Intervention Review

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Acupuncture and related interventions for smoking cessation

  1. Adrian R White1,*,
  2. Hagen Rampes2,
  3. Jian Ping Liu3,
  4. Lindsay F Stead4,
  5. John Campbell5

Editorial Group: Cochrane Tobacco Addiction Group

Published Online: 23 JAN 2014

Assessed as up-to-date: 26 NOV 2013

DOI: 10.1002/14651858.CD000009.pub4


How to Cite

White AR, Rampes H, Liu JP, Stead LF, Campbell J. Acupuncture and related interventions for smoking cessation. Cochrane Database of Systematic Reviews 2014, Issue 1. Art. No.: CD000009. DOI: 10.1002/14651858.CD000009.pub4.

Author Information

  1. 1

    Plymouth University Peninsula Schools of Medicine and Dentistry, Primary Care, Plymouth, UK

  2. 2

    University of Toronto, Department of Psychiatry, Toronto, Ontario, Canada

  3. 3

    Beijing University of Chinese Medicine, Centre for Evidence-Based Chinese Medicine, Beijing, China

  4. 4

    University of Oxford, Nuffield Department of Primary Care Health Sciences, Oxford, UK

  5. 5

    Peninsula Medical School University of Exeter, Department of General Practice and Primary Care, Exeter, UK

*Adrian R White, Primary Care, Plymouth University Peninsula Schools of Medicine and Dentistry, 25 Room N32, ITTC Building, Tamar Science Park, Plymouth, PL6 8BX, UK. adrian.white@pms.ac.uk.

Publication History

  1. Publication Status: New search for studies and content updated (no change to conclusions)
  2. Published Online: 23 JAN 2014

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Characteristics of included studies [ordered by study ID]
Antoniou 2005

MethodsRandomized trial of electrostimulation

Country: Greece

Recruitment. no details


ParticipantsSmokers (no other details)


InterventionsSingle application of an electrical probe to the ear, (duration not stated) giving

a) electrical stimulus with current intensity between 12-20 mAmp, or b) no current


OutcomesSmoking cessation at 12 months, no details on how data were collected or verified


NotesAbstract only. 390 smokers randomised, but group sizes at baseline not stated


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskrandomized in a 2:1 manner

Allocation concealment (selection bias)Unclear riskno details

Blinding (performance bias and detection bias)
All outcomes
Unclear riskdescribed as 'double-blind' in the title, but stimulation was at a level that could be detected in the intervention group; blinding was not checked

Incomplete outcome data (attrition bias)
All outcomes
High risk390 smokers enrolled, 339 evaluated. No group size at baseline so dropouts cannot be accounted for by allocation group

Other biasUnclear riskno baseline details

Aycicegi-Dinn 2011

MethodsRandomized trial of electrostimulation

Country: Turkey

Recruitment: media advertisements & personal contact


Participants47 smokers aged 18 to 65 scoring ≥5 on FTND


Interventionsa) Three sessions of auriculotherapy with electrical stimulation (points, stimulation parameters and duration not specified; use of surface electrodes implied, not stated; not stated whether uni- or bilateral) at 0, 2 days & 3 weeks

b) Sham therapy (device turned off) on same schedule


OutcomesCessation 30 day after last treatment. CO validation planned but not used due to low quit rates. Average CO levels reported


NotesControls offered active treatment after 3rd session so longer term outcomes not used


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)High risk"we were forced to match participants on two key variables (i.e., age and educational level) after approximately 30 patients had been [randomly] assigned to treatment or placebo groups"

Allocation concealment (selection bias)High riskSee above

Blinding (performance bias and detection bias)
All outcomes
High risk"after the initial treatment session, research technicians were not blind to group status. Research Technicians were not aware of the patients’ group status when conducting interviews and administering measures during the initial baseline assessment and treatment session."

Incomplete outcome data (attrition bias)
All outcomes
Low risk1 active group lost at 30 day follow-up

Other biasLow riskNo significant differences between groups; but "placebo group more likely to report that their spouses/partners used tobacco" (ns trend)

Bier 2002

MethodsRandomized trial of acupuncture

Country: United States
Recruitment: media advertisements


Participants141 smokers aged 18 or over, at least one previous attempt to stop, no major medical condition, not taking listed drugs e.g. phenothiazines, ephedrine


Interventionsa) true acupuncture
b) true acupuncture and intensive education programme
c) sham acupuncture plus intensive education programme
True acupuncture consisted of 5 auricular points and LI4. Sham acupuncture consisted of sham points 5mm away from real points. In both groups, needles were inserted for 30 minutes, and not stimulated. Acupuncture and sham were given in 20 sessions in 4 weeks.
Educational programme was 7 x 1.5 hour sessions over 5 weeks


OutcomesReported smoking cessation at 1, 3, 6, 12, 15 and 18 months.
Outcome not validated.
Percentage decrease in cigarette consumption also reported.
Depression and anxiety scores analysed, not reported in detail.


NotesData inconsistent and cannot be interpreted, not included in meta-analysis


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskRandom number table

Allocation concealment (selection bias)Unclear risk 'Randomization ... conducted by a research associate blind to treatment assignment'

Blinding (performance bias and detection bias)
All outcomes
Low riskGroups b) and c) blinded: 'participants remained unaware of their [acupuncture] treatment group assignment'

Incomplete outcome data (attrition bias)
All outcomes
High riskNumbers lost substantially different in different groups

Other biasLow riskNo baseline differences for important variables

Cai 2000

MethodsRandomized trial of laser therapy

Country: Singapore
Recruitment: not stated


Participants330 smokers, aged 12 to 18 smoking 3 yrs and minimum 5 cigs/day


Interventionsa) laser (wavelength 633 nm, 2.5-3mW for total 4 minutes) or b) deactivated laser to points in left ear, 12 times in 4 weeks. Patients wore blindfolds during treatment.


OutcomesSmoking cessation immediately after and 3 months later reported. Validation: expired air CO concentration taken after 6th and 11th treatments (not at the first measurement point, which was after 12th treatment) and at 3 month follow-up


NotesTherapist not blinded: blinded assessor.

Some indexing systems cite authors as Yiming C, Changxin Z, Ung WS, Lei Z, Kean LS


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskBlock randomization, no details given

Allocation concealment (selection bias)Unclear risk No information given

Blinding (performance bias and detection bias)
All outcomes
Low riskParticipants blindfolded; independent observer not involved in the treatment

Incomplete outcome data (attrition bias)
All outcomes
Low riskDropout rates 19%, similar in both groups

Other biasLow riskNo meaningful differences in baseline variables

Circo 1985

MethodsRandomized trial of acupuncture and continuous stimulation

Country: Italy
Recruitment: from patients with cardiovascular disorders, method of recruitment unclear


Participants90 adults (80 male), no inclusion or exclusion criteria reported


InterventionsAll participants received information and personalized advice, in addition to:
a) illustration material
b) medical treatment combining quinine ascorbate, vitamins and herbal extract (hawthorn), for 30 days
c) auricular acupuncture to 9 ear points ('Nogier' anti-smoking programme) given for 15 minutes, 6 hours after stopping smoking and repeated after 4 and a further 7 days; combined with 3 indwelling auricular needles for 15 days. Other ear points (Shenmen, Sympathetic, Lung) could be added bilaterally


OutcomesReported cessation, time-point unspecified (we assume end-of-treatment)
Validation: none reported


Notes[in Italian]. Combine groups a) and b) as Intervention of unknown effectiveness


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskNo details reported: 'suddivisi in modo random'

Allocation concealment (selection bias)Unclear risk No information

Blinding (performance bias and detection bias)
All outcomes
High riskOpen study

Incomplete outcome data (attrition bias)
All outcomes
Low riskOutcomes reported for all included smokers

Other biasUnclear riskNo baseline variables reported

Clavel 1985

MethodsRandomized trial of acupuncture

Country: France
Recruitment: Community volunteers, per advertisement


Participants651 adults smoking >5 cigs/day


Interventionsa) facial acupuncture using two points bilaterally, single session
b) nicotine gum - 105 pieces of 2mg gum
c) cigarette case with lock controlled by time-switch
All groups also received 3 one-hour sessions of group therapy in first month


OutcomesSustained cessation at 1 and 13 months
Validation: none at 1 month; at 13 months, expired air CO concentration was tested in half of those claiming success (method of selection not reported)


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear risk'Balanced randomization' no further details

Allocation concealment (selection bias)Unclear risk No details

Blinding (performance bias and detection bias)
All outcomes
Unclear riskParticipants not blinded. No report of blinding observer

Incomplete outcome data (attrition bias)
All outcomes
Unclear riskDropout rates over 80%, higher in control group

Other biasLow riskNo significant differences in baseline variables

Clavel 1992

MethodsRandomized trial of acupuncture

Country: France
Recruitment: Community volunteers responding to circulated leaflet
2x2 factorial design
(Smokers in this study who were randomized to active nicotine gum are represented by the study labelled 'Clavel 1992 +NG')


Participants515 adults aged over 18, smoking >10 cigs/day


Interventionsa) facial acupuncture to two points (GB8 and Bitong), with placebo nicotine gum
b) sham acupuncture (wrong points 2cm from the above), with placebo nicotine gum
Acupuncture given on days 0, 7 and 28


OutcomesSustained abstinence at 1 and 13 months. (Outcome at 4 years reported in Clavel 1997)
'Need for cigarette' estimated weekly for 1 month
Validation: nil


NotesThis study was first reported in French as Clavel 1990


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskNo details: 'Tirés au sort'

Allocation concealment (selection bias)Unclear risk No information

Blinding (performance bias and detection bias)
All outcomes
Low riskFactorial, double-dummy design; described as double blind; no details of blinding of the observer

Incomplete outcome data (attrition bias)
All outcomes
Unclear risk80% dropout at one month

Other biasUnclear riskNo description of baseline differences

Clavel 1992 +NG

MethodsRandomized trial of acupuncture

Country: France
Recruitment: Community volunteers responding to circulated leaflet
2x2 factorial design
(Smokers in this study who were randomized to placebo nicotine gum are represented by the study labelled 'Clavel 1992')


Participants481 adults aged over 18, smoking >10 cigs/day


Interventionsa) facial acupuncture to two points (GB8 and Bitong), with active nicotine gum (2mg dose, up to 30 pieces/day, during first 6 months)
b) sham acupuncture (wrong points 2cm from the above), with active nicotine gum (administration as above)
Acupuncture given on days 0, 7 and 28


OutcomesSustained abstinence at 1 and 13 months. (Outcome at 4 years reported in another publication)
'Need for cigarette' estimated weekly for 1 month
Validation: nil


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskNo details: 'Tirés au sort'

Allocation concealment (selection bias)Unclear risk No information

Blinding (performance bias and detection bias)
All outcomes
Low riskFactorial, double-dummy design; described as double blind; no details of blinding of the observer

Incomplete outcome data (attrition bias)
All outcomes
Unclear risk80% dropout at one month

Other biasUnclear riskNo description of baseline differences

Cottraux 1983

MethodsRandomized trial of acupuncture

Country: France
Recruitment: Community volunteers responding to TV and radio adverts


Participants558 French citizens, aged 18-50, smoking >10 cigs/day for 2 years


Interventionsa) facial acupuncture, 3 weekly sessions

b) behaviour therapy, weekly for 3 weeks

c) placebo capsules prescribed at 2 consultations, labelled 'Medel 50' with instructions to avoid alcohol and stating that an overdose would result in gastric side-effects
d) waiting-list control (assessed at 12 months only)


OutcomesSustained abstinence at 2 weeks, and 3, 6, 9 and 12 months
Validation: none


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskRandomization stratified by presence of smoker at home, but no further details

Allocation concealment (selection bias)Unclear risk No information

Blinding (performance bias and detection bias)
All outcomes
High riskOpen study, though the observers were blinded

Incomplete outcome data (attrition bias)
All outcomes
Unclear risk5% lost to follow up, 5% lost to follow up, included in ITT analysis

Other biasLow riskGroups balanced at baseline for several variables

Docherty 2003

MethodsRandomized trial of laser therapy

Country: Scotland
Recruitment: via social marketing campaign & general practitioners (GPs)


Participants355 smokers from a community with high levels of social deprivation, No other details in abstract


Interventionsa) Laser therapy. Duration and number of sessions not specified
b) Placebo laser

All participants received counselling and access to a telephone helpline


OutcomesCessation at 6 and 12 months, CO measured, cut off not specified


NotesAbstract only. No further information available


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskRandomized, no details given

Allocation concealment (selection bias)Unclear riskMethod not described

Blinding (performance bias and detection bias)
All outcomes
Low risk'Subjects and laser therapist blind'

Incomplete outcome data (attrition bias)
All outcomes
Unclear riskNo description of dropouts or explanation for different group sizes

Other biasUnclear riskNo baseline information reported

Fritz 2013

MethodsRandomized trial of electrostimulation

Country: USA

Recruitment: Veterans Affairs Medical Centres


Participants152 military veterans aged ≥19, smoking ≥10 cpd


Interventionsa) 5 weekly 20 min sessions of auriculotherapy (80Hz; Lung, Shen Men, Nicotine, Point Zero, and Palate), bilateral

b) Sham auriculotherapy (unit disabled)

All participants attended a stop smoking class before enrolment


OutcomesCessation at week 6 (point prevalence)

Validation: urine cotinine (<200 ng/mL)


NotesCotinine based abstinence were higher than self reported (i.e. some people admitting smoking did not have cotinine levels above cut off) so self reported used


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low risk"Permuted block assignments were generated … from a random-number generator in advance of the trial’s start date."

Allocation concealment (selection bias)Low risk"Treatment assignment was indicated inside sealed, sequentially numbered opaque envelopes, opened … at the time of randomization."

Blinding (performance bias and detection bias)
All outcomes
Low riskAll personnel with patient access remained blinded to which machine had been altered and which provided the stimulation.

Incomplete outcome data (attrition bias)
All outcomes
Low riskDrop out rate low and similar between groups, analysis not sensitive to alternative assumptions

Other biasHigh risk"Intervention group reported higher motivation to quit (p = 0.003). More patients in the active group (67%) believed they received the intervention than those in the placebo group (46%) (P = 0.03) at week 6."

Georgiou 1999

MethodsRandomized trial of electrostimulation

Country: England
Recruitment: general public, nursing staff, government employees
2x2x2 factorial design to test the following factors: electrical stimulation; stimulation frequency (constant or modulated); location (mastoid process as active, back as the control)


Participants265 adults smoking at least 10 cigs/day for 1 year


InterventionsEither electrical stimulation (0.150 msec biphasic pulse, 0.5 to 0.8 mA into 1 KΩ load) or sham (control, no output) stimulation; with either continuous 10Hz or modulated 7-14Hz current (both active); to disposable pre-gelled electrodes placed on either mastoid (active) or upper back (location control); total of 8 groups
Active groups: a) modulated current to mastoid process b) continuous current to mastoid
Control groups: c) modulated current to back d) continuous current to back. e) sham modulated current to mastoid f) sham modulated current to back g) sham continuous current to mastoid h) sham continuous current to back. After initial stimulation, home use as required for 7 days


OutcomesSmoking cessation at end of treatment, validated by expired air CO; withdrawal symptoms by VAS; follow-up data were collected for up to 12 months, but data are not presented by group


Notes18% dropouts, numbers in each group are unknown. Follow-up data given as aggregate only. No significant differences.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskTable of random numbers

Allocation concealment (selection bias)Unclear risk No information

Blinding (performance bias and detection bias)
All outcomes
Low riskParticipant blinded. 'Treatment was administered by a single clinician blinded ... to ... treatment'

Incomplete outcome data (attrition bias)
All outcomes
Low riskDropouts 18% 'Atrrition rates did not differ significantly across treatment conditions'

Other biasUnclear riskNo description of baseline differences between treatment groups

Gilbey 1977

MethodsRandomized trial of acupuncture (continuous stimulation)

Country: Canada
Recruitment: Community volunteers responding to newspaper adverts


Participants92 subjects aged 30-39 who smoked >15 cigs/day for 3 years


Interventionsa) indwelling needle in active auricular point ('Lung') for 1 week
b) indwelling needle in inactive auricular point ('Kidney') for 1 week


OutcomesSustained abstinence at 1 week, 1 month and 3 months
Validation: none


NotesSome authors regard 'Kidney' point (used as a control) as an effective treatment for dependency


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear risk'randomly assigned', no details

Allocation concealment (selection bias)Unclear risk No information

Blinding (performance bias and detection bias)
All outcomes
Low riskParticipants and person collecting the follow-up data were blinded

Incomplete outcome data (attrition bias)
All outcomes
Unclear riskNo information on dropout rate

Other biasHigh risk39% of treatment group and 65% of control group reported that they had been advised by their doctor to stop smoking

Gillams 1984

MethodsRandomized trial of acupuncture (continuous stimulation)

Country: UK
Recruitment: volunteers responding to poster in health centre


Participants81 adults smoking >50 cigs/week for 5 years


Interventionsa) indwelling needle in active auricular point ('Lung') for 4 weeks
b) indwelling needle in inactive auricular point (as far from 'Lung' as possible) for 4 weeks
c) group therapy sessions, one hour/ week for 4 weeks


OutcomesSustained abstinence at 4 weeks, 3 months, and 6 months
Validation: none


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskComputer programme

Allocation concealment (selection bias)Low risk Sealed envelopes containing cards defining the treatment group

Blinding (performance bias and detection bias)
All outcomes
Low riskParticipants in the two acupuncture groups blinded. Acupuncturist not blinded, and no blinded observer

Incomplete outcome data (attrition bias)
All outcomes
Low riskData collection was completed for all patients entered into the study

Other biasUnclear riskNo report of baseline differences

Han 2006

MethodsRandomized trial of acupuncture

Country: Heilongjiang province, China
Recruitment: Hospital based acupuncture clinic


Participants42 participants (25 male, 17 female); age:19-72 (female), 23-70 (male). Average age: 40 years; history of smoking > 10 years; 20-40 cigarettes per day


Interventions10 day course of treatment in both conditions
a) body + auricular acupuncture. Body points: tianmi point (the sensitive point on the line of lieque point and yangxi point); auricular points: mouth, lung, pizhixia, neifenmi, heart, thirst points
b) auricular acupuncture. Auricular points: mouth, lung, pizhixia, neifenmi, heart, thirst points.


OutcomesAbstinence at end of treatment sustained until 1 month follow-up


NotesAcupuncture vs acupuncture [in Chinese]


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskRandomly allocated, no details

Allocation concealment (selection bias)Unclear riskNo information

Blinding (performance bias and detection bias)
All outcomes
Unclear riskNo information

Incomplete outcome data (attrition bias)
All outcomes
Low riskNo cases lost to follow-up

Other biasUnclear riskNo information

He 1997

MethodsRandomized trial of acupuncture and continuous stimulation

Country: Norway
Recruitment: employees recruited by internal advertisement through occupational health service


Participants46 adults smoking for at least 5 years, daily average of 10-30 cigarettes in the last year; no other form of treatment for smoking cessation: no current acupuncture
Exclusions: diabetes, coronary heart disease, pregnancy, breast-feeding


InterventionsBoth groups received a combination of body electroacupuncture, ear acupuncture and ear acupressure:
a) using genuine points described for smoking cessation: Body: LU6, LU7; Ear: Shenmen, mouth, lung; Ear sustained acupressure: Shenmen, mouth, lung, trachea, hunger, endocrine
b) using sham points described for treating musculoskeletal conditions: Body: LI10, TE8; Ear: knees, lumbar vertebra, neck; Ear sustained acupressure: knees, lumbar vertebra, neck, shoulder, shoulder joint, buttock.
6 treatments over 3 weeks
Manual and electrical stimulation were the same in the 2 groups
In addition, 6 plant seeds were placed on either a) 'correct' or b) 'incorrect' points in the ear, according to group, and retained in place with adhesive tape: subjects were instructed to press on each seed 100 times on 4 occasions each day


OutcomesAbstinence at 1 week and 8 months after the last acupuncture treatment (sustained at each previous point). Outcomes at 5 years are also reported.
Validation: cessation confirmed by serum cotinine and thiocyanate concentrations. (Serum concentrations of fibrinogen and lipid peroxide were also measured)
Daily cigarette consumption, taste for tobacco and desire to smoke were assessed by questionnaire


NotesStandardized interaction
8 month data used in 6 month meta-analysis. 5 yr data used in 1 yr + comparison does not include participants lost to follow-up due to change of address etc

LI10 used in the control group was used as an active treatment point in another study


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low risk'Drawing lots with replacement'

Allocation concealment (selection bias)Unclear risk No information

Blinding (performance bias and detection bias)
All outcomes
Low riskParticipant blinded

Incomplete outcome data (attrition bias)
All outcomes
Low riskOnly 10% loss to follow-up, equal in the two groups

Other biasLow riskNo baseline differences

Huang 2012

MethodsRandomized trial of acupuncture and continuous stimulation

Country: China

Recruitment: volunteers, invitation letter


Participants60 smokers ≥ 15 cigs/day, aged 18-70, FTND >5


Interventionsa) Acupressure with vaccinia seed fixed to 5 auricular points [TF4, CO14, CO15, TG2P, AT4]. Participants had to apply 3-5 minute’s pressure 3-5 times a day. Active acupuncture at ‘Three-Needles’ [Tim Mee Point, Yang-xi Point (LI5) and Lie-que Point (LU7)], needles retained for 15 minutes after “deqi”. Daily for 6 days, then 6 times in 14 days.

b) Sham acupressure with sponge similar to vaccinia seed in colour and size. Instructed to apply pressure, as intervention group. Sham acupuncture by bringing the needle point in contact with skin without penetration to same points with the same course of treatment.


OutcomesReported smoking cessation at end of treatment and 3 months follow-up.

Outcome not validated by expired air CO

Other outcomes: cigarette consumption, Fagerstrom Test for Nicotine Dependence (FTND), Self-rating Tobacco Dependence Scale.


NotesClaimed no dropouts, no mention about any previous attempts to quit


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)High risk“Participants were randomly divided into the treatment group and placebo group according to their order of hospitalization in turn by the method of simple randomization”

Allocation concealment (selection bias)High riskAllocation cannot be concealed because patients are allocated alternately

Blinding (performance bias and detection bias)
All outcomes
Low riskSingle blinding (participants were blinded by covering the points with flexible dressing)

Incomplete outcome data (attrition bias)
All outcomes
Low riskOutcomes reported for all included smokers

Other biasLow riskNo significant differences in baseline variables

Kerr 2008

MethodsRandomized trial of laser therapy

Country: UK
Recruitment: media announcement


Participants387 motivated smokers without previous use of laser randomised. Excluded for age <16 years, pregnancy, uncontrolled Ischaemic heart disease, asthma, unstable diabetes mellitus and unstable epilepsy


Interventionsa) Low-level laser treatment (Omega, power output 50mW, wavelength 820 nm, pulse repetition 20 Hz, radiant exposure 24J/cm sq) for 1 minute to 4 auricular and 3 wrist points bilaterally, total duration 14 minutes: on days 1, 3, and 7, plus sham laser on day 14

b) same active laser used on days 1, 3, 7 and 14

c) sham laser inactivated by manufacturer and identical except for no laser output, on days 1, 3, 7 and 14


OutcomesSelf-reported smoking cessation at end of treatment and after 3 and 6 months


NotesAuthor provided additional data on group size at baseline. Data from group a) could not be used in meta-analysis (mixed interventions)


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskNot clear, but mentions use of random number table, selecting and allocating them sequentially to each of the study groups

Allocation concealment (selection bias)High riskAllocation of next patient could be ascertained from table

Blinding (performance bias and detection bias)
All outcomes
Low riskSham or inactive probe

Incomplete outcome data (attrition bias)
All outcomes
High risk23 lost before treatment, 24 did not complete treatment. Unequal dropouts, 38/47 were in group C. Effect is likely small bias in favour of intervention

Other biasUnclear riskNo baseline characteristics reported

Labadie 1983

MethodsRandomized trial of acupuncture

Country: France
Recruitment: Community volunteers attending anti-smoking clinic


Participants130 smokers (criteria not specified)


Interventionsa) medical treatment (advice plus benzodiazepine, lobeline and a 'detoxicant')

b) acupuncture to auricular and body points; not stated whether repeated
Both groups followed up weekly for 1 month, fortnightly for 3 months, monthly for a year


OutcomesAbstinence and reduction of smoking at 8 weeks and 1 yr
Validation: none


NotesControl data deemed as 'intervention of unknown effectiveness'.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)High riskBy alternation

Allocation concealment (selection bias)High risk (alternation)

Blinding (performance bias and detection bias)
All outcomes
High riskOpen study

Incomplete outcome data (attrition bias)
All outcomes
Low riskDropout during treatment a) 25% b) 17%. 8.5% loss to follow-up

Other biasUnclear risk Only age reported at baseline

Lacroix 1977

MethodsRandomized trial of acupuncture

Country: France
Recruitment: not stated


Participants117 smokers; the only inclusion criterion was the wish to stop


Interventionsa) facial acupuncture, 3 points on each side for 30 minutes, weekly for 3 weeks
b) sham acupuncture, 2 non-points on each side (duration not stated), weekly for 3 weeks

All smokers also given standardised advice


OutcomesAbstinence at 3 weeks
Validation: none


Notes[in French]


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskDescribed as randomised but no details presented

Allocation concealment (selection bias)Unclear risk No information

Blinding (performance bias and detection bias)
All outcomes
Low riskNot specifically described as blinded, but overtly designed for participant- (but not practitioner-) blinding

Incomplete outcome data (attrition bias)
All outcomes
Unclear riskDropout rate 16% in treatment group, 34% in sham/placebo group

Other biasUnclear riskNo baseline information

Lagrue 1980

MethodsRandomized trial of acupuncture

Country: France
Recruitment: not stated


Participants154 smokers (criteria not specified)


Interventionsa) facial acupuncture, repeated after 1 week
b) sham acupuncture, (using facial points called 'placebo' but not further described) repeated after 1 week

All smokers also given standardised advice


OutcomesAbstinence and 80% reduction in consumption at 1 week
Validation: none


NotesPractitioner specially trained to give both treatments without knowing which was active (i.e. a truly double-blind study) [in French]


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)High riskAllocated into groups of 5-7 receiving the same treatment

Allocation concealment (selection bias)High risk Groups were pre-arranged

Blinding (performance bias and detection bias)
All outcomes
Low riskTruly double-blind: both participant and practitioner blinded - practitioner was non-acupuncturist, specially trained for this study

Incomplete outcome data (attrition bias)
All outcomes
High riskover 20% dropout in both groups

Other biasUnclear riskNo baseline information

Lamontagne 1980

MethodsRandomized trial of acupuncture

Country: Canada
Recruitment: Community volunteers responding to newspaper advert


Participants75 subjects aged 20-50, smoking between 15 and 50 cigs/day, not taking drugs, and in good health


Interventionsa) acupuncture to auricular points ('Zero' and 'Lung')
b) acupuncture to body points used for 'relaxation'
c) self-monitor and report back
All subjects given 2 appointments 1 week apart. All smokers also given written advice on smoking cessation


OutcomesAbstinence at 2 weeks, 3 months, and 6 months; mean smoking rates for 14 day periods during study
Validation: none


NotesPoor choice of acupuncture control procedure, since anti-smoking effect of 'relaxation' treatment cannot be ruled out


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear risk'randomly' with no further details

Allocation concealment (selection bias)Unclear risk No information

Blinding (performance bias and detection bias)
All outcomes
Low riskAcupuncture control clearly designed to ensure blinding of participants, though not described as 'blind'

Incomplete outcome data (attrition bias)
All outcomes
Low riskOne smoker in each group dropped out

Other biasUnclear riskNo baseline information reported

Leung 1991

MethodsRandomized trial of acupuncture and continuous stimulation

Country: Hong Kong
Recruitment: Community volunteers responding to newspaper and radio adverts


Participants95 subjects who had smoked for at least 1 year and were motivated to stop


Interventionsa) 10 daily sessions of behaviour therapy lasting 1.5 hours
b) Indwelling needles in auricular points ('Shenmen' and 'Lung') checked every 7 days ; two introductory information sessions followed by eight attendances in total, for supervision of the needles; not stated whether the indwelling needles were in place throughout the course
c) waiting-list control


OutcomesAbstinence and percentage reduction in consumption immediately after treatment and at 1, 3, and 6 months.


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear risk'randomly assigned' no further details

Allocation concealment (selection bias)Unclear risk No information

Blinding (performance bias and detection bias)
All outcomes
High riskOpen study, no description of observer blinding

Incomplete outcome data (attrition bias)
All outcomes
Unclear riskAttrition 18%, some difference between groups

Other biasLow riskNo major differences at baseline

Li 2009

MethodsRandomized trial of acupressure (continuous stimulation)

Country: Shanghai, China
Recruitment: 140 smokers from the community. The clinical trial was carried out in the outpatient department of acupuncture-moxibustion in Tian Shan TCM hospital, Shanghai. 20 cases of healthy non-smokers were also recruited to provide data for normal levels of sulfocyanide in urine.
Statistics: Ridit test


ParticipantsInclusion criteria: smoking >1 year; > 10 cigs/day, desire to give up smoking in 3 months; age: l8-65 years old

Intervention group: 70 (52 male, 18 female), age ranging from l8-58 (38.23±9.79) years old; smoking duration:1-29 years (10.46±7.08); daily intake: l0-35 cigarettes (17.07±5.02).
Control group: 70 (55 male, 15 female), age ranging from 20-59 (38.26±9.56) years old; smoking duration: 1-30 years (10.67±7.60); daily intake: l0-33 cigarettes (16.97±5.03).
Baseline comparability: age, gender, smoking age, smoking amount.


InterventionsAcupressure using the seed of cowherb

a) auricular points: mouth, lung, shenmen, shenshangxian, stomach, neifenmi.
b) (control): auricular points: thyroid, shoulder, sciatic nerve, clavicle, cervical vertebrae, eye.

Seed applied to the main points in one ear and the accompanying points in the other ear: replaced every two days. Course of treatment: 20 days. Follow-up visit in 3 months.


OutcomesAbstinence at 20 days (early) and 3 months (not used in meta-analysis). Confirmed by concentrations of sulfocyanide of urine tested in the morning


NotesA sulfocyanide concentration of <(2.23±2.41)mg/L was observed in the non-smokers. Values above mean 2.23 mg/L were therefore taken to indicate smoking, i.e. that the intervention was not successful.

No intention-to-treat (ITT) analysis was applied.

3 month follow-up too short for long-term abstinence outcome [in Chinese]


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskThe cases are randomly allocated into the two groups, but method of sequence generation is not described.

Allocation concealment (selection bias)Unclear riskNo details

Blinding (performance bias and detection bias)
All outcomes
Unclear riskNo details

Incomplete outcome data (attrition bias)
All outcomes
Low riskNumber of participants with loss to follow-up reported; 1/70 in intervention group, 3/70 in control group

Other biasUnclear riskNo information reported

Martin 1981a

MethodsRandomized trial of acupuncture (continuous stimulation)

Country: New Zealand
Recruitment: Community volunteers


Participants126 smokers (criteria not specified)


Interventionsa) indwelling needles to 'effective' auricular points (lung and hunger) for 3 weeks
b) indwelling needles to 'ineffective' auricular points (elbow and eye)
Other groups with needling in the ankle or with cut-off studs were not conducted in parallel with the above and have been excluded from the review


OutcomesAbstinence and reduction in cigarette consumption at 3 weeks, 3 months and 6 months
Validation: nil


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskStudy run in three phases, randomisation method not described

Allocation concealment (selection bias)Unclear riskNo information

Blinding (performance bias and detection bias)
All outcomes
Low riskDescribed as single blind, and the interventions were appropriate

Incomplete outcome data (attrition bias)
All outcomes
Unclear riskDropout rate 22%, 31% overall

Other biasLow riskGroups similar in sex, age and smoking habits

Martin 1981b

MethodsRandomized trial of acupuncture (continuous stimulation)

Country: New Zealand
Recruitment: Community volunteers
Randomization: in groups, method not stated


Participants134 smokers (unspecified)


Interventionsa) indwelling needles to 'effective' auricular points (lung and hunger) for 3 weeks plus electroacupuncture for 20 minutes to LI4 in the hand and tongue point in the ear at the second attendance
b) indwelling needles to 'ineffective' auricular points (elbow and eye) plus electroacupuncture for 20 minutes to LI4 in the hand and tongue point in the ear at the second attendance
Other groups with needling in the ankle or with cut-off studs were not conducted in parallel with the above and have been excluded from the review


OutcomesAbstinence and reduction in cigarette consumption at 3 weeks, 3 months and 6 months
Validation: nil


Notes LI4 was used as an active intervention in other studies: but since it was given to both groups in this study, and only at week 2, it does not annul the comparison between 'effective' and 'ineffective' points.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskStudy run in three phases, randomisation method not described

Allocation concealment (selection bias)Unclear riskNo information

Blinding (performance bias and detection bias)
All outcomes
Low riskDescribed as single blind, and the interventions were appropriate

Incomplete outcome data (attrition bias)
All outcomes
Unclear riskDropout rate 22% in short term, 31% overall

Other biasLow riskGroups similar in sex, age and smoking habits

Parker 1977a

MethodsRandomized trial of acupuncture (continuous stimulation)

Country: USA
Recruitment: Volunteers from hospital employees


Participants18 smokers (aged 19 to 60 years, other characteristics unspecified)


Interventionsa) indwelling needles placed in effective auricular points ('Shenmen' and 'Lung')
b) indwelling needles placed in points considered inactive ('Shoulder' and 'Eye')
Needles replaced in both groups twice weekly for 3 weeks


OutcomesAbstinence and reduction in consumption at 6 weeks
Validation: none


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear risk'randomly' no further details

Allocation concealment (selection bias)Unclear risk No information

Blinding (performance bias and detection bias)
All outcomes
Low riskDesigned to be participant blind

Incomplete outcome data (attrition bias)
All outcomes
Low riskNo dropouts

Other biasUnclear riskBaseline data not reported

Parker 1977b

MethodsRandomized trial of acupuncture

Country: USA
Recruitment: Volunteers from hospital employees


Participants23 smokers (aged 19 to 60 years, other characteristics unspecified)


Interventionsa) electrical stimulation to effective auricular points ('Shenmen' and 'Lung')
b) electrical stimulation to points considered inactive ('Shoulder' and 'Eye')
Both groups treated for 20 minutes twice weekly for 3 weeks


OutcomesAbstinence and reduction in consumption at 6 weeks
Validation: none


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear risk'randomly' no further details

Allocation concealment (selection bias)Unclear risk No information

Blinding (performance bias and detection bias)
All outcomes
Low riskDesigned to be participant blind

Incomplete outcome data (attrition bias)
All outcomes
Low riskNo dropouts

Other biasUnclear riskBaseline data not reported

Pickworth 1997

MethodsRandomized trial of electrostimulation

Country: USA
Recruitment: 'from community'


Participants121 adults aged over 21 yrs, smoking >20/day for at least 1 yrs, no psychoactive medications; without pregnancy, drug history, medical condition, implanted device, history of seizures or migraine


Interventions5 consecutive days of 60 min of
a) electrostimulation, 10Hz 2 msec pulse, 30 µamp to mastoid, or
b) sham electrostimulation


OutcomesAbstinence after 5 days and 1 month, verified by exhaled CO. Withdrawal symptoms.


NotesStimulation parameters were criticised by Boutros 1998


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear risk"the instrument manufacturer 'prepared sealed envelopes containing a cartridge and an insert that was randomly assigned to each subject' but method of sequence generation not described

Allocation concealment (selection bias)Low risk Sealed envelopes prepared with cartridge and insert

Blinding (performance bias and detection bias)
All outcomes
Low riskDescribed as double-blind, and interventions were appropriate

Incomplete outcome data (attrition bias)
All outcomes
Low riskDropout rates 16% and 17%

Other biasLow riskNo baseline differences

Scheuer 2005

MethodsRandomized trial of electrostimulation

Country: Switzerland

Recruitment: method not stated


ParticipantsSmokers willing to quit (66 randomized, 64 followed up)


InterventionsNeuroelectric therapy (NET) in region of mastoid bone for 96 hours. Devices delivered a constant current of 10.0 mA and 35.0 V. Devices were fully automated and programmed to deliver either

a) active treatment at 300 Hz

b) placebo at 700 Hz (no justification or explanation given)


OutcomesSmoking cessation at 4 days, 2 and 6 weeks, 3 and 6 months, validated by cotinine tests (no details)


NotesAbstract only. No group sizes were given, only percentages of quitters in each group, and we were unable to contact the author. We therefore assumed two equal groups. [We imputed denominators at follow-up from percentages that lead to whole numbers]

The authors concluded that the 'placebo' stimulation might be active


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskrandomly assigned

Allocation concealment (selection bias)Unclear riskno details given

Blinding (performance bias and detection bias)
All outcomes
Low risk'Placebo' used, no information on blinding of therapists

Incomplete outcome data (attrition bias)
All outcomes
Unclear riskno details given for dropouts

Other biasUnclear riskno baseline details given

Steiner 1982

MethodsRandomized trial of acupuncture

Country: USA
Recruitment: Community volunteers responding to newspaper and radio adverts


Participants32 subjects over 21, smoking over 20 cigs/day for 2 consecutive years, not pregnant and not on chronic pain medication or mood-altering drugs
Selected from 82 volunteers, matched according to age, sex, and cigarette consumption


Interventionsa) acupuncture to genuine body and ear points; needle sensation achieved.
b) sham acupuncture to nearby areas without needling sensation
Both interventions given twice weekly for 2 weeks


OutcomesAbstinence and cigarette consumption at 4 weeks
Validation: none


NotesSubjects were not advised to stop smoking at any particular time, but to 'follow your motivation and appetite to the best of your ability'


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskMatched pairs selected from volunteers, one of each pair randomly assigned, method not stated

Allocation concealment (selection bias)Unclear riskThe description of the timing of randomisation does not provide reliable information that it was concealed

Blinding (performance bias and detection bias)
All outcomes
Low risk'Neither research volunteer nor data gatherers were aware of group assignments'

Incomplete outcome data (attrition bias)
All outcomes
Unclear risk28% dropout rate

Other biasLow riskMatched for age, sex and smoking history

Tian 1996

MethodsRandomized trial of acupressure (continuous stimulation)

Country: China
Recruitment: not stated


Participants120 smokers over 20 yrs old, regularly smoking >10 cigs/day, exhaled CO>10ppm, and 'likely to attend follow-up for 1 year'


Interventionsa) acupressure, 'Ear Point Seed Pressing' method: seed fixed to 4 points in one ear, treatment changed to alternate ear twice/wk for course of 1 month, repeated for 2 or 3 months. Seeds to be pressed by smoker 6 times daily
b) advice: no description given


OutcomesAbstinence at 1 month and 1 yr, confirmed by CO measurement


NotesReport lacks details (e.g.. randomization, advice given, baseline characteristics)
Error in results table: figures at 1 month do not reach correct total of 60


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear risk'randomly' with no details

Allocation concealment (selection bias)Unclear risk Not described

Blinding (performance bias and detection bias)
All outcomes
High riskOpen study

Incomplete outcome data (attrition bias)
All outcomes
Unclear riskDropouts not reported, estimated at 77%

Other biasLow riskGroups similar at baseline

Vandevenne 1985

MethodsRandomized trial of acupuncture

Country: France
Recruitment: volunteers attending anti-smoking clinic


Participants200 self-referred smokers, no criteria stated


Interventionsa) acupuncture to 3 auricular and 2 body points
b) sham acupuncture to nearby areas
both interventions given on days 1, 4, 10 and 20


OutcomesAbstinence (point-prevalence) at 6 weeks, 6 months and 1 year
Not validated


Notes[in French]


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskRandom number table

Allocation concealment (selection bias)Unclear risk Not described

Blinding (performance bias and detection bias)
All outcomes
Low riskDescribed as blinded, and interventions appropriate

Incomplete outcome data (attrition bias)
All outcomes
Unclear risk42% dropout at 6 weeks

Other biasLow riskGroups similar in smoking history at baseline

Vibes 1977

MethodsRandomized trial of acupuncture and continuous stimulation

Country: France
Recruitment: not stated


Participants200 smokers of at least 20 cigs /day; already tried to reduce their consumption; no previous acupuncture; not using any other therapy for smoking cessation


Interventions6 treatment sessions 3 times a week for groups a) b) e). Indwelling needle for groups c) and d)
a) 3 or 4 traditional acupuncture body points for cessation
b) two nasal points
c) auricular point Zero
d) auricular point Lung
e) control group: 2 points on hands/feet


OutcomesSmoking cessation at 14 days (not validated); reduction in cigarette consumption


Notes[in French]


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskrandomised, no further details

Allocation concealment (selection bias)Unclear risk No information

Blinding (performance bias and detection bias)
All outcomes
Low riskAll groups received needling treatments, differences unlikely to lead to unblinding in the context

Incomplete outcome data (attrition bias)
All outcomes
Low riskDropout rate reported as less than 5%

Other biasUnclear riskNo baseline data presented

Waite 1998

MethodsRandomized trial of acupuncture and continuous stimulation

Country: UK
Recruitment: community volunteers recruited by advertisements in on-line news pages, posters in hospital and word of mouth.


Participants78 adults over 18 years old who were smoking at least 10 cigs/day.
Exclusions: cardiac pacemaker, previous acupuncture


InterventionsBoth groups received one 20-minute session of acupuncture with electrical stimulation followed by placement of a seed on the needle site held in place with adhesive tape. 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, lung point in ear
b) control group, medial aspect of the patella, not on recognised acupuncture point

All smokers received structured counselling and written information before randomisation


OutcomesCessation at 2 weeks, and 2, 4 and 6 months (point prevalence)
Validation at 6 months only: urinary cotinine


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskRandomization, no further details

Allocation concealment (selection bias)Unclear riskNo information

Blinding (performance bias and detection bias)
All outcomes
Low riskdescribed as single blind, and interventions appropriate

Incomplete outcome data (attrition bias)
All outcomes
Low risk100% follow-up at 6 months

Other biasLow riskSlightly heavier smokers in active group

White 1998

MethodsRandomized trial of acupuncture

Country: UK
Recruitment: community volunteers from media invitation


Participants76 adults over 21 years smoking at least 15 cigs/day
Exclusions: previous acupuncture, pregnancy, breast-feeding, cardiac pacemaker, known bleeding tendency


Interventionsa) acupuncture with electrical stimulation to lung point in both ears
b) sham acupuncture consisting of either needle or carbon pad placed over the mastoid bone attached to sham (inactivated) stimulator
Interventions were given on day 1, 3 and 7 of the smoking cessation
All smokers also received counselling by a nurse


OutcomesSustained cessation at 2 weeks
Validation: expired air CO concentration
Withdrawal symptoms assessed by Visual Analogue Scale
Reported cessation at 9 months (not validated)


NotesCredibility of interventions tested by questionnaire
Standardized, minimal interaction by acupuncturist
All counselling by blinded nurse


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskcomputer-generated

Allocation concealment (selection bias)Low risk Sealed envelopes opened immediately before intervention

Blinding (performance bias and detection bias)
All outcomes
Low riskBlinded participant (though control group felt no electrical stimulation), blinded assessor

Incomplete outcome data (attrition bias)
All outcomes
Unclear risk32% dropout or withdrawal rate

Other biasLow riskMarginally heavier smokers in active treatment group

White 2007

MethodsRandomized trial of acupressure (continuous stimulation)

Country: England

Recruitment: smoking cessation clinic


Participants19 smokers, aged ≥18 years, smoked ≥10 cigs/day, prescribed NRT; no general or auricular medical conditions or specified medications


InterventionsAll participants received the usual NRT and group counselling and support. In addition, Pyonex type acupressure beads (specially manufactured for the study) were used.

a) two beads, in Lung and Shenmen points

b) one bead in Lung point

c) no bead. Beads worn for 4 weeks, replaced when necessary or every 14 days


OutcomesReported cessation at 4 weeks verified by expired air CO ≤9 ppm


NotesPilot study, mainly testing recruitment and feasibility. Data from two intervention groups combined


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskcode generated by computerised blocked randomisation prepared by researcher unconnected with the study

Allocation concealment (selection bias)Low riskparticipant opened opaque, numbered envelope

Blinding (performance bias and detection bias)
All outcomes
High riskopen study

Incomplete outcome data (attrition bias)
All outcomes
High risk5 randomised patients not included in the analysis, and no information on group allocation

Other biasLow riskno major baseline differences

Wing 2010

MethodsRandomized trial of acupressure (continuous stimulation)

Country: Hong Kong

Recruitment: outpatient clinics and community


Participants70 smokers. Aged ≥18, motivated to quit


Interventionsa) active acupressure using hard beads on ear (Shenmen, Lung, Mouth, and Brain) and hand (LI4 and PC6) for 3 weeks. Not stated whether uni- or bilateral. To be pressed 3/day or whenever urge to smoke

b) sham acupressure beads


OutcomesCessation 3 months after end of treatment

Validation: CO < 6 ppm


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskBlocked randomization, no further details

Allocation concealment (selection bias)Unclear riskNot described

Blinding (performance bias and detection bias)
All outcomes
Unclear riskNot described

Incomplete outcome data (attrition bias)
All outcomes
Unclear riskNot clear

Other biasLow risk"no major differences between the active and sham groups at baseline level"

Wu 2007

MethodsRandomized trial of acupuncture (continuous stimulation)

Country: Taipei, Taiwan

Recruitment: advertisements through hospital; those attending smoking cessation clinic


Participants131 smokers aged ≥18 years, smoking ≥10 cigs/day, and smoked ≥1 year; has no specified diseases, not taking specified medication, not abusing drugs


InterventionsIndwelling needles inserted into four auricular points and retained for one week, then replaced. Total treatment period 8 weeks. Points used:

a) 'real' points Shenmen, Lung, Mouth, Sympathetic

b) 'irrelevant' points Eye, Elbow, Shoulder, Knee

All participants also received counselling from a nurse


OutcomesReported cessation at end of treatment and 6 months follow-up; verbal report validated by exhaled air CO concentration in those who could attend clinic; telephone call to defaulters (numbers of defaulters not reported)


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskblock randomization method with random number table

Allocation concealment (selection bias)Unclear riskno details given

Blinding (performance bias and detection bias)
All outcomes
Low riskstudy not described as blinded, but clearly designed subject-blinded

Incomplete outcome data (attrition bias)
All outcomes
Low riskfull details of dropouts and reasons: 5 in group a) and 8 in group b)

Other biasLow riskno baseline differences

Yeh 2009

MethodsRandomized trial of electrostimulation and continuous stimulation

Country: Taiwan
Recruitment: community volunteers


Participants79 healthy smokers, serum cotinine >100 ng/ml, daily consumption >1 CPD


Interventionsa) active acupoint stimulation; shenmen, lung, stomach, mouth, endocrine & tim mee
b) sham stimulation, 5mm away from real acupoint locations

(We were unable to clarify whether the intervention was applied uni- or bilaterally)

All participants used the electron acupuncture with low frequency (9V,< 60Hz) once a week for 6 weeks, for twenty minutes each time. A seed-embedding method was then used on these auricular points. All participants were instructed to apply pressure on the auricular points for one minute each time, and three to five times each day for six weeks. The auricular seeds were replaced with new ones each week.


OutcomesCessation based on serum cotinine <100 ng/ml at 6 weeks, participant self- report not used


NotesGroups only differed in the site that the stimulation was given, i.e. a true test of point location. Included in both continuous stimulation and electrostimulation analyses.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear risk‘Randomly assigned’, no further details

Allocation concealment (selection bias)Unclear riskNo details given

Blinding (performance bias and detection bias)
All outcomes
Low riskstudy not described as blinded, but clearly designed subject-blinded

Incomplete outcome data (attrition bias)
All outcomes
Unclear risk9 I and 11 C withdrew before end of treatment, excluded from reported outcomes, reincluded in denominators for MA

Other biasLow riskno major baseline differences

Zhang 2013

MethodsRandomized trial of acupressure (continuous stimulation)

Country: Australia

Recruitment: community volunteers


Participants43 smokers aged ≥18 years, >10 cpd


Interventionsa) Acupressure (stainless steel beads) to ear points Shenmen (TF4), Lung [AW1] (CO14), Mouth (CO1), Hunger (extra), and Liver (CO12) for 4 weeks.

b) Sham acupressure; pressure on non specific points Helix 2 (HX10), Shoulder (SF4, 5), Clavicle (SF6), Occiput (AT3), and Tooth (LO1).

All participants instructed to press all beads 3 times daily. Beads unilateral, alternated between ears every week


OutcomesCessation at 8 weeks & 5 months

Validation: CO ≤ 10ppm


Notes(Outcomes same at 8 weeks & 5 months)


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low risk"An independent researcher conducted block randomisation using a computer generated randomisation list."

Allocation concealment (selection bias)Low risk"The randomised group codes were placed into sealed, opaque envelopes by another independent person. Participants, data entry personnel, and data analysts were blinded to treatment allocation." "participants randomly selected a sealed opaque envelope with their randomisation code inside"

Blinding (performance bias and detection bias)
All outcomes
Low risk"The single acupuncturist was trained to perform the same procedures at each consultation and was instructed not to discuss any aspect of the treatment procedures with the participants, to ensure participant blinding and consistency of treatment."

Incomplete outcome data (attrition bias)
All outcomes
High riskLess than half of each group reached at 5 months

Other biasLow risk"At baseline, no significant differences between the two groups were found ..."

 
Characteristics of excluded studies [ordered by study ID]

StudyReason for exclusion

Boureau 1978This study compared 2 groups who both received identical acupuncture following an injection: one group were injected with saline, the other with naloxone. Therefore, 2 hypotheses are tested simultaneously: does acupuncture help smoking cessation by releasing endogenous opioid peptides?

Boutros 1998This letter in response to the study of Pickworth commented on the stimulus parameters used in the study, but included no original data

Chen 2006All participants received acupressure; test of an internet programme; not randomised

Fang 1983Outcome was reduction in amount smoked by half or more, not cessation

He 2012Outcome depression, not smoking cessation

Huang 2001Compares acupressure to acupuncture

Hyun 2010Cessation outcomes not reported

Kang 2005School children in two schools allocated according to which school they attended, without mention of randomisation. One case of smoking cessation recorded, so exclusion unlikely to bias review

MacHovec 1978This study does not specify that the subjects were randomized

Man 1975Subjects were allocated by place of residence, not randomly

Sun 2000The two intervention groups received the same acupuncture, and differed only in the use of psychological nursing care

Tan 1987Not described as randomized: complete abstinence not reported.

Wang 2010All participants received acupressure; test of a multimedia programme. Not randomised

Wang 2013Compares two types of acupuncture.

Zhang 1989Compares two active acupuncture conditions: both use 'Lung' auricular point which is widely considered an active intervention.

Zhou 2010The trial compared electronic acupuncture combined with ear acupressure with magnetic balls against electronic acupuncture alone, therefore, electronic acupuncture is considered as co-intervention, and any potential effect would be come from acupressure combined with magnetic balls on ear acupoints.

 
Characteristics of studies awaiting assessment [ordered by study ID]
Shahrokhi 2013

Methods"Participants were divided to two groups by randomized sample method"

Participants"One hundred and thirty-two men smokers who were ready to quit smoking"

Interventions"One group was for acupuncture and another group was for acupuncture in sham points."

Outcomes"All participants followed for 1 year and the quit rate evaluated in 1, 6, 12 months of the study."

NotesInformation from conference abstract with insufficient detail to include. Attempts to contact authors so far unsuccessful.

 
Characteristics of ongoing studies [ordered by study ID]
Leung 2012

Trial name or titleEffect of Self-administered Auricular Acupressure on Smoking Cessation—a Pilot Study

MethodsThree arm RCT, partially double blind

Participants60 smokers aged between 18 and 75 years of age, wanting to quit, no more than 2 failed attempts in previous 3 years

Interventions1. National Acupuncture Detoxification Association (NADA) points + digital pressure

2. Random acupuncture points + digital pressure

3. Advice & support only

OutcomesContinuous abstinence during treatment weeks (1-6), week 13 and week 26

Starting dateJuly 2011

Contact informationlawrence.leung@dfm.queensu.ca, jyoti.kotecha@cspc.queensu.ca

Notes

 
Comparison 1. Acupuncture vs waiting list/no intervention

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Short-term smoking cessation2Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

 2 Long-term smoking cessation3393Risk Ratio (M-H, Fixed, 95% CI)1.79 [0.98, 3.28]

 
Comparison 2. Acupuncture vs sham acupuncture

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Short-term smoking cessation192588Risk Ratio (M-H, Fixed, 95% CI)1.22 [1.08, 1.38]

 2 Long-term smoking cessation111892Risk Ratio (M-H, Fixed, 95% CI)1.10 [0.86, 1.40]

 
Comparison 3. Acupuncture vs other intervention

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 NRT2Risk Ratio (M-H, Fixed, 95% CI)Subtotals only

    1.1 Short-term smoking cessation
2914Risk Ratio (M-H, Fixed, 95% CI)0.76 [0.59, 0.98]

    1.2 Long-term smoking cessation
2914Risk Ratio (M-H, Fixed, 95% CI)0.64 [0.42, 0.98]

 2 Counselling and psychological approaches3Risk Ratio (M-H, Fixed, 95% CI)Subtotals only

    2.1 Short-term smoking cessation
3396Risk Ratio (M-H, Fixed, 95% CI)0.95 [0.72, 1.26]

    2.2 Long-term smoking cessation
3396Risk Ratio (M-H, Fixed, 95% CI)1.34 [0.80, 2.24]

 3 Interventions of unknown effectiveness4Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

    3.1 Short-term smoking cessation
4Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

    3.2 Long-term smoking cessation
3Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

 
Comparison 4. Acupressure vs waiting list/no intervention

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Short-term smoking cessation2Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

 2 Long-term smoking cessation1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

 
Comparison 5. Acupressure vs sham acupressure

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Short-term smoking cessation3253Risk Ratio (M-H, Random, 95% CI)2.54 [1.27, 5.08]

 
Comparison 6. Continuous auricular stimulation vs sham stimulation

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Short-term smoking cessation141155Risk Ratio (M-H, Fixed, 95% CI)1.69 [1.32, 2.16]

    1.1 Indwelling needles
7659Risk Ratio (M-H, Fixed, 95% CI)1.24 [0.91, 1.69]

    1.2 Continuous acupressure
7496Risk Ratio (M-H, Fixed, 95% CI)2.73 [1.78, 4.18]

 2 Long-term smoking cessation6570Risk Ratio (IV, Fixed, 95% CI)1.47 [0.79, 2.74]

    2.1 Indwelling needles
4446Risk Ratio (IV, Fixed, 95% CI)1.20 [0.62, 2.32]

    2.2 Continuous acupressure
2124Risk Ratio (IV, Fixed, 95% CI)9.45 [1.26, 70.92]

 
Comparison 7. Laser therapy vs sham laser

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Short-term smoking cessation2Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

 2 Long-term smoking cessation2Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

 
Comparison 8. Electrostimulation vs sham stimulation

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Short-term smoking cessation6634Risk Ratio (M-H, Fixed, 95% CI)1.13 [0.87, 1.46]

 2 Long-term smoking cessation2405Risk Ratio (M-H, Fixed, 95% CI)0.87 [0.61, 1.23]

 
Summary of findings for the main comparison. Acupuncture compared to sham acupuncture for smoking cessation

Acupuncture compared to sham acupuncture for smoking cessation

Patient or population: People trying to stop smoking
Intervention: Acupuncture

Comparison: Sham acupuncture

OutcomesIllustrative comparative rates* (95% CI)Relative effect
(95% CI)
No of Participants
(studies)
Quality of the evidence
(GRADE)
Comments

Assumed cessation rateCorresponding rate

Sham acupunctureAcupuncture

Smoking cessation
Follow-up: 6+ months
Study populationRR 1.1
(0.86 to 1.4)
1892
(11 studies)
⊕⊕⊕⊝
moderate1,2,3
No evidence of long-term benefit, though evidence of short-term effect (RR 1.22, 95% CI 1.08 to 1.38)

108 per 1000119 per 1000 (93 to 152)

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: Confidence interval; RR: Risk ratio

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

 1 Risk of bias unclear for some domains in most studies; however, as pooled result did not detect an effect, risk of bias did not significantly alter authors' confidence in result.
2 There was clinical heterogeneity in the type and duration of acupuncture used, but little statistical heterogeneity (I² = 23%).
3 There was some evidence of funnel plot asymmetry.
 
Summary of findings 2. Acupressure compared to sham acupressure for smoking cessation

Acupressure compared to sham acupressure for smoking cessation

Patient or population: People trying to stop smoking
Intervention: Acupressure
Comparison: Sham acupressure

OutcomesIllustrative comparative rates* (95% CI)Relative effect
(95% CI)
No of Participants
(studies)
Quality of the evidence
(GRADE)
Comments

Assumed cessation rateCorresponding rate

Sham acupressureAcupressure

Smoking cessation - early
Follow-up: 3 to 12 weeks
Study populationRR 2.05
(1.11 to 3.77)
312
(4 studies)
⊕⊕⊝⊝
low1,2
No studies report long-term follow-up.

84 per 1000173 per 1000 (94 to 318)

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: Confidence interval; RR: Risk ratio

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

 1 One study with significant effect had shortest follow-up
2 Small number of small studies without long-term follow-up
 
Table 1. Lengths of follow-up available for included studies, grouped by intervention type

Study IDShort-term outcomes

(≤ 6 weeks after quit date)
Long-term outcomes

(≥ 6 months after quit date)
Notes

Acupressure

Li 2009xAlso in continuous stimulation (acupressure) subgroup

Tian 1996xx

White 2007x

Wing 2010xShort-term follow up > 6 weeks (3 months from treatment)

Also in continuous stimulation (acupressure) subgroup

Zhang 2013xShort-term follow up > 6 weeks (8 weeks)

Also in continuous stimulation (acupressure) subgroup

Acupuncture

Bier 2002(x)(x)Data not consistent so not included in any meta-analysis

Circo 1985x

Clavel 1985xx

Clavel 1992xx

Cottraux 1983xx

Gilbey 1977xAlso in continuous stimulation (indwelling needle) subgroup

Gillams 1984xxAlso in continuous stimulation (indwelling needle) subgroup

Han 2006(x)Compares acupuncture with acupuncture, not included in any meta-analyses

He 1997xxAlso in continuous stimulation (acupressure) subgroup

Huang 2012xAlso in continuous stimulation (acupressure) subgroup

Labadie 1983xxShort-term follow up >6 weeks (8 weeks)

Lacroix 1977x

Lagrue 1980x

Lamontagne 1980xx

Leung 1991xx

Martin 1981a; Martin 1981bxxAlso in continuous stimulation (indwelling needle) subgroup

Parker 1977a; Parker 1977bxParker 1977a also in continuous stimulation (indwelling needle) subgroup

Steiner 1982x

Vandevenne 1985xx

Vibes 1977xAlso in continuous stimulation (indwelling needle) subgroup

Waite 1998xxAlso in continuous stimulation (acupressure) subgroup

White 1998xx

Wu 2007xxAlso in continuous stimulation (indwelling needle) subgroup

Electrostimulation

Antoniou 2005x

Aycicegi-Dinn 2011x

Fritz 2013x

Georgiou 1999x

Pickworth 1997x

Scheuer 2005xx

Yeh 2009xAlso in continuous stimulation (acupressure) subgroup

Laser therapy

Cai 2000x

Docherty 2003x

Kerr 2008xx

 
Table 2. Comparisons of different forms of acupuncture

StudyType of acupunctureN includedNot smoking (early)Success rate

Han 2006body points only221673%

Han 2006body and auricular points201155%

Vibes 1977classical (body) points441432%

Vibes 1977Zero point (ear)391128%

Vibes 1977Lung point (ear)3439%

Vibes 1977nose points4848%

Vibes 1977sham control (hands/feet)3027%