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A meta-analysis of the effectiveness of acupuncture in smoking cessation.
Ashenden R, Silagy C A, Lodge M, Fowler G..
A meta-analysis of the effectiveness of acupuncture in smoking cessation.
Drug and Alcohol Review,
1997,
16,
pp.33-40
Record status
This record is a structured abstract written by CRD reviewers. The original
has met a set of quality criteria. Since September 1996 abstracts have been
sent to authors for comment. Additional factual information is incorporated
into the record. Noted as [A:....].
Author's objective
To undertake a systematic review of all randomised controlled trials which
have examined the effectiveness of acupuncture as an aid to smoking cessation.
Type of intervention
Treatment.
Specific interventions included in the review
The following acupuncture points were used: lung, ear, hunger auricular, gall
bladder, Shuai gu, Tong zi Liao, Qiuhou, Shenmen, Yin Tang, Giap Ty and Zu San
Li with or without small plastic bead or press needles being left in situ.
Acupuncture and electro acupuncture were studied.
Participants included in the review
Volunteers including those of both sexes participated in the trials.
Inclusion and exclusion criteria varied between studies and details are given
of the criteria used for each study.
Outcomes assessed in the review
The outcome assessed was smoking cessation at 1,3, 6 and 12 months (where
available). The strictest criteria used to define abstinence was used for each
study. Smoking cessation was defined by self-reporting, validated by expired
CO<5ppm or validated by two significant others nominated by the subject.
Study designs of evaluations included in the review
Randomised controlled trials which examined the effectiveness of acupuncture
in smoking cessation were included if they had at least two treatment groups
and allocation to groups was by formal randomisation. Excluded were studies
with historical controls, trials of short (less than three months) duration
and those that did not include measurement of smoking cessation. Follow-up
periods ranged from 6 to 12 months.
What sources were searched to identify primary studies?
The following databases were searched from inception until December 1994:
MEDLINE, Psych Abstracts, Dissertation Abstracts, Health Planning and
Administration, Social Scisearch, Smoking and Health, Embase, Biological
Abstracts and Drug. The key search words used were "smoking cessation" and
"acupuncture" in combination. Also examined were published reviews, reference
lists from clinical trials, conference abstracts (from primary care meetings
and the World Conference on Tobacco and Health), smoking and health bulletins
and the bibliography on smoking and health.
Criteria on which the validity (or quality) of studies was assessed
The following criteria were used to assess the primary studies: quality of
randomisation, intention to treat analysis and the blinding of assessors of
cessation to the treatment group. A score from one to three was given to each
study for each dimension, with one being scored if little or no attempt had
been made to control potential bias. The original authors were contacted for
further information if methods to control bias were unclear. Scores for
individual trials on these three criteria are given.
How were the judgements of validity (or quality) made?
Not stated.
How were decisions on the relevence of primary studies made?
Not stated.
How was the data extracted from primary studies?
The following data were extracted from the primary studies by two authors
independently with disagreement being resolved by referral to a third author:
country of origin, study population, eligibility criteria, nature of the
intervention, details of study design (including method of allocation,
blinding, study structure), outcome measures and validation of smoking status.
Patients lost to follow-up were treated as continuing smokers.
Number of studies included
9 randomised controlled trials (RCTs) were used to assess effectiveness of
acupuncture on smoking cessation at 6 months: N = 4115 volunteers, with 1237
receiving acupuncture.
4 RCT's were used to assess effectiveness of acupuncture on smoking cessation
at 12 months: N = 2941 volunteers.
5 RCT's were used to compare acupuncture with sham acupuncture N = 463 plus
one RCT with four arms of combinations of acupuncture, nicotine gum, sham
acupuncture and placebo gum N= 1532.
2 RCT's were used to assess acupuncture compared to group therapy N = 332.
2 RCT's were used to assess acupuncture compared to nicotine gum N = 1425.
1 RCT was used to assess acupuncture compared to behaviour therapy N = 64.
1 RCT was used to assess acupuncture compared to individual hypnosis N = 24.
1 RCT was used to assess acupuncture compared to group hypnosis N = 22.
How were the studies combined?
The odds ratios were combined using the methods of Peto, a fixed effects
model.
How were differences between studies investigated?
The Mantel-Haenszel test was used to assess heterogeneity between trials.
Sensitivity analysis was performed by omitting one trial in which the number
of subjects was small and doubt existed about the randomisation method and
after considering only trials comparing acupuncture with placebo or no
acupuncture.
Results of the review
Most studies scored poorly in their method of randomisation and in the
assessment of outcome.
At 6 months: OR = 1.83 (95%CI: 0.97, 3.46 ). Test for heterogeneity 9.45 (P =
0.05).
At 12 months: OR = 1.47 (95%CI: 1.10, 1.98). Test for heterogeneity 7.22 (P =
0.07).
Total: OR = 1.53 (95%CI: 1.17, 2.00). Test for heterogeneity 17.03 (P = 0.09).
Acupuncture versus sham acupuncture: OR 1.16 (95%CI: 0.90, 1.49). Test for
heterogeneity: 5.36 (P = 0.37).
Acupuncture versus group therapy: OR 2.23 (95%CI: 1.16, 4.28).
Acupuncture versus nicotine gum: OR 0.77 (95%CI: 0.54, 1.11).
Acupuncture versus behaviour: OR 0.77 (95%CI: 0.29, 2.09).
Acupuncture versus individual hypnosis: OR 0.36 (95%CI: 10.07, 3.01).
Acupuncture versus group hypnosis: OR 0.52 (95%CI: 0.09, 3.01).
Was any cost information reported?
Not stated.
Author's conclusions
While acupuncture appears promising there is insufficient evidence at present
to recommend it as an effective form of therapy. More direct comparative
trials with larger numbers of subjects are required before the effectiveness
of acupuncture can be reliably compared against these other therapies.
CRD commentary
This is a clearly written and well conducted review. The extensive literature
search should have revealed most of the relevant studies though as the authors
point out some results from unpublished trials with less favourable results
may have been omitted. The inclusion criteria for the primary studies were
defined as were the criteria for evaluating the quality of the included
studies. The quality scores obtained by the individual trials and reported in
the review reveal that most of the primary studies had not accounted for
potential sources of bias. Details are given of the rigorous methodology used
in data extraction but similar detail is not given on the methods of study
selection or quality scoring. The potential for bias in the primary studies
justifies the authors reservations about the effectiveness of acupuncture
based on the studies included in this review.
Subject index terms
Subject indexing assigned by CRD: Acupuncture-Therapy; Smoking-Cessation/mt
[Methods]
Correspondence address
Professor C A Silagy, Department of General Practice, Flinders University of
South Australia, Bedford Park, SA, 5042, Australia.
Copyright
University of York, 1998
Database no.: DARE-978083
