Date Last Updated: 27/10/04

Acupuncture for smoking cessation

Overview

Tobacco smoking is responsible for approximately 15 percent of all deaths in New Zealand, with up to 4,700 New Zealanders dying each year from smoking related illnesses, such as lung cancer, coronary heart disease, stroke, peripheral vascular disease, and chronic obstructive lung disease. Second hand smoke also has a major impact on people’s health. Stopping smoking (smoking cessation) can therefore significantly improve a smoker’s health. The earlier the person quits smoking the greater the benefit. Many methods are available to help quit smoking, such as simply stopping (often referred to as “cold turkey”), nicotine replacement therapy, the use of certain medications (such as antidepressants), behavioral and/or educational programs, and counseling. Acupuncture (of many types and techniques including needle, laser therapy, ear acupuncture, and electrostimulation) is also used for smoking cessation. This evidence summary identified ten systematic reviews, 27 clinical trials (involving approximately 4,949 people), two clinical guidelines and two narrative reviews (that included 64 studies of more than 15,000 people) on the use of acupuncture for smoking cessation. Findings from the most recent systematic review indicate that acupuncture is no more effective than sham acupuncture or other smoking cessation methods. However, there is a small amount of evidence to suggest that acupuncture may be better than no intervention for smoking cessation, particularly in the early stages of quitting. Results from the other reviews in this area are broadly consistent with these findings. Side effects related to the use of acupuncture for smoking cessation tend to be uncommon, mild and reversible, and include minor bleeding upon needle removal and inflammation / infection (related to ear acupuncture). Side effects for acupuncture in general (such as fainting, bleeding and bruising around the needle site, and nausea) also tend to be uncommon, mild and reversible. Serious side effects (such as punctured organs, infection, or death) can occur with acupuncture but are extremely rare.

Background

Smoking cessation (tobacco smoking)
Quitting smoking has many benefits and health gains for smokers of all ages¹. Evidence suggests that the earlier a smoker quits smoking the greater the health gain. For example:

The chance of a heart attack decreases within one day of quitting¹.
After one year of abstinence, the excess risk of heart disease is reduced by half¹
Within five years of abstinence the risk of a major coronary event (such as a severe heart attack, myocardial infarction, or death) reduces to the level of a person who never smoked¹.
In those with existing heart disease, smoking cessation reduces the risk of having a heart attack or dying by half¹.
After 10-15 years of abstinence, the risk of dying almost returns to that of people who never smoked¹.

Nicotine is addictive. Consequently, when people try and stop smoking they experience significant withdrawal symptoms. Symptoms tend to occur within hours of the last cigarette and are at greatest severity during the first week². Symptoms involve feeling light-headed, sleep disturbance, poor concentration, craving for nicotine, irritability or aggression, depression, and increased appetite². Most symptoms resolve within three to four weeks, but hunger and cravings may persist for several months².

Acupuncture
Acupuncture is one of the oldest and most commonly used medical procedures in the world. Acupuncture usually involves the insertion of fine needles into specific acupuncture points. Small metal beads, lasers, diodes, heat from the herb ‘moxa’ (moxabustion), suction cups and finger pressure may be used instead of needles. Generally acupuncture needles are stimulated manually but some acupuncturists stimulate the needles electrically. Acupuncture is used for the treatment of nicotine dependence with the aim of reducing the withdrawal symptoms people experience when they try to quit smoking³. Treatment sessions involve the insertion of acupuncture needles for 15-20 minutes at the time of cessation, and may be repeated each day. Inserting specially designed indwelling needles in specific points of the ear also help with smoking cessation. Such needles tend to be held in position with surgical tape for several days. Patients are instructed to press these indwelling needles when they become aware of withdrawal symptoms. As an alternative to indwelling needles, small seeds may be attached to the ear with adhesive tape and pressed intermittently (acupressure).

The practice of acupuncture is not currently regulated in New Zealand. Many acupuncture therapists are affiliated with a self-regulating professional body (such as the New Zealand Register of Acupuncturists, the Medical Acupuncturists Society of New Zealand, or the Physiotherapy Acupuncture Association of New Zealand).

Evidence reviewed in this summary

Efficacy information

Systematic reviews: This evidence summary identified ten systematic reviews on this topic, published since 1990^3-12. One of the reviews was written in French⁶, one in Dutch⁵, and one in Swedish⁸. The most recent review on acupuncture and smoking cessation was conducted by the Cochrane Tobacco Addiction Group and was last updated on the 15th August 2003³. Two systematic reviews^{10, 12} included three studies that were not included in the Cochrane review. The remaining reviews^{4, 7, 9, 11} included trials that were all included in the above Cochrane review.
Clinical trials: The above systematic reviews identified 26 randomised controlled trials conducted between 1977 and 2000, representing approximately 4,808 people. Since the above reviews were conducted, one additional randomised clinical trial (with 141 participants) has been published¹³. No clinical trials on the use of acupuncture for smoking cessation are known to be currently underway (http://www.controlled-trials.com).
Case-control studies/Cohort studies/Case studies: Given the extensive coverage of the above systematic reviews, no case-control, cohort studies or case studies were assessed for this evidence summary.
Other studies: This evidence summary identified two clinical guidelines related to this topic^{1, 14}. Two narrative reviews (that summarized 64 published studies involving a total of 15,000 people) were also identified^{15, 16}. However, it was not clear from the reviews what type of studies (e.g. trials, cohort studies, case-control studies etc) were included.

Safety information

Health Technology Assessment: One health technology assessment was identified that included information on complications of acupuncture in general¹⁷.
Systematic reviews: The systematic reviews identified in the efficacy section above did not report on adverse events related to the use of acupuncture for smoking cessation. However the health technology assessment above identified two systematic reviews^{18, 19} that reported on the side effects of acupuncture in general. One of these reviews¹⁹ identified ten articles representing nine prospective surveys of 17,925 patients from Europe and the Far East. The second review¹⁸ identified 56 articles published between 1965-1996 that reported serious and /or life-threatening adverse reactions following acupuncture. A further systematic review²⁰ that was not included in the above health technology assessment was also identified for this summary. This review reported on 89 Japanese articles on case reports for adverse events related to acupuncture (representing 124 events).
Other studies: One randomised controlled trial¹³ reported limited information on the side effects of acupuncture for smoking cessation. The health technology assessment above also identified a literature review²¹ and three surveys^22-24 that reported on the side-effects of acupuncture in general. The literature review summarised 78 case reports of adverse events identified between 1981-1994²¹, representing 193 treatments. A further narrative review²⁵ on side effects of acupuncture was identified for this summary, as well as one case report²⁶. Three studies reporting on six cases of infection associated with ear (auricular) acupuncture were also identified^27-29. Given the comprehensive information provided by the above studies, no further information on side effects was sought.

Evidence on efficacy

Trial results
Information on the use of acupuncture for smoking cessation is available from ten systematic reviews^{3-11, 12} , summarising the results of 26 clinical trials (involving approximately 4,808 smokers). The trials involved between 20 to 996 participants, aged between 12-81 years. Results from the trials were difficult to compare due to the various types and techniques of acupuncture used, the different acupuncture points stimulated, as well as the different number of treatments. Furthermore smoking cessation was not clearly defined in many of the trials. Some of the types of acupuncture used in the trials were needle (including indwelling), pressure, laser, heat (moxibustion), and electroacupuncture. The various sites of the body that were involved included the ear (auricular acupuncture), the face, and the body. Treatment periods in the trials ranged from five days³⁰ to four weeks^31-34. In one study, involving electrical stimulation and acupressure, participants were instructed to keep the seed in place as long as they found it helpful³⁵. Follow-up periods in the trials ranged from one week³⁶ to four years³³. Findings from the most recent systematic review indicate that acupuncture is no more effective than sham acupuncture or other smoking cessation methods³. However, there is a small amount of evidence to suggest that acupuncture may be better than no intervention for smoking cessation, particularly in the early stages of quitting. Overall:

Twelve trials (involving 2,069 people) compared acupuncture to sham acupuncture^{33, 34, 36-45}. Combined results showed that acupuncture had no significant effect on the number of cigarettes smoked or overall smoking cessation rates one week, six months or 12 months after treatment, compared to sham acupuncture. One study (involving 996 people) found that after four years, 5.6% of people who underwent three sessions of active acupuncture therapy over a one month period had stopped smoking, compared to 6.9% who underwent sham acupuncture³³.
Six trials (involving 1,370 people) compared acupuncture to other smoking cessation methods^{32-34, 46-48}. These methods included nicotine gum^{32, 33}, counselling and herbal extract⁴⁶, behavioural therapy^{47, 48}, placebo capsules⁴⁷, waiting-list⁴⁷, and group therapy sessions³⁴. No trial showed that acupuncture had any significant effect on smoking cessation rates one week, six months or 12 months after treatment, compared to other interventions. One study (involving 996 people) found that after four years, 5.6% of people who underwent three sessions of active acupuncture therapy over a one month period had completely stopped smoking, compared to 6.1% of people who took active nicotine gum³³.
Thirteen trials (involving 2,705 people) compared different acupuncture techniques (namely ear acupuncture^{32, 33, 39, 40, 43, 47} or non-ear acupuncture^{34, 36, 41, 42, 45, 46, 48}). No trial found any differences in the number of cigarettes smoked or the overall smoking cessation rates one week, six months or 12 months after treatment according to the type of acupuncture technique used.
Three trials (involving 393 people) compared acupuncture to no intervention^47-49. Combined results from two of the studies (involving 113 people) showed that the chance of completely stopping smoking or having a lower smoking rate within two weeks of treatment was increased by almost 39% in those people receiving acupuncture, compared to those that received no intervention^{48, 49}. However, no difference between the two groups was found six months after treatment had finished. One study (involving 280 people) showed that smoking cessation rates 12 months after treatment had finished was increased by almost 9% in those people receiving acupuncture, compared to those who received no intervention⁴⁷.
Two studies (involving 386 people) compared acupuncture involving electrostimulation to a placebo³⁰ or to various other electrical stimulation procedures⁵⁰. Both studies found no evidence of any effect of acupuncture involving electrostimulation on smoking cessation rates after five days of treatment³⁰, and six and 12 months⁵⁰ after treatment had finished.
One study (involving 330 people) compared laser acupuncture to placebo laser⁵¹. No significant difference in smoking cessation rates was found between the two groups after four weeks of treatment or six months after treatment had finished.
One study (involving 120 people) compared acupressure to advice⁵². Results showed that the chance of completely stopping smoking at the end of one month of treatment and 12 months after treatment had finished was increased by approximately 40% in those people receiving acupressure, compared to those who received advice.

Results from the nine other systematic reviews^4-12 and two narrative reviews^{15, 16} were broadly consistent with the main findings above. In contrast, results from one clinical trial not included in the systematic reviews showed that acupuncture alone and in combination with a cessation education programme had a significant effect on smoking cessation, compared to a combined sham acupuncture and education programme¹³. The chance of completely stopping smoking was increased by almost 18% (one month after the treatment) and by 29% (one year after the treatment) in those people receiving true acupuncture with education, compared to those that received sham acupuncture with education. The chance of reducing the number of cigarettes smoked was increased by 13% (one month after the treatment) and by 25% (one year after the treatment) in those people receiving true acupuncture with education, compared to those receiving sham acupuncture with education. This effect was also significantly greater with the combined treatment than with acupuncture alone. Results also showed that sham acupuncture with education was significantly more effective than acupuncture alone. However, these results should be interpreted with caution as the study is small (involved 141 people), 34% of participants did not finish the study, and appropriate statistical analyses were not undertaken. Consequently, results from this study may be extremely biased.

Evidence on safety

Findings from one clinical trial¹³ and three observational studies^27-29 reviewed for this summary indicate that:

There is little information available about side effects related to the use of acupuncture for smoking cessation.
Side effects tend to be infrequent, mild and reversible, and include minor bleeding upon needle removal¹³, and inflammation / infections (associated with ear acupuncture)^27-29.
- In the one clinical trial that reported on side effects, only infrequent minor bleeding upon needle removal was noted¹³. No other adverse effects were reported.
- Four cases of inflammation of the outer part of the ear canal (external otitis) and ear lobe associated with the use of ear acupuncture for smoking cessation have been recorded²⁷.
- One case of infection of the cartilage and the lining membranes surrounding the ear (perichondritis) has been reported in a patient receiving ear acupuncture with an in-dwelling needle for smoking cessation²⁸.
- A patient with known rheumatic heart (valve) disease, who was receiving ear acupuncture for smoking cessation, went on to develop a bacterial infection in the endocardium in the heart (subacute bacterial endocarditis) and blood poisoning (sepsis)²⁹.

Findings from one health technology assessment¹⁷, three systematic reviews^18-20, three surveys^22-24, one narrative review²⁵, and one case report²⁶ on the safety of acupuncture in general reviewed for this summary, indicate that side effects with acupuncture tend to be uncommon, mild and reversible. These side effects include sleepiness, fainting, nausea, vomiting, aggravation of symptoms, and bleeding, bruising and/or pain at the needle site^{18, 20, 22, 23}. Other side effects may include infection and dermatitis²⁵. Estimates of the risk of developing any side effects due to acupuncture are given below:

Minor side effects (total)²³ - 67 in every 1,000 acupuncture visits
- Eg. Bleeding - 31 in every 1,000 acupuncture visits
- Eg. Needling pain - 11 in every 1,000 acupuncture visits
- Eg. Aggravation of symptoms - 10 in every 1,000 acupuncture visits
Severe nausea and vomiting²² - 1 in every 1,000 acupuncture visits

Although extremely rare, evidence of serious, potentially life threatening complications associated with acupuncture have been reported, and include punctured organs²⁰, serious infection (e.g. hepatitis^{20, 25} and streptococcal²⁰), spinal cord injury²⁰, and shortness of breath²⁵. For this summary we found that over a period of 33 years (1966-1999) information on six deaths associated with acupuncture had been published. Two deaths were from infections (streptococcal toxic shock-like syndrome and pyohemothorax)²⁰ one was due to compression of the heart by blood (cardiac tamponade)²⁶, one was from a collapsed lung (pneumothorax)²¹, one was from inflammation of the lining of the heart (endocarditis)²¹, and one was from a severe asthma attack²¹.

Cited references

To find out more about any of the references listed below go to the "About page" of this website and read the section titled "How can referenced articles be obtained."

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