Acupuncture and related interventions for smoking cessation

Adrian R White; Hagen Rampes; Jian Ping Liu; Lindsay F Stead; John Campbell

doi:10.1002/14651858.CD000009.pub4

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Figure 1

Flow diagram for Update 2014

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Figure 2

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

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Figure 3

Analysis 2.1: Acupuncture vs sham acupuncture, Short‐term smoking cessation

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Figure 4

Funnel plot of comparison: 2 Acupuncture vs sham acupuncture, outcome: 2.1 Short‐term smoking cessation

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Figure 5

Analysis 2.2: Acupuncture vs sham acupuncture. Long‐term smoking cessation

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Figure 6

Analysis 8.1: Continuous auricular stimulation vs sham stimulation. Short‐term smoking cessation

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Figure 7

Funnel plot of continuous auricular stimulation vs sham stimulation, Short‐term smoking cessation

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Analysis 1.1

Comparison 1 Acupuncture vs waiting list/no intervention, Outcome 1 Short‐term smoking cessation.

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Analysis 1.2

Comparison 1 Acupuncture vs waiting list/no intervention, Outcome 2 Long‐term smoking cessation.

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Analysis 2.1

Comparison 2 Acupuncture vs sham acupuncture, Outcome 1 Short‐term smoking cessation.

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Analysis 2.2

Comparison 2 Acupuncture vs sham acupuncture, Outcome 2 Long‐term smoking cessation.

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Analysis 3.1

Comparison 3 Acupuncture vs other intervention, Outcome 1 NRT.

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Analysis 3.2

Comparison 3 Acupuncture vs other intervention, Outcome 2 Counselling and psychological approaches.

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Analysis 3.3

Comparison 3 Acupuncture vs other intervention, Outcome 3 Interventions of unknown effectiveness.

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Analysis 4.1

Comparison 4 Acupressure vs waiting list/no intervention, Outcome 1 Short‐term smoking cessation.

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Analysis 4.2

Comparison 4 Acupressure vs waiting list/no intervention, Outcome 2 Long‐term smoking cessation.

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Analysis 5.1

Comparison 5 Acupressure vs sham acupressure, Outcome 1 Short‐term smoking cessation.

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Analysis 6.1

Comparison 6 Continuous auricular stimulation vs sham stimulation, Outcome 1 Short‐term smoking cessation.

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Analysis 6.2

Comparison 6 Continuous auricular stimulation vs sham stimulation, Outcome 2 Long‐term smoking cessation.

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Analysis 7.1

Comparison 7 Laser therapy vs sham laser, Outcome 1 Short‐term smoking cessation.

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Analysis 7.2

Comparison 7 Laser therapy vs sham laser, Outcome 2 Long‐term smoking cessation.

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Analysis 8.1

Comparison 8 Electrostimulation vs sham stimulation, Outcome 1 Short‐term smoking cessation.

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Analysis 8.2

Comparison 8 Electrostimulation vs sham stimulation, Outcome 2 Long‐term smoking cessation.

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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
Outcomes	*Illustrative comparative rates (95% CI)**		Relative effect (95% CI)	No of Participants (studies)	Quality of the evidence (GRADE)	Comments
	Assumed cessation rate	Corresponding rate
	Sham acupuncture	Acupuncture
Smoking cessation Follow‐up: 6+ months	Study population		RR 1.1 (0.86 to 1.4)	1892 (11 studies)	⊕⊕⊕⊝ moderate^1,2,3	No evidence of long‐term benefit, though evidence of short‐term effect (RR 1.22, 95% CI 1.08 to 1.38)
	108 per 1000	119 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 for the main comparison. Acupuncture compared to sham acupuncture for smoking cessation

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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
Outcomes	*Illustrative comparative rates (95% CI)**		Relative effect (95% CI)	No of Participants (studies)	Quality of the evidence (GRADE)	Comments
	Assumed cessation rate	Corresponding rate
	Sham acupressure	Acupressure
Smoking cessation ‐ early Follow‐up: 3 to 12 weeks	Study population		RR 2.05 (1.11 to 3.77)	312 (4 studies)	⊕⊕⊝⊝ low^1,2	No studies report long‐term follow‐up.
	84 per 1000	173 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

Summary of findings 2. Acupressure compared to sham acupressure for smoking cessation

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Table 1. Lengths of follow‐up available for included studies, grouped by intervention type

Study ID	Short‐term outcomes (≤ 6 weeks after quit date)	Long‐term outcomes (≥ 6 months after quit date)	Notes
*Acupressure*
Li 2009	x		Also in continuous stimulation (acupressure) subgroup
Tian 1996	x	x
White 2007	x
Wing 2010	x		Short‐term follow up > 6 weeks (3 months from treatment) Also in continuous stimulation (acupressure) subgroup
Zhang 2013	x		Short‐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 1985	x
Clavel 1985	x	x
Clavel 1992	x	x
Cottraux 1983	x	x
Gilbey 1977	x		Also in continuous stimulation (indwelling needle) subgroup
Gillams 1984	x	x	Also in continuous stimulation (indwelling needle) subgroup
Han 2006	(x)		Compares acupuncture with acupuncture, not included in any meta‐analyses
He 1997	x	x	Also in continuous stimulation (acupressure) subgroup
Huang 2012	x		Also in continuous stimulation (acupressure) subgroup
Labadie 1983	x	x	Short‐term follow up >6 weeks (8 weeks)
Lacroix 1977	x
Lagrue 1980	x
Lamontagne 1980	x	x
Leung 1991	x	x
Martin 1981a; Martin 1981b	x	x	Also in continuous stimulation (indwelling needle) subgroup
Parker 1977a; Parker 1977b	x		Parker 1977a also in continuous stimulation (indwelling needle) subgroup
Steiner 1982	x
Vandevenne 1985	x	x
Vibes 1977	x		Also in continuous stimulation (indwelling needle) subgroup
Waite 1998	x	x	Also in continuous stimulation (acupressure) subgroup
White 1998	x	x
Wu 2007	x	x	Also in continuous stimulation (indwelling needle) subgroup
*Electrostimulation*
Antoniou 2005	x
Aycicegi‐Dinn 2011	x
Fritz 2013	x
Georgiou 1999	x
Pickworth 1997	x
Scheuer 2005	x	x
Yeh 2009	x		Also in continuous stimulation (acupressure) subgroup
*Laser therapy*
Cai 2000	x
Docherty 2003		x
Kerr 2008	x	x

Table 1. Lengths of follow‐up available for included studies, grouped by intervention type

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Table 2. Comparisons of different forms of acupuncture

Study	Type of acupuncture	N included	Not smoking (early)	Success rate
Han 2006	body points only	22	16	73%
Han 2006	body and auricular points	20	11	55%
Vibes 1977	classical (body) points	44	14	32%
Vibes 1977	Zero point (ear)	39	11	28%
Vibes 1977	Lung point (ear)	34	3	9%
Vibes 1977	nose points	48	4	8%
Vibes 1977	sham control (hands/feet)	30	2	7%

Table 2. Comparisons of different forms of acupuncture

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Comparison 1. Acupuncture vs waiting list/no intervention

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Short‐term smoking cessation Show forest plot	2		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

2 Long‐term smoking cessation Show forest plot	3	393	Risk Ratio (M‐H, Fixed, 95% CI)	1.79 [0.98, 3.28]

Comparison 1. Acupuncture vs waiting list/no intervention

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Comparison 2. Acupuncture vs sham acupuncture

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Short‐term smoking cessation Show forest plot	19	2588	Risk Ratio (M‐H, Fixed, 95% CI)	1.22 [1.08, 1.38]

2 Long‐term smoking cessation Show forest plot	11	1892	Risk Ratio (M‐H, Fixed, 95% CI)	1.10 [0.86, 1.40]

Comparison 2. Acupuncture vs sham acupuncture

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Comparison 3. Acupuncture vs other intervention

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 NRT Show forest plot	2		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

1.1 Short‐term smoking cessation	2	914	Risk Ratio (M‐H, Fixed, 95% CI)	0.76 [0.59, 0.98]
1.2 Long‐term smoking cessation	2	914	Risk Ratio (M‐H, Fixed, 95% CI)	0.64 [0.42, 0.98]
2 Counselling and psychological approaches Show forest plot	3		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

2.1 Short‐term smoking cessation	3	396	Risk Ratio (M‐H, Fixed, 95% CI)	0.95 [0.72, 1.26]
2.2 Long‐term smoking cessation	3	396	Risk Ratio (M‐H, Fixed, 95% CI)	1.34 [0.80, 2.24]
3 Interventions of unknown effectiveness Show forest plot	4		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

3.1 Short‐term smoking cessation	4		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
3.2 Long‐term smoking cessation	3		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]

Comparison 3. Acupuncture vs other intervention

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Comparison 4. Acupressure vs waiting list/no intervention

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Short‐term smoking cessation Show forest plot	2		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

2 Long‐term smoking cessation Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

Comparison 4. Acupressure vs waiting list/no intervention

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Comparison 5. Acupressure vs sham acupressure

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Short‐term smoking cessation Show forest plot	3	253	Risk Ratio (M‐H, Random, 95% CI)	2.54 [1.27, 5.08]

Comparison 5. Acupressure vs sham acupressure

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Comparison 6. Continuous auricular stimulation vs sham stimulation

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Short‐term smoking cessation Show forest plot	14	1155	Risk Ratio (M‐H, Fixed, 95% CI)	1.69 [1.32, 2.16]

1.1 Indwelling needles	7	659	Risk Ratio (M‐H, Fixed, 95% CI)	1.24 [0.91, 1.69]
1.2 Continuous acupressure	7	496	Risk Ratio (M‐H, Fixed, 95% CI)	2.73 [1.78, 4.18]
2 Long‐term smoking cessation Show forest plot	6	570	Risk Ratio (IV, Fixed, 95% CI)	1.47 [0.79, 2.74]

2.1 Indwelling needles	4	446	Risk Ratio (IV, Fixed, 95% CI)	1.20 [0.62, 2.32]
2.2 Continuous acupressure	2	124	Risk Ratio (IV, Fixed, 95% CI)	9.45 [1.26, 70.92]

Comparison 6. Continuous auricular stimulation vs sham stimulation

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Comparison 7. Laser therapy vs sham laser

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Short‐term smoking cessation Show forest plot	2		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

2 Long‐term smoking cessation Show forest plot	2		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

Comparison 7. Laser therapy vs sham laser

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Comparison 8. Electrostimulation vs sham stimulation

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Short‐term smoking cessation Show forest plot	6	634	Risk Ratio (M‐H, Fixed, 95% CI)	1.13 [0.87, 1.46]

2 Long‐term smoking cessation Show forest plot	2	405	Risk Ratio (M‐H, Fixed, 95% CI)	0.87 [0.61, 1.23]

Comparison 8. Electrostimulation vs sham stimulation

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