WITHDRAWAL FROM TOBACCO SMOKING
The effectiveness of acupuncture for drug withdrawal, including smoking cessation, has been proclaimed by acupuncturists in the U.S. since the early 1980’s. Much of the work in this area was stimulated by the reports of Michael Smith, who developed an acupuncture protocol for “drug detox” in the late 1970’s. His work focused especially on the use of ear acupuncture, following the work of surgeon-acupuncturist Paul Nogier in France. Smith has also pursued the question of the nature of addiction and the setting required to help patients overcome addiction. Though Smith’s work was mainly involved with difficult inner-city drug problems like heroin addiction, the principles and methods have been applied to nicotine addiction in daily smokers. Explanations for the role of acupuncture in drug withdrawal, such as inducing enkephalins and endorphins to reduce the anxiety and stress as the blood levels of the drug decline, were proposed. The results of testing for these substances have been somewhat contradictory.
Several state and city governments have indicated their support by providing funds for acupuncture centers focusing on drug withdrawal for illegal drugs or illegal use of drugs (such as driving under the influence of alcohol). Such support continues in several cities (there are more than 300 acupuncture-based substance abuse programs in the U.S., many of them funded by governmental agencies) and an organization to promote this methodology, the National Acupuncture Detoxification Association (NADA), was formed in 1988. It has a current membership of nearly half of all American acupuncturists.
There is now great social reinforcement for stopping smoking. The medical profession, to the extent it is represented by the largest member organization, the American Medical Association, has taken up a campaign to encourage all smokers to quit, regardless of their current health status (formerly, this effort was made only when smoking was a known contributor to the disease the patient suffered from). Public health messages about the harm associated with smoking have dramatically increased in numbers. As a result, personal support for continued restraint is easily obtained. Nonetheless, the long-term quit rate for tobacco smoking appears to be holding fairly constant, with slightly more than half of all people who take up the habit giving it up at some time in their life.
The currently accepted stop-smoking methods usually involve counseling plus application of nicotine in doses that reduce craving for the drug while being diminished gradually. Nicotine patches and nicotine gum are examples of delivery systems that separate the nicotine from the act of smoking. The effectiveness of these methods can be determined with some accuracy because it is possible to provide placebo alternatives and observe the difference in smoking cessation rates.
In order to interpret the studies of acupuncture effects on smoking cessation, it is important to examine some basic considerations in any kind of smoking cessation approach:
<![if !supportLists]>1. <![endif]>Patients who volunteer to stop smoking, because they desire to quit, are more likely to succeed than patients who are assigned, cajoled, or otherwise induced to enter a program with little personal desire to quit.
<![if !supportLists]>2. <![endif]>Short-term smoking cessation, that is, stopping smoking at the end of a stop-smoking program, is easier to attain than long-term smoking cessation. Regardless of the method used to stop smoking, once the stop-smoking treatment method is withdrawn (with successful cessation), a variety of factors can affect the individual so as to induce re-initiation of smoking. Generally, if a person has stopped smoking for a full six months, the chances of starting smoking again are very low. Therefore, six month cessation rates, one year cessation rates, and two year cessation rates are similar regardless of the method employed.
<![if !supportLists]>3. <![endif]>Short term smoking cessation success may depend on the extent to which the intervention provides regular reinforcement of the stop-smoking effort. A person left to his or her own is more likely to resume smoking than a person who daily encounters someone who reinforces the stop smoking attempt.
<![if !supportLists]>4. <![endif]>Those who take up smoking in their teens and maintain the habit for many years have a more difficult time quitting smoking than those who take up smoking later in life. The “early-onset” smoking addiction may correlate with genetic and behavioral patterns that lead to addiction, while “late onset” smoking is more often a habit of choice. About 80% of U.S. smokers begin their habit by age 18.
For these reasons, acupuncture research that involves daily treatment of volunteer patients—especially those who took up smoking late and who desire to stop smoking—should attain a high level of short-term effect, and the long-term effect should be reasonably good, but not necessarily better than other methods that take volunteer patients of similar characteristics.
Research about acupuncture effects on smoking cessation have mostly been conducted without a control group. This means that all of the non-specific effects of a stop-smoking program, such as the decision to stop smoking, the regular visits to a stop-smoking assistant (a health professional, for example), and the cessation of smoking at least for a day or two during the program as occurs for those who do not quit the program, all contribute to a positive outcome that could also be attained by a placebo treatment. Therefore, it is difficult to know the full contribution, if any, of acupuncture to the success rate.
REVIEWS OF ACUPUNCTURE RESEARCH ON SMOKING CESSATION
Two major reviews of this subject have been presented recently. One, a two part report in the Journal of Traditional Chinese Medicine (1, 2), is by Cui Meng, at the Institute of Information on Traditional Chinese Medicine, in Beijing. The other appeared in a special issue of the Journal of Alternative and Complementary Medicine, which presented the papers from the NIH Technology Assessment Workshops on acupuncture (3). The article of interest in the latter journal was authored by Patricia Culliton (who works at the Hennepin Faculty Associates in Minneapolis, which may be the biggest Chinese medicine treatment center in the U.S.), and Tom Kiresuk, who works at the Center for Addiction and Alternative Medicine Research.
In Cui’s article, about using acupuncture for attaining abstinence from drug use, under abstaining from smoking, this is said:
The long-term effective rate was about 30%. Lebeau, et al., analyzed and studied a total of 84 papers involving over 10,000 volunteers for giving up smoking with acupuncture and psychotherapy, and found that the average withdrawal rate was about 60% at the end of treatment and it was about 30% at 12 months after treatment. Schwartz analyzed nearly 30 papers of studies on acupuncture abstaining from smoking, and found that the mean withdrawal rate ranged between 8% and 40% at 12 months after the end of treatment, and it was around 25% as followed up for six months in 13 papers involving 4,000 smokers...
To put this in perspective, what is being said is that after a few days of treatment (all that is needed for initial withdrawal, see below), about 60% of patients (average of all studies) had stopped smoking, and that rate dropped to about 25–30% within six months and stayed at that level (follow-up for two years gave the same result, as indicated elsewhere in his report). Of course, some individual reports analyzed to attain these averages indicated much higher short-term withdrawal rates, sometimes claiming over 90%. Because Chinese journals mainly publish only successful studies, the figures of 60% short-term and 30% long-term positive results are undoubtedly somewhat high, as the studies with low success rates usually don’t get published and, therefore, don’t get included in the calculated average outcome. Also included in his summary, Ciu mentioned that Yves Requena in Paris reported on the use of ear plus nose acupuncture for smoking withdrawal. His study involved a total of 1138 smokers: 56% gave up smoking, and most of the others reduced the amount that they smoked (29% reduced smoking by less than half their previous amount). This outcome (for short-term smoking cessation) is consistent with the figure of 60% given above.
In the second part of his report, Cui describes factors that influence the outcome of treatment, based on the reported results. In sum, he concluded that the desire to stop smoking did not impact the short-term effects, but did affect long-term success; confidence in the possible effectiveness of the stop-smoking attempt did not influence outcome, and “psychic” support from the doctor exhibits “remarkable effect” on the cure. By psychic support, he refers to talks by the doctor and tips on maintaining a non-smoking environment. He has a section of this article titled “Regarding the possibility of a placebo effect in acupuncture as a method in giving up smoking.” Here, he says:
Results of 11 controlled studies on therapeutic acupuncture and placebo acupuncture treatments were that in only two studies the effects of the therapeutic acupuncture were significantly superior to those in placebo acupuncture (P<0.05), while the therapeutic effects of placebo were somewhat better in another 3 of the 11 studies, suggesting that acupuncture may be a placebo therapy in stopping smoking.”
Since sham acupuncture was used as a control, the failure of standard acupuncture to do better than the sham acupuncture may not rule out the value of acupuncture; it may simply indicate that the site of applying the needles is not especially important. This conclusion would be consistent with the high degree of variability among stop-smoking acupuncture treatments that are claimed to be effective (though an equally consistent conclusion would be that none of the treatments are effective).
In the review article by Culliton and Kirusek, which describes acupuncture therapy for treating persons with substance abuse problems, under the heading “nicotine” they state:
Generally, the literature regarding the use of acupuncture for smoking appears to be similar to the rest of the substance abuse acupuncture literature. Several articles can be characterized by their emotional tone and evident, prior beliefs. Believers find minimal supporting evidence as very encouraging, whereas debunkers dismiss the value of any preliminary findings. The studies are not comparable and have not been replicated....Overall, one might conjecture that many forms of psychosocial and other treatments will reduce smoking behavior temporarily. The treatments can be expected to become indistinguishable in longer term relapse rate comparisons. Nonspecific and placebo treatment effects may form the basis of the efficacy of all treatments. Generally, the research in this area is inconclusive....
In their section on “additional studies,” this is said:
The meta-analysis by Ter, Reit, Kleijnen, and Knipschild (1990) reviewed 22 controlled clinical studies of the efficacy of acupuncture, including 15 cigarette smoking, 5 heroin, and 2 alcohol treatment studies. The authors concluded that the quality of research was generally poor and that the results did not support the efficacy of substance abuse acupuncture treatment.
These reviews suggest that acupuncture therapy for withdrawal from smoking may have marginal or no substantial effects beyond the non-specific influence of program participation (encouragement by the acupuncturist, structured setting, repeated office visits, etc.). This raises the question of whether or not it is worthwhile to delve in detail into any specific treatment protocols. In fact, Culliton and Kirusek point out that:
The acupuncture protocols vary as to location and number of needle site placement. The methods include staples, needles, lasers, and stitches, with and without electrical stimulation. The frequency and duration of treatments is not comparable [between studies]. Studies that use a total of two or three treatments on a once-per-week schedule may be testing subclinical dosages....
Similarly, Cui gives examples of several different treatment methods and point sets, and these serve just as a few examples of the dozens of methods used in the reports, with no mention of any specific treatment having been studied repeatedly.
In a review of pharmacotherapy for smoking (4), it was reported that in placebo controlled trials, nicotine gum and patches increased quit rates (all measured at six months) over placebo by a factor of 1.6 to 2.8. Nicotine nasal spray and nicotine inhaler had similar benefits, with improvements ranging from 1.0 (no improvement) to 3.5. A non-nicotine withdrawal drug, bupropion hydrochloride (an antidepressant), had two tests indicating an improvement by a factor of 1.5–1.7. According to these carefully designed studies, six month quit rates among the placebo groups ranged from 4–19%, with the wide range of variation attributed to differences in trial designs. The highest quit rates reported with the tested therapies were in the range of 25–35%, consistent with the rates claimed in the Chinese studies summarized above (25–30%). Unfortunately, the American and Chinese studies cannot be compared directly, because the setting of the studies is so different. Still, it is tempting to suggest that acupuncture therapy may be as successful as the treatments currently accepted in the U.S., both attaining about a 30% long-term quit rate.
On the other hand, it has now been suggested that by combining two of the standard methods, the nicotine patch with either nicotine gum or nicotine nasal spray, it is possible to improve on the smoking cessation rates. In the British Medical Journal, a study conducted in Finland yielded results that suggested using the two methods together could double the smoking cessation rate compared to using only one of the methods. If that finding is confirmed by further studies, it would mean that a very effective method, superior to acupuncture therapy, is now available.
POSSIBLE CONTRIBUTIONS OF ACUPUNCTURE TO SMOKING CESSATION SUCCESS
The poor status of the acupuncture literature does not rule out the possibility that acupuncture, when performed properly, aids some people in drug withdrawal. Acupuncture is known to stimulate the production of enkephalins and endorphins, which have a potential effect if acupuncture stimulation is given at least daily or, more suitably, if stimulation can be repeated several times throughout each day of withdrawal (this is why once a week acupuncture may be “under-dosing”). However, Pomeranz studied the levels of these substances in the brain and found that they were not changed during acupuncture (3); since the brain is the site of the drug addiction problem, this negative finding may counter the claimed benefit of acupuncture on the basis of this important mechanism of action.
One of the possible contributions to smoking cessation is a possible change in the taste experience of cigarettes. This affect would be suited to persons who are unwilling to simply stop smoking and have their symptoms treated, and who, instead, want help in overcoming the desire for smoking.
In an evaluation conducted in China (5), it was reported that there is a change in taste thresholds caused by ear acupuncture with points selected for cigarette smoking withdrawal; the change occurs in both smokers and non-smokers. In a group of 28 smokers treated by acupuncture, 26 found that the taste of the smoke became less desirable or even objectionable.
The English-Chinese Encyclopedia of Practical Traditional Chinese Medicine (6) describes a treatment for stopping smoking using the ear points treated with strong stimulation, followed by retention of needles for 15–20 minutes; subcutaneous needles retained for longer periods could also be used. Body acupuncture is another method suggested; the points are to be needled by the reducing method, retaining the needles for 20–30 minutes (manipulating them 2–3 times). Further, electric stimulation can be undertaken for 15–20 minutes. From all these efforts, it is said that the smoker will know that the treatment is effective if after 2–3 days there is a change in the taste of the smoke, making it less desirable. It is also recommended, in this text, that the person increase nutritional food intake, take herbal pills to calm the heart and mind, and also take some vitamins.
Dr. Tan Yee-ying, reported on his experience treating tobacco smoking addiction at the Fourth International Congress of Chinese Medicine (7). Relying primarily on ear acupuncture, he would apply the needle twice per week for 5 weeks (10 treatments). During the first 2–3 weeks, nearly all smokers are able to quit (90%). A few smokers who did not respond to the auricular acupuncture alone would also get treated with appropriate body points to achieve success. Only 10% of the individuals he treated were unable to stop smoking by the end of the treatment. The long-term effectiveness of treatment was claimed to be high; of 270 who quit, only 25 (9%) resumed smoking. The change of taste of the smoke was noted by 210 persons, complaining that the taste had turned bad. Additionally, 30 persons felt nauseated by smoking as a result of treatment, and another 30 felt hot.
In all these studies, the patients did not simply quit smoking, but withdrew gradually. This withdrawal was largely as a result, at least according to the author’s claims, of a change in taste, or other discomfort that occurred with smoking. Further research efforts to show that the taste of cigarette smoke could change markedly by acupuncture therapy would be worthwhile, despite the fact that, at least thus far, no reports of acupuncture changing the taste of food and beverages have been reported. For example, acupuncture for treatment of obesity due to overeating is not said to function by making the food taste less desirable.
OTHER CONTRIBUTIONS OF ACUPUNCTURE
Because clinical studies of acupuncture for quitting smoking use success in smoking cessation as the measured end-point, other possible benefits of acupuncture treatment are not taken into consideration. Even in those situations where acupuncture fails to provide an increase in smoking cessation success rates compared to a placebo treatment, acupuncture may contribute to a better experience for the smoker attempting to quit. Acupuncture therapy is claimed, by recipients, to alleviate several symptoms, including nervousness, agitation, and other signs of mental distress. This calming effect may make the smoking cessation experience less stressful. In fact, some of the ear acupuncture protocols used for stopping smoking are also applied to non-smokers for simple treatment of stress reactions. Advertisements for one of the standard stop smoking products emphasize the ability of the product to “soothe” and to “calm” as the means of providing the desired effect on smoking cessation.
For those who succeed in stopping smoking, the positive experience of acupuncture on the discomforts during withdrawal may lead the recipient to encourage other smokers to try the stop-smoking procedure, using acupuncture as a means of making the process more acceptable. For those who fail to stop smoking, by minimizing the adverse symptoms of nicotine withdrawal may increase the likelihood that the individual will make a second attempt later, which might provide the opportunity for success.
Perhaps the best evaluation of this field was referring again to Cui’s review, he concluded:
The results of the present studies show that the therapeutic effect of acupuncture for stopping smoking and drinking are not lower than for other withdrawal therapies....It is an alternative when other methods fail. However, as with other therapies, there may be recurrence. The therapeutic effect decreases with time, and short-term therapeutic effects are also unstable....The therapeutic effects can be enhanced by the combined use of acupuncture and psychotherapy, giving a higher withdrawal rate....
As evidence of the instability of results, Cui cites a study by Lamontagne, in which smokers were divided into two groups, one with a high expectation of success in quitting and one with a low expectation of success. The study revealed no difference in outcomes between those two groups, but the resumption of smoking over time was evident. At the end of the acupuncture treatment period, 28% had quit smoking; after one month, 24% of the original group was still not smoking; after three months the figure was down to 20%; and by 6 months it was down to 10%. Researchers in the U.S. have indicated that persons who simply stop smoking on their own (cold turkey), do not have much long-term success, about 5% are still not smoking after one year, and this figure seems to correspond to the changes that are observed in the Lamontagne study. While the sum of all acupuncture stop-smoking studies suggests a long-term quit rate on the order of 25–30% (which is considerably higher than in this study), the general trend seems to be similar to this reported result: when there is as much as a 60% quit rate at the end of treatment, there is only a 25–30% maintained quit rate at six months.
Certainly, smokers who wish to quit smoking have a wide range of effective techniques available to them, including nicotine administration (patch, gum, nasal spray, and inhaler), psychotherapy, and acupuncture, and anyone who is encountering difficulty may be able to combine these therapies to attain their goal.
<![if !supportLists]>1. <![endif]>Cui Meng, Advances in studies on acupuncture abstinence, Journal of Traditional Chinese Medicine, 1995, 15(4): 301–307.
<![if !supportLists]>2. <![endif]>Cui Meng, Advances in studies on acupuncture abstinence (continued), Journal of Traditional Chinese Medicine 1996; 16 (1): 65–69.
<![if !supportLists]>3. <![endif]>Culliton PD and Kiresuk TJ, Overview of substance abuse acupuncture treatment research, Journal of Alternative and Complementary Medicine 1996; 2(1): 149–159.
<![if !supportLists]>4. <![endif]>Huges JR, et al., Recent advances in the pharmacotherapy of smoking, Journal of the American Medical Association 1999; 281(1): 72–76.
<![if !supportLists]>5. <![endif]>Li Qisong, et al., A preliminary study on the mechanism of ear-acupuncture for withdrawal of smoking, Journal of Traditional Chinese Medicine 1987; 7(4): 243–247.
<![if !supportLists]>6. <![endif]>Xu Xiangcai (chief ed.), English-Chinese Encyclopedia of Practical Traditional Chinese Medicine, 1990 Higher Education Press, Beijing.
<![if !supportLists]>7. <![endif]>Tan Yee-ying, Clinical observation of the treatment of cigarette smoking by implanted auricular acupuncture, 1988 Proceedings of Fourth International Congress of Chinese Medicine: p 14.