is more effective than other interventions for smoking cessation c) is more effective than no treatment for smoking cessation Criteria for considering studies for this review Types of participants Tobacco smokers aged over 18 years who wished to stop smoking. He concluded that acupuncture is as good as nicotine replacement therapy. We undertook a new review and meta-analysis in order to evaluate the short and long-term outcome of acupuncture for smoking cessation. there was insufficient evidence to recommend it as an effective form of therapy. concluding that acupuncture had "little or no effect" (Law 1995). However there was uncertainty as to what the actual stimulation contributed and whether acupuncture helped prevent relapse (Vincent 1987). Needles usually remain in position for the duration of a treatment session (often lasting 15 . to the above needling. Lewith criticised this review and argued that trials in which the controls received needling in inappropriate sites were likely to underestimate the effects of acupuncture: the control procedure was not inactive since needling random sites could trigger the release of endorphins (Lewith 1995). either small seeds may be attached to the ear with adhesive tape. while acupuncture appears to be promising. . specially designed indwelling needles may be inserted. Such studies were also included in the review.

Description of studies See: Table of included studies. Confidence intervals were set at 95%. giving a total of 20 controlled studies for analysis (see Table of Included Studies). Repeated comparisons were made between acupuncture and different control procedures (i. In addition. SMOKING & HEALTH. When more than one control group was used. Methods of the review Data for smoking cessation rates early after treatment (the first recorded. authors were contacted to provide missing data.e. HEALTH PLANNING & ADMINISTRATION. each with its own control group. another intervention or no treatment.e. for smoking cessation. data from control groups were combined in the subsequent comparison of different methods of acupuncture. two groups with different treatment procedures. Martin (1981) and Parker (1977) both reported parallel studies. relevant references were obtained from published reviews. but less than 6 weeks) and at 6 and 12 months were extracted from the reports by ARW and HR independently. 2 comparisons were performed. and no intervention) and between different techniques of acupuncture. However. counting all drop-outs as smokers. The three time-points were selected in an attempt to identify separately the possible effects of acupuncture on a) cessation in the acute withdrawal period. Therefore. and b) sustained abstinence. Where necessary the published data have been recalculated on an intention-to-treat basis i. Where possible. very few studies used withdrawal symptoms as an endpoint. but in any case less than 6 weeks) and after 6 and 12 months. SOCIAL SCISEARCH. data from each of these groups have been entered separately. DISSERTATION ABSTRACTS. Data have been extracted (where they are presented in the report) on early outcome (i. The review has not been limited to studies where the outcome was confirmed biochemically (see 'Methodological quality'). first measure after the treatment. i. Table of excluded studies 18 reports were found of studies which qualified for inclusion in the review. Data on withdrawal symptoms were not extracted.e. Sustained smoking cessation was chosen in preference to point prevalence where these figures were available. sham acupuncture. EMBASE. In each case a weighted estimate of the OR (with a positive outcome shown as >1) was calculated using the fixed effects model. other active treatment control. . clinical trials and conference abstracts. Subjects lost to follow-up were regarded as having continued smoking. PSYCLIT. However. Types of studies All randomised controlled trials comparing acupuncture with either sham acupuncture. Disagreements were resolved by discussion. one using the data most favorable to acupuncture and the other using the data least favorable.e. Search strategy for identification of studies See: Collaborative Review Group search strategy All publications containing the terms "smoking" and "acupuncture" were identified using computerised searches of MEDLINE.Types of outcome measures Only complete abstinence from smoking was considered. BIOLOGICAL ABSTRACTS and DRUG (a database maintained by the Alcohol and other Drugs Council of Australia). as well as smoking and health bulletins and bibliographies. This situation occurred with Circo 1985 and Cottreaux 1983. The reviewers were not blinded.

and 1.11 (95% CI 0.61 to 1.99 to 1. Acupuncture appeared to be superior to no intervention in the early results (OR 5. The OR for early outcomes was 1.90 to 2. Labadie (1983) randomised subjects by alternation.87 (95% CI 0.Initial group sizes for the study by Martin (1981) were not available in the published report and were obtained from the authors. even if the word 'blind' was not specifically mentioned by the author.88. there were no differences in outcome at any time point. Martin (1981) and Lagrue (1977) randomised subjects in groups in order to prevent individuals who were receiving different procedures from mixing together and attempting to guess their group allocation. In view of the lack of information on methods of randomisation.82 to 1. Methodological quality See: Table of included studies We assessed four dimensions of study design which may lead to bias in studies of smoking cessation: a) reporting of method of randomisation and allocation concealment b) blinding of subjects to treatment status c) verification of cessation d) duration of outcome. the OR after 6 months was 1. Acupuncture was only compared with no intervention in 3 studies.49).01). After 6 months the OR was 1. only 5 of the 16 studies measured outcomes at 12 months.62 to 1.63 to 1. but there was no .76 (95% CI 0. Lamontagne 1980 and White 1998). 0.02) using the least favourable data. and Waite 1998 measured urinary cotinine concentrations.22 (95% CI 0. cessation at 12 months is considered the most important outcome.66 to 13. Results for the different arms of the study by Clavel (1990) were obtained from the authors. with the least favourable data. b) Blinding A study was adjudged to be single-blind if it involved some form of sham therapy that was designed to be indistinguishable to the participant. To avoid this.80 (95% CI 0. One trial (Lagrue.35) using the most favourable data.54 to 1.72 to 1.08). Even if subjects are blinded. Single-blinded studies appear in the comparisons 'Acupuncture vs sham acupuncture'. 1977) achieved blinding of the therapist by training a novice to use the two interventions without knowing which was genuine.02 (95% CI 0. d) Duration of smoking cessation Since sustained cessation is the prime object of anti-smoking programmes. we did not assign a formal quality score to the studies. He 1997 measured serum cotinine.11) and after 12 months 1. minimal or standardised interaction between therapist and patient is a recognised method of reducing bias in acupuncture research. However. they may be influenced by the interaction with the practitioner.05 (95% CI 0. None of these methods is regarded as true randomisation. 95% CI 2. Achieving full double-blinding is problematic in acupuncture studies. This procedure was adopted in 4 studies (Gilbey 1977.24) or. Results • List of comparisons Acupuncture was not superior to sham acupuncture in smoking cessation at any time point considered in this review.43). The respective ORs for early outcomes were 0.38 (95% CI 0. c) Outcome measure verification Smoking cessation was verified by biochemical testing in four of the trials: Clavel 1985 and White 1998 used a carbon monoxide meter. when acupuncture was compared with other anti-smoking interventions. He 1997. The studies varied considerably in methodology as well as the technique of acupuncture used. Similarly. a) Randomisation and concealment Only one report included sufficient details to be certain whether correct method of randomisation with adequate concealment was used (White 1998). and Steiner (1982) used a matched pairs design.94) and after 12 months the OR was 0.

ear acupuncture and prolonged ear acupressure. Animal experiments have also suggested that acupuncture might have a place in the acute withdrawal syndrome (Cheng 1980.44 (95% CI 1. The comparisons of acupuncture and sham acupuncture reveal three studies with results that are strongly positive and clearly different from all other results (He 1997.24). The results with different techniques did not show any one particular method (i. . No explanation for this difference can be identified in the study by Lacroix.30 to 3. Investigations should also consider whether acupuncture may lead to a reduction of nicotine withdrawal symptoms. It would seem important to study the possible effect of acupuncture in the acute stages of nicotine withdrawal. and this deserves further research. It is possible that acupuncture stimulation that is both intensive and continuous may have an effect which is not seen with more limited treatment. the majority of studies neither reported how randomisation was performed nor verified smoking cessation biochemically.99. The study by He 1997. OR 2. Discussion Acupuncture was not shown to be superior to sham acupuncture or any other intervention in smoking cessation. Reviewers' conclusions Implications for practice There is no evidence for the specific effectiveness of acupuncture in smoking cessation greater than a placebo effect. 95% CI 0. however. auricular acupuncture or non-auricular acupuncture) to be superior to control intervention at any timepoint. However. In particular. Waite 1998).difference at 6 months (OR 0. involved a combination of acupuncture approaches. However such biases might be expected to exaggerate the effects of acupuncture rather than underestimate them. White 1998 measured withdrawal symptoms in those who were successful in stopping smoking and found no effect of acupuncture compared with sham. It appears that acupuncture. The sensitivity of the results to study quality was not tested because of the problems in assigning formal quality scores to this set of studies. Implications for research Future research should concentrate on using adequate stimulation. The studies included in this review are subject to a number of biases. The study by Waite 1998 involved ear acupuncture and prolonged ear acupressure. The effect of prolonged ear acupressure on withdrawal symptoms remains untested. Clavel 1990 made an attempt to measure withdrawal symptoms but less than a quarter of the subjects completed the questionnaires. Lacroix 1977. Ng 1975).15 to 5. Choy 1978. It should be emphasised that the initial observation of an effect of acupuncture in dependency was in patients who were in the acute stage of opiate withdrawal (Wen 1973) . like some other interventions. Potential conflict of interest AW and EE are authors of a trial included in this review. may be better than doing nothing in order to aid smoking cessation.e. this conclusion is based on only 3 studies. Changes in opioid peptides accompanied these observations (Clement-Jones 1979). This negative conclusion limits rather than prohibits further investigation of the place of acupuncture in withdrawal from habituating substances.20). Han 1993. with body electroacupuncture. and the effect appears not to be sustained. The result at 12 months is dependent on only one study.

Fréour P.26:25-28 Clavel 1990 +NG (published data only) Cottraux 1983 (published data only) Cottraux JA. Hostmark AT.3:147-51. Behav Res Ther 1983. Benhamou S. Acupuncture and group therapy in stopping smoking. Gaz Méd de France 1983. Paoletti C. Lewith GT. A randomised 2x2 factorial design to evaluate different smoking cessation methods. and to Dr F Clavel of the Unite de Recherche en Epidemiologie des Cancers. Company-Huertas A. Cardillo R. Huynh Van Thao JP. Désintoxication tabagique: acupuncture et traitement médical. Helping people to stop smoking: randomised comparison of groups being treated with acupuncture and nicotine gum with control group. Berg JE.90:2741-2747 Lacroix 1977 (published data only) . Machin D. Bouvard M. Rev Epidém et Santé Publ 1992. Une étude de différents programmes de désintoxication tabagique portant sur près de 1000 volontaires recrutés dans la population générale : résultats à 1 mois. Practitioner 1984.228:341-344 He 1997 (published data only) He D. Am J Acup 1977. Paoletti C. Harf R. Prev Med 1997. Flamant R.38:133-138Clavel-Chapelon F. Riv Cardiol Prev Riabil 1985. Benhamou S.21(4):417424 Gilbey 1977 (published data only) Gilbey V. Oliveri M et al. We are grateful to Prof P Waite of the University of New South Wales. Dones JP.40:187-190Clavel F. Schbath J. Gulizia M.a controlled study. Gillet J. Smoking cessation with behaviour therapy or acupuncture .Acknowledgements We are grateful to Ruth Ashenden and Chris Silagy for kindly giving us access to their own review of acupuncture in smoking cessation as the basis for much of the present review. Australia for providing further data for the study by Martin and Waite (1981). Rev Epidém et Santé Publ 1990. Primi risultati di un ambulatori antifumo [First results of an anti smoke outpatient unit: Comparison among three methods]. Auricular acupuncture for smoking withdrawal. Gachie JP. References References to studies included in this review Circo 1985 (published data only) Circo A. Perchoc S. BMJ 1985. Villejuif France for providing data for the study Clavel (1990). Boissel J-P. Neumann B. Smoking cessation rates 4 years after treatment by nicotine gum and acupuncture. Clavel 1985 (published data only) Clavel F. Preventive Medicine 1997. Paoletti C.26:208-214 Labadie 1983 (published data only) Labadie JC. Tosto A. Benhamou S. Raciti S.5:239-247 Gillams 1984 (published data only) Gillams J. Effects of acupuncture on smoking cessation or reduction for motivated smokers.291:1538-1539 Clavel 1990 (published and unpublished data) Clavel F.

1998.128:405-408 Lagrue 1977 (published data only) Lagrue G. Resch K-L.5:363-366 Steiner 1982 (published data only) Steiner RP. Annable L. The use of acupuncture for smoking withdrawal. Besancon F. 1978 Boureau F. NZ Med J 1981. Etude de l'action spécifique de l'acupuncture dans la cure de sevrage tabagique. Man SC.93:421-423 Martin 1981b (published data only) Martin GP. 1998. Arch. Nouv Presse Med 1977. Le sevrage du tabac.9:966 Lamontagne 1980 (published data only) Lamontagne Y. Hay DL.93:421-423 Parker 1977a (published data only) Parker LN.Lacroix JC. Efficacité de l'acupuncture dans un essai comparatif. Randomized trial of acupuncture for nicotine withdrawal symptoms. Rempp M. NZ Med J 1981. Waite PME. of General Practice. Am J Acup 1977.34:177-187 Martin 1981a (published data only) Martin GP. 1978. Willer J-C. Acupuncture anti-tabagique. Clough JB.5:787-790 Leung 1991 (published data only) Leung JP.61:2155-2160 Waite 1998 (published data only) Waite NR. Ansquer JC. Acupuncture for smokers: lack of long-term therapeutic effect in a controlled study.158:2251-55 * indicates the major publication for the study References to studies excluded from this review Boureau. Can Med Assoc J 1980. Grillot A. Am J Acup 1977. La Nouvelle Presse medicale. Acupuncture and hypnosis compared: fifty-eight cases.10:107-121 Vandevenne 1985 (published data only) Vandevenne A. Resultats a court terme d'une etude comparative menee a double insu. Psychologia 1991. The efficacy of acupuncture as an aid to stopping smoking. The efficacy of acupuncture as an aid to stopping smoking. Sem Hôp Paris 1985. Intern. Am J Chin Med 1982.5:363-366 Parker 1977b (published data only) Parker LN. Mok MS. Gagnon MA. Med. Poupy JL. Davis AW.48:1487-90 White 1998 (published data only) White AR. The use of acupuncture for smoking withdrawal. Desintoxification tabagique par l'acupuncture: essai negative de blocage par la naloxone. Am J Clin Hypnosis 1978. Mok MS. A single-blind. Ernst E. Smoking cessation by auricular acupuncture and behavioral therapy. placebo-controlled trial of a simple acupuncture treatment in the cessation of smoking. British J.21(1):45-47 . Ann Méd Interne 1977. Waite PME. Acupuncture therapy for the treatment of tobacco smoking addiction.7(6):1401 MacHovec 1978 MacHovec FJ. Burghard G.

Lipton D. Proceedings of the Third World Symposium on Acupuncture and Chinese Medicine. Thoa NB.10:575-580 Schwartz 1988 . Albert CA. The treatment of tobacco addiction. Brewington 1994 Brewington V.82:305-309 Choy 1983 Choy DS. Eur J Pharmacol 1980. Effective treatment for smoking cessation. A preliminary clinical study of smoking treated by stitch-auriculo-acupuncture. Zhang RL. New York. Drug Alcohol Rev 1997. Arch Intern Med 1995. Lancet 1979. without showing cross-tolerance.1:28-29 Han 1993 Han JS. USA March 1975 Additional references Ashenden 1997 Ashenden R. Suppression of morphine abstinence syndrome by body electroacupuncture of different frequencies in rats. 2:380-383 Fuller 1982 Fuller JA. Pomeranz B.16:33-40. Comp Ther Med 1995.31:169175 Law 1995 Law M. Meltzer L. Acupuncture in heroin addicts: changes in met-enkephalin and beta-endorphin in blood and cerebrospinal fluid. Tang JL. Fung KP.68:477-481 Choy 1978 Choy YM.Man 1975 Man SC. Acupuncture as a detoxification treatment: an analysis of controlled research. Smith M. Modification of morphine-withdrawal syndrome in rats following transauricular stimulation: an experimental paradigm for auricular acupuncture. Lowry PJ. Am J Med 1983. Silagy CA. McLoughlin L. An analysis of the effectiveness of interventions intended to help people stop smoking. Suppression of narcotic withdrawals and plasma ACTH by auricular electroacupuncture. Drug Alcohol Depend 1993.11(4):289-307 Cheng 1980 Cheng RS. J Subst Abuse Treatment 1994. Lodge M. Leung KC. A meta-analysis of the effectiveness of acupuncture in smoking cessation. et al. Biochem Biophys Res Comm 1978. Fowler G. Tsang YF. Electroacupuncture treatment of morphine-dependent mice reduces signs of withdrawal.155:1933-1941 Lewith 1995 Lewith GT. Biological Psychiatry 1975. Douthitt TC. Smoking withdrawal and acupuncture. Lutzker L. Med J Aust 1982. Tso WW.75:1033-6 Clement-Jones 1979 Clement-Jones V. Lee CY et al.3:142-145 Ng 1975 Ng LKY. Yu G.

Issue 4. Acupuncture for some common disorders: a review of evaluative research.9:138-141 Cover sheet Acupuncture for smoking cessation Reviewer(s) Date of most recent amendment Date of most recent substantive amendment White AR.37:77-81 Wen 1973 Wen HL. Evaluation of acupuncture as a treatment for smoking. TREATMENT-OUTCOME. J R Coll Gen Pract CD000009 Cochrane Tobacco Addiction Group HM-TOBACCO Contact address Cochrane Library number Editorial group Editorial group code This review should be cited as : White AR. Rampes H. SMOKING-CESSATION.40:379-382 Vincent 1987 Vincent CA. England UK Intramural sources of support to the review • University of Exeter UK Keywords ACUPUNCTURE-THERAPY. TIMEFACTORS. Cheung SYC. Treatment of drug addiction by acupuncture and electrical stimulation. Acupuncture for smoking cessation (Cochrane Review). Kleijnen England UK • NHS Research and Development National Cancer Programme.16:135-142 Ter Riet 1990 Ter Riet G. RANDOM-ALLOCATION. ODDS-RATIO.white@exeter. Ernst E. Ernst E 13 July 1999 17 June 1999 Dr Adrian White MA BM BCh Research Fellow Department of Complementary Medicine University of Exeter 25 Victoria Park Road Exeter UK EX2 4NT Telephone: +44 1392 424839 Facsimile: +44 1392 424989 E-mail: a. Rampes H. In: The Cochrane Library.Schwartz JL. . Knipschild P. Asian Med J 1973. Oxford: Update Software. Br J Gen Pract 1990. Am J Acupuncture 1988. RANDOMIZED-CONTROLLED-TRIALS. A meta-analysis of studies into the effect of acupuncture on addiction. Richardson PH. 1999. Sources of support Extramural sources of support to the review • NHS Anglia and Oxford Region Research and Development Programme.

00 Auricular acupuncture vs all controls (6 months) 04. NICOTINE / therapeutic-use. HUMAN Tables & Graphs • • • • MetaView graphs List of comparisons Table of included studies Table of excluded studies List of comparisons Fig 01 ACUPUNCTURE VS SHAM ACUPUNCTURE 01.00 Early 01.PUBLICATION-BIAS.01.00 6 months 02. COMPARATIVE-STUDY.00 6 months 03. SAMPLE-SIZE.00 12 months Fig 03 ACUPUNCTURE VS NO TREATMENT CONTROLS 03.02.00 Non-auricular points vs all controls (early) 04.00 12 months Fig 04 COMPARISON OF DIFFERENT TECHNIQUES Auricular acupuncture vs all controls (12 months) Tables of other data Tables of other data are not available for this review Table of included studies St Method Participants Interventions Outcomes Notes .00 Auricular acupuncture vs all controls (early) 04.00 Early 03.00 Non-auricular acupuncture vs all controls (12 months) 04.01. PLACEBO-EFFECT.00 6 months 01.03.00 Non-auricular acupuncture vs all controls (6 months) 12 months Fig 02 ACUPUNCTURE VS OTHER INTERVENTION CONTROLS SUBSTANCE-WITHDRAWAL-SYNDROME / therapy.01.05.00 Early 02.

with estimated weekly comparison of genuine or placebo for 1 month acupuncture vs nicotine gum Validation: nil sham Both given on days acupuncture. by time-switch expired air CO All groups also concentration was received 3 one-hour tested in half of sessions of group those claiming therapy in first success month 996 adults over 18. 7 and 28 with placebo gum entered in this study and arms with nicotine gum in Clavel 1990 +NG The comparison of acupuncture v nicotine gum was performed . per advertisement Randomisatio n method: not stated Cl Country: av France el Recruitment: 19 Community 90 volunteers responding to circulated leaflet Randomisatio n method: not stated 2x2 factorial design All participants Reported received cessation. for 30 days c) acupuncture to 9 ear points ('Nogier' anti-smoking) given 6 hours after stopping smoking. method of recruitment unclear Randomisatio n method: not stated 90 adults. arms 0. no inclusion or exclusion criteria reported Cl Country: av France el Recruitment: 19 Community 85 volunteers. timecounselling in point unspecified addition to: (we assume enda) illustration of-treatment) material Validation: none b) medical treatment combining vitamins with herbal extract (Hawthorn). at with lock controlled 13 months.ud y Ci Country: Italy rc Recruitment: o from patients 19 with 85 cardiovascular disorders. a) facial Sustained Later results were smoking >10 acupuncture. repeated after 4 days and a further 7 days. combined with 3 indwelling needles for 15 days 651 adults a) facial Sustained smoking >5 acupuncture. with abstinence at 1 reported as Clavel cigs/day genuine or placebo and 13 months. 1990. long-term nicotine gum and after 4 years follow-up as b) sham 'Need for Clavel 1997 acupuncture (wrong cigarette' Analysis: for points). single cessation at one cigs/day session and 13 months b) nicotine gum Validation: none c) cigarette case at one month.

6. 1 month years week and 3 months b) indwelling needle Validation: none in inactive auricular point ('Kidney') for 1 week H Country: e Norway 81 adults smoking a) indwelling needle Sustained >50 cigs/week for in active auricular abstinence at 4 5 years point ('Lung') for 4 weeks. weeks and 6 months b) indwelling needle Validation: none in inactive auricular point (as far from 'Lung' as possible) for 4 weeks c) group therapy sessions. 3 Validation: none weekly sessions c) placebo capsules prescribed at 2 consultations d) waiting-list control (assessed at 12 months only) Some authors regard 'Kidney' point (used as a control) as an effective treatment for dependency 92 subjects aged a) indwelling needle Sustained 30-39 who smoked in active auricular abstinence at 1 >15 cigs/day for 3 point ('Lung') for 1 week. acupuncture. 9 b) facial and 12 months. 3 months. smoking >10 cigs/day for 2 years a) behaviour Sustained therapy. weekly for abstinence at 2 3 weeks weeks. one hour/ week for 4 weeks 46 adults smoking Both groups Abstinence at 1 Standardised for at least 5 years. and 3.between 'genuine acupuncture and placebo gum' group and 'sham acupuncture and genuine gum' group Cl See Clavel av 1990 el Used to enter 19 results of 90 Acupuncture + plus nicotine N gum vs Sham G acupuncture plus nicotine gum C Country: ot France tr Recruitment: au Community x volunteers 19 responding to 83 TV and radio adverts Randomisatio n method: not stated Gi Country: lb Canada ey Recruitment: 19 Community 77 volunteers responding to newspaper adverts Randomisatio n method: not stated Gi Country: UK lla Recruitment: m volunteers s responding to 19 poster in 84 health centre Randomisatio n: sealed envelopes 558 French citizens. aged 1850. received a week after the last interaction .

breast. fortnightly for 3 months. coronary b) using sham (Serum n: drawing lots heart disease.19 Recruitment: daily average of combination of acupuncture 97 employees 10-30 cigarettes in body treatment (point recruited the last year.treating fibrinogen and replacement feeding musculoskeletal lipid peroxide conditions were also 6 treatments over 3 measured) weeks Daily cigarette Manual and consumption. b) medical Validation: none treatment (advice plus benzodiazepine. according to group. monthly for a year a) facial Abstinence at 3 acupuncture. weekly for Validation: none 3 weeks b) sham La Country: 117 smokers cr France (criteria not oi Recruitment: specified) x not stated 19 Randomisatio . Randomisatio diabetes. no electroacupuncture. prevalence) through other form of ear acupuncture Validation: internal treatment for and ear cessation advertisement smoking cessation: acupressure: confirmed by through no current a) using genuine serum cotinine occupational acupuncture points described for and thiocyanate health service Exclusions: smoking cessation concentrations. not stated smoking at 8 whether repeated weeks and 1 year. lobeline and a 'detoxicant') Both groups followed up weekly for 1 month. 6 plant questionnaire seeds were placed on either a) 'correct' or b) 'incorrect' points in the ear. and retained in place with adhesive tape: subjects were instructed to press on each seed 100 times on 4 occasions each day La Country: 130 smokers ba France (criteria not di Recruitment: specified) e Community 19 volunteers 83 attending antismoking clinic Randomisatio n: by alternation a) acupuncture to Abstinence and auricular and body reduction of points. weeks bilateral. electrical taste for tobacco stimulation were the and desire to same in the 2 smoke were groups assessed by In addition. points described for concentrations of with pregnancy.

80% reduction in ue Recruitment: specified) repeated after 1 consumption at 1 19 not stated week week 77 Randomisatio b) sham Validation: none n: allocated by acupuncture. smoking auricular points weeks.acupuncture. on Recruitment: between 15 and 50 ('Zero' and 'Lung') and 6 months. and 6 and radio and 'Lung') for 7 months. ta Community cigs/day. adverts days or until they Randomisatio became n method: not uncomfortable. for supervision of the needles c) waiting-list control M Country: New 132 smokers a) indwelling Abstinence and ar Zealand (criteria not needles to effective reduction in tin Recruitment: specified) auricular points cigarette 19 Community ('Lung' and consumption at 3 81 volunteers 'hunger') for 3 weeks. not taking b) acupuncture to mean smoking gn volunteers drugs. weekly for 3 weeks La Country: 154 smokers a) facial Abstinence and gr France (criteria not acupuncture. 3. since innervated by the vagus nerve . and in good body points used rates for 14 day e responding to health for 'relaxation' periods during 19 newspaper c) self-monitor and study 80 advert report back Validation: none Randomisatio All subjects given 2 n method: not appointments 1 stated week apart Le Country: Hong 95 subjects who a) 10 daily sessions Abstinence and un Kong had smoked for at of behaviour percentage g Recruitment: least 1 year and therapy lasting 1. 3 months a Randomisatio weeks.5 reduction in 19 Community were motivated to hours consumption 91 volunteeers stop b) Indwelling immediately after responding to needles in auricular treatment and at newspaper points ('Shenmen' 1. 10 stated attendances in total. bilateral. plus and 6 months n: in groups. group repeated after 1 week La Country: 75 subjects aged a) acupuncture to Abstinence at 2 m Canada 20-50. 3 months. electroacupuncture Validation: nil method not for 20 minutes to stated points in the hand and the ear at the second attendance b) indwelling needles to ineffective auricular points ('elbow' and 'eye') 77 n method: not stated Practitioner specially trained to give both treatments without knowing which was active (ie truly double-blind study) Poor choice of acupuncture control procedure. since anti-smoking effect of 'relaxation' treatment cannot be ruled out Some authors would consider 'elbow' and 'eye' points (used as controls) as possibly effective.

needle consumption at 4 consecutive years. 3 months weeks and 6 months b) indwelling Validation: nil needles to ineffective auricular points ('elbow' and 'eye') for 3 weeks 20 smokers a) indwelling Abstinence and (unspecified) needles placed in reduction in effective auricular consumption at 6 points ('Shemmen' weeks and 'Lung') Validation: none b) indwelling needles placed in points considered inactive ('Shoulder' and 'Eye') Needles replaced in both groups twice weekly for 3 weeks 21 smokers a) electrical Abstinence and (unspecified) stimulation to reduction in effective auricular consumption at 6 points ('Shemmen' weeks and 'Lung') Validation: none b) electrical stimulation to points considered inactive ('Shoulder' and 'Eye') Both groups treated for 20 minutes twice weekly for 3 weeks 32 subjects over a) acupuncture to Abstinence and 21. sex. weeks not pregnant and Validation: none not on chronic pain b) sham medication or acupuncture to mood-altering nearby areas drugs without needling Selected from 82 sensation volunteers. since innervated by the vagus nerve Some authors would not agree that 'shoulder' and 'eye' points are 'inactive' Some authors would not agree that 'shoulder' and 'eye' points are 'inactive' Subjects were not advised to stop smoking at any particular time. but to 'follow your motivation and appetite to the best of your ability' . Both interventions matched according given twice weekly to age. method not stated Pa Country: USA rk Recruitment: er Vounteers 19 from hospital 77 employees a Randomisatio n method: not stated Pa Country: USA rk Recruitment: er Vounteers 19 from hospital 77 employees b Randomisatio n method: not stated St Country: USA ei Recruitment: ne Community r volunteers 19 responding to 82 newspaper and radio adverts Randomisatio n: matched pairs.M Country: New 128 smokers ar Zealand (unspecified) tin Recruitment: 19 Community 81 volunteers b Randomisatio n: in groups. sensation achieved. no a) indwelling Abstinence and needles to effective reduction in auricular points cigarette ('Lung' and consumption at 3 'hunger') for 3 weeks. one of each pair randomly assigned. smoking over genuine body and cigarette 20 cigs/day for 2 ear points. and for 2 weeks cigarette consumption a) acupuncture to 3 Abstinence (pointauricular and 2 prevalence) at 6 Some authors would consider 'elbow' and 'eye' points (used as controls) as possibly effective. method not stated Va Country: 200 self-referred nd France smokers.

by placement of a previous seed on the needle acupuncture site held in place with adhesive tape. 10 and 20 78 adults over 18 Both groups Cessation at 6 years old who received one 20months (point were smoking at minute session of prevalence) least 10 cigarettes acupuncture with Validation: urinary a day. breastsealed opaque feeding. 6 months b) sham and 1 year acupuncture to nearby areas both interventions given on days 1.ev Recruitment: en volunteers ne attending anti19 smoking clinic 85 Randomisatio n: random number table (not stated to be concealed) W Country: UK ait Recruitment: e community 19 volunteers 98 recruited by advertisement s in on-line news pages. 4. lung point in ear b) control group. posters in hospital and word of mouth. Participants were instructed to keep the seed in place as long as they found it helpful and press it when they experienced the desire to smoke Points used were: a) active group. cardiac envelopes. Stratified by gender criteria stated body points weeks. not on recognised acupuncture point a) acupuncture with Sustained electrical cessation at 2 stimulation to lung weeks point in both ears Validation: b) sham expired air carbon acupuncture monoxide consisting of either concentration needle or carbon Withdrawal pad placed over the symptoms mastoid bone assessed by attached to sham Visual Analogue (inactivated) Scale stimulator Interventions were given on day 1. minimal interaction by acupuncturist All counselling by blinded nurse W Country: UK 76 adults over 21 hit Recruitment: years smoking at e community least 15 cigarettes 19 volunteers daily 98 from media Exclusions: invitation previous Randomisatio acupuncture. electrical cotinine Exclusions: cardiac stimulation followed pacemaker. known opened bleeding tendency immediately before intervention . n method: pregnancy. pacemaker. 3 and 7 of the smoking cessation Credibility of interventions tested by questionnaire Standardised. medial aspect of the patella. Randomisatio n method: not stated.

the other with naloxone.Table of excluded studies Study Reason for exclusion Bourea This study compared 2 groups who both received identical acupuncture following an u. 2 hypotheses are tested simultaneously: does acupuncure help smoking cessation by releasing endogenous opioid peptides? MacHo This study does not specify that the subjects were randomised vec 1978 Man Subjects were allocated by place of residence. not randomly 1975 The Cochrane Library . 1978 injection: one group were injected with saline. Therefore.

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