Review Article

Split Viewer

Journal of Acupuncture Research 2022; 39(4): 258-266

Published online November 23, 2022

https://doi.org/10.13045/jar.2022.00185

© Korean Acupuncture & Moxibustion Medicine Society

A Literature Review of Randomized Controlled Trials on Tobacco Cessation Using Auricular Acupuncture and Auricular Acupressure

Min-Gi Jo1, Jun-Yeong Jang1, Min-Jung Ko1, Sang-Yeup Chae1, Seungeun Lee2, Dongmin Lee2, Won Suk Sung3, Jung-Hyun Kim1, Bonhyuk Goo1, Yeon-Cheol Park1, Yong-Hyeon Baek1, Sang-Soo Nam1, Byung-Kwan Seo1*

1Department of Acupuncture and Moxibustion Medicine, Kyung Hee University Korean Medicine Hospital at Gangdong, Seoul, Korea;2Department of Clinical Korean Medicine, Graduate School, Kyung Hee University, Seoul, Korea;3Department of Acupuncture and Moxibustion Medicine, Dongguk University Bundang Oriental Hospital, Seongnam, Korea

Received: July 9, 2022; Revised: September 27, 2022; Accepted: October 12, 2022

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

This study aimed to analyze auricular acupressure and auricular acupuncture used in smoking cessation research by analyzing published randomized controlled trials. Eight databases (PubMed, Cochrane, EMBASE, CNKI, CiNII, KMbase, KISS, OASIS) were searched until December 2021, and 21 out of 1,919 studies met inclusion criteria. Data on the treatment site, time, frequency, period, and outcomes were analyzed. Lung (MA-IC1) and Ear Shenmen (MA-TF1) were the most used acupoints. The number of treatments varied between a minimum of 2 to a maximum of 24, and treatment duration varied between a minimum of 2 weeks to a maximum of 8 weeks. Cigarette consumption and smoking cessation rate were the most studied outcome, followed by multiple other psychological indications.

Keywords acupuncture, acupressure, auricular acupuncture, randomized controlled trial, traditional medicine

Smoking, referring to the act of smoking tobacco, is an activity that is considered a personal preference. However, since it was confirmed that smoking causes various conditions/diseases and that smokers who quit often experience withdrawal symptoms, smoking has been recognized as a chronic condition/disease facilitated by “nicotine dependence” [1]. Smoking is a major risk factor for cancer, cardiovascular disease, and respiratory disease [2]. The direct and indirect socioeconomic cost of smoking was reported to be 185.2 billion dollars in 2012, accounting for 1.8% of global gross domestic product (data from 152 countries) [3]. The incidence of smoking in Korea has been decreasing over the last decade from 27.5% of the national population in 2010, to 20.6% in 2020 [4]. Nevertheless, smoking is the cause of 58,000 deaths yearly in Korea, and its socioeconomic cost reaches 12 trillion won each year [5].

Smoking cessation is a recommendation the world over. In Korea, various anti-smoking campaigns have been implemented, including the use of health risk warning photos, increasing tobacco tax, and strengthening regulations on cigarette advertising and promotion. In the US, an approach welcomed by patient focus groups is a source of medical care including complementary medicine together with conventional medicine [6], whereby anti-smoking acupuncture should be considered an option covered by healthcare providers.

Quitting smoking is defined as the act of stopping smoking. Following smoke cessation, as the nicotine concentration in the body decreases, the effects of tobacco abstinence (anger, anxiety, depression, difficulty concentrating, impatience, insomnia, and restlessness) peak in the 1st week and last for 2–4 weeks [7].

In 2014, Cochrane published a systematic review related to various acupuncture therapies Among them, auricular acupuncture and auricular acupressure were determined to have the strongest effect on smoking cessation in a short period of time, however these studies were not free from bias [8].

This study reviewed anti-smoking acupuncture practices up to December 2021 by reviewing literature on auricular acupuncture and auricular acupressure.

Data sources and search strategy

A comprehensive literature search in domestic and foreign electronic databases was conducted up to December 2021. Records from PubMed, Excerpta Medica database (EMBASE), Cochrane Library, Citation Information by NII (CiNii), China National Knowledge Infrastructure (CNKI), Korean Medical database (KMBASE), Korean Studies Information Service System (KISS) and Oriental Medicine Advanced Searching Integrated System (OASIS) were analyzed.

The search terms were “smoking,” “quit,” and “ear,” “auricular,” and “acupressure,” “acupuncture” to cover the intervention methods. Depending on the characteristics of each search engine, additional languages were used. Details of the search strategy used in each electronic databases are described in Supplement 1.

Study selection

After performing database searches, duplicate literature was excluded by two Korean medicine doctors who also performed the process of selection by assessing the titles and abstracts. Then full paper texts were assessed and in cases without an agreement, a supervisor made the final decision.

Data analysis

Analysis of the characteristics of selected studies

The studies were analyzed according to their treatment method, time, frequency, and period. Acupoints that indicated treatment sites were also included. In the treatment method, not only were the types of treatment divided into auricular acupressure and auricular acupuncture, but the accompanying treatment was also described and classified.

Analysis by outcome measures

The outcome measures of acupuncture and acupressure treatments aimed to cease smoking including the comparison between the intervention group and the control group were analyzed. Only studies with numerical outcomes were included.

Study selection and description

A total of 1,919 studies were retrieved from the databases and 1,357 articles were screened after duplicates were excluded. There were 1,133 studies excluded following screening of the abstracts and 203 articles were excluded following screening of the full text. There were 21 RCTs reviewed, and of these, 16 studies were written in English, 3 studies were written in Chinese, and 2 studies were written in Korean (Fig. 1). Extracted data such as treatment method, time, frequency, period, sites, and outcome measures are described in Table 1 [929].

Treatment groups of selected studies

There were 3 cases of auricular acupuncture alone, 13 cases of auricular acupressure alone, 1 case of acupuncture and auricular acupressure combined, and 4 cases of acupuncture plus auricular acupressure with electroacupuncture. In all studies using auricular acupuncture and auricular acupressure together, auricular acupressure was applied following auricular acupuncture treatment.

Fine acupuncture needles were used for auricular acupuncture treatment. For auricular pressure, treatment tools were classified in various ways including a sterile 36-gauge 0.5-inch (0.2 × 13 mm) acupuncture needle fixed with tape, ion pellets fixed with tape, and seeds of plants (such as Semen vaccaria, and Semen sinapis albae) fixed with tape. In all studies using auricular acupressure (in which the treatment method was mentioned), alternate targeting of the left and right auricle was adopted.

In the analysis for auricular acupuncture and auricular acupressure, MA-IC1 was used the most frequently (17 studies), MA-TF1 ranked second (15 studies), and Mouth (MA-IC5) ranked third (13 studies). When auricular acupuncture and auricular acupressure were analyzed separately, MA-IC1 was used the most in both groups, followed by MA-TF1. Detailed acupuncture points used for auricular acupuncture and auricular acupressure are described in Table 2.

Classification of the number of studies through treatment points, frequency, and period

Regarding the number of acupuncture points used for treatment, 6 points were the most common (5 studies). There were 4 studies that used 4 or 5 points. The maximum number of acupoints used was 7 and the minimum number was 1 point (Fig. 2A). As for the frequency of treatment, 6 studies used treatment once a week and 6 studies used treatment twice a week (Fig. 2B). The period of treatment was observed to be a minimum of 2 weeks and a maximum of 8 weeks. The largest proportion of studies treated for 8 weeks (5 studies; Fig. 2C).

Control group and outcome domains

As a control group, sham treatment was most often used. Psychological techniques such as counseling and education, Western medicine treatments such as nicotine replacement therapy, and transcutaneous electrical nerve stimulation are were also used. Studies with an untreated group as a control group were also included (Table 3 [929]). The results included smoking cessation rate, cigarette consumption based on daily smoking volume, efficacy rate and psychological indicators. Psychological indicators included smoking cessation questionnaires such as Fagerstrom Nicotine Dependence Test (FTND), Hughes and Hatsukami’s Nicotine Withdrawal Symptom Score (HHWQ), Heaviness of Smoking Index, and Minnesota Nicotine Withdrawal Scale were used. The Short Form Health Survey 36 was used to measure Quality of Life, the Beck Depression Inventory (BDI), a depression related questionnaire, and the Symptom Checklist-90 were employed to assess psychiatric symptoms. Among the psychological indicators, FTND was the most frequently used (6 cases). Overall, the tobacco consumption index and smoking cessation index were used most often (10 cases; Table 4).

Smoking not only causes various conditions and diseases, but is also associated with high economic costs. Thus, global anti-smoking campaigns aim to prevent/stop people smoking. Nevertheless, many people smoke. A report released by the World Health Organization in 2020, determined that 22.3% of the world’s population were smokers and 36.7% were men and 7.8% were women [30]. The main reasons why quitting smoking is difficult are due to the withdrawal symptoms experienced by the individual and the desire to smoke because of their addiction to nicotine. To ease these withdrawal symptoms, nicotine replacement therapy (providing nicotine without using cigarettes), pharmacotherapy such as varenicline and bupropion (used to improve abstinence), and counseling are recommended [31].

In the Diagnostic and Statistical Manual of Mental Disorders, 5th edition, tobacco withdrawal criteria (for daily use of tobacco for several weeks or more) includes at least four of the following signs and symptoms: irritability, frustration, anger, anxiety, difficulty concentrating, increased appetite, restlessness, depressed mood, insomnia within 24 hours of abrupt cessation of tobacco use, or reduction in the amount of tobacco use [32]. Short-term smoking cessation has been reported to cause not only physical symptoms such as changes in systolic blood pressure, but also to induce negative mood and cognitive decline [33].

Auricular acupressure is a nonpharmacological intervention. It treats a wide range of conditions through the application of pressure to acupoints [34]. The various therapeutic effects can be delivered by pressing a specific acupuncture point in order to decrease tissue adhesion, promote relaxation and regional blood circulation, increase parasympathetic nerve activity and intramuscular temperature along with reduction in neuromuscular excitability [35].

There are many mechanisms responsible for the effect of auricular acupuncture and auricular acupressure. In the case of relaxation, the auricular branch of the vagus nerve is stimulated during treatment, leading to an increase in parasympathetic nerve activity and modification of both autonomic and central nervous system activity [36]. The representative acupoints for relaxation are MA-TF1 and Sympathetic (MA-AH6), and auricular acupressure applied to auricular acupoints has various positive effects including improvement in quality of sleep, and reduced blood pressure [3739]; auricular acupuncture also reduces symptoms of depression [40].

We believe the reason MA-TF1 and MA-AH6 are the most commonly used acupuncture points, besides the Lungs (MA-IC1) and MA-IC5, is because of the direct connection of these acupoints with breathing and relaxation which may be related to the treatment of the psychological symptoms associated with smoking withdrawal.

Various numerical psychological indicators were used in addition to the numbers which directly related to the amount of smoking. Among these indicators, questionnaires designed for smoking cessation such as FTND and HHWQ, and psychological indicators such as BDI and SCL-90, were used. Measuring tools related to smoking cessation not only measure amounts of smoked cigarettes per day, but also include psychometric indicators such as nicotine dependence, craving, withdrawal symptoms, self-efficacy, and quality of sleep [41]. BDI measures symptoms of depression [42] and SCL-90 is a questionnaire that evaluates the overall level of mental health, including depression [43]. This highlights the relationship between smoking cessation and mental status.

Treatment methods specifying the acupoints, treatment time, frequency of treatments, and duration of treatment period significantly influence the efficiency of acupuncture [44]. The treatment time of each study was different, but due to the characteristic of the auricular acupressure, it is considered that treatment was continuously performed except for the replacement time. Therefore, the stability of auricular acupressure can be determined due to the fact that there were no serious side effects (even though treatment has been continuously performed during the study period of up to 8 weeks). The side effects of auricular acupuncture are similar to those of body acupuncture, and the efficacy and stability of auricular acupuncture, and auricular acupressure have been previously reported [45].

Most of the RCT studies reported that auricular acupuncture and auricular acupressure were effective compared with the control group. However, only 9 of the 21 studies showed statistical significance i.e., p < 0.05. One study determined that nicotine replacement therapy was more effective than auricular acupressure [24], and one study reported that auricular acupressure was more effective than transcutaneous electrical nerve stimulation but less effective than nicotine replacement therapy [23].

This study has several limitations. Firstly, the risk of bias of the RCTs included in this review was not assessed. Secondly, due to linguistic limitations, the databases used were limited to English, Chinese, and Korean studies. Finally, we did not conduct quality evaluation to determine the level of the selected literature.

In the 21 RCT studies reviewed, many authors were aware of the importance of psychological aspects of smoking cessation treatment, and to treat tobacco withdrawal symptoms more studies used auricular acupressure than auricular acupuncture on auricular acupoints, and electronic acupuncture was typically an additional intervention. Auricular acupoints were mainly selected from two categories: directly related to breathing, such as MA-IC1, MA-IC5 and Trachea (MA-IC2), and related to mental health, such as Ear Shenmen (MA-TF1) and MA-AH6. The number of treatments varied between 2 and 24, and the treatment duration ranged from 2 weeks to 8 weeks. Cigarette consumption and smoking cessation rate were the most commonly used outcomes, but other psychological indicators were also assessed using scales such as FTND, HHWQ, QOL, MPSS, and BDI.

Conceptualization: MGJ. Methodology: MGJ. Formal investigation: SL and DL. Data analysis: MJK, SYC, WSS, JHK and BG. Writing original draft: MGJ. Writing - review and editing: YCP, YHB, SSN and BKS.
This research was supported by a grant from the Korea Health Technology R&D Project through the Korea Health Industry Development Institute, funded by the Ministry of Health and Welfare, Republic of Korea (grant no.: HF21C0192). The funding did not affect the content of the study.
Fig. 1.

Study selection and exclusion flow chart.


Fig. 2.

Classification of the number of studies. (A) According to the number of treatment points; (B) According to the treatment frequency and (C) According to the number of treatment period.


Characteristics of Selected Studies.

Author [ref] (y)Type of studyTreatment methodTreatment site (acupoints)Treatment timeTreatment frequencyTreatment periodOutcome measure
Silva [9] (2014)RCTAuricular acupressureEar shenmen, kidney, sympathetic, thirstNot recorded2 times/wk5 wkFTNDCigarette consumption
Kang [10] (2005)RCTAuricular acupressureEar shenmen, lung, mouthNot recordedNot recorded4 wkSmoking cessation rateDesire to Smoke
Wu [11] (2007)RCTAuricular acupunctureEar shenmen lung, mouth, sympatheticNot recorded1 time/wk8 wkSmoking cessation rateHHWQ
Lamontagne[12] (1980)RCTAuricular acupunctureLung, point zero20 min1 time/wk2 wkSmoking cessation rate
Bier [13] (2002)RCTAuricular acupunctureEar shenmen, sympathetic, lung, kidney, liver30 min4 times/wk5 wkSmoking cessation rateEffective rate
Zhang [14] (2013)RCTAuricular acupressureEar shenmen, lung, mouth, hunger, liver3 session/dNot recorded8 wkSmoking cessation rateCigarette consumptionQOL
Lee [15] 2017RCTAuricular acupressureEar shenmen, lung, subcortex, hunger, stomach, mouthNot recorded1 time/wk6 wkFTNDSelf efficacy for smoking cessationCigarette consumption
Wing [16] (2010)RCTAuricular acupressureEar shenmen, lung, mouth, brainAt least 3 times/d1 time/wk3 wkMPSS
Li [17] (2009)RCTAuricular acupressureEar shenmen, lung, stomach, mouth, adrenal, endocrine2–3 min/session, 3–5 session/d3 times/wk20dEffective rate
Ayse [18] (2011)RCTAuricular acupressureNot recordedNot recordedNot recorded3 wkFTNDBDICigarette consumption
Kwon [19] (2015)RCTAuricular acupressureEar shenmen, thirst, hunger, lung, mouth, subcortex5 d1 time/wk2 wkCigarette consumptionDesire to Smoke
Machovec [20] (1978)RCTAuricular acupressureNot recordedNot recordedNot recordedNot recordedEffective rate
Seok [21] (2006)RCTAuricular acupressureEar shenmen, thirst, hunger, trachea, brain3 d (frequently press)2 times/wk2 wkCigarette consumptionFTNDDesire to Smoke
Li [22] (2011)RCTAuricular acupressureEar shenmen, lung, trachea, mouth3–5 min/session2–3 session/d3 times/wk8 wkCigarette consumption
Chai [23] (2019)RCTAuricular acupressureEar shenmen, endocrine, subcortex sympathetic, lung, stomach3–5 min/d3 times/wk8 wkSmoking cessation rateFTNDHSI
Wang [24] (2018)RCTAuricular acupressureEar shenmen, endocrine, subcortex sympathetic, lung, stomach, mouth20 sec/1–2 h2 times/wk8 wkSmoking cessation rateFTNDMNWS
Waite [25] (1998)RCTEA+Auricular acupuncture+Auricular acupressureLungAcupuncture: 20 minAcupressure:As long as possible (press when experience the desire to smoke)Not recordedNot recordedSmoking cessation rate
Yeh [26] (2009)RCTEA+Auricular acupuncture+Auricular acupressureEar shenmen, lung, stomach, mouth, endocrineAcupuncture:20 minAcupressure:1 min/session3–5 session/d1 time/wk6 wkSmoking cessation rateCigarette consumption
Steiner [27] (1982)RCTAcupuncture+Auricular acupressureLung, mouthnot recorded2 times/wk2 wkCigarette consumption
He [28] (1997)RCTEA+Auricular acupuncture+Auricular acupressureEar shenmen, mouth, lung, trachea, hunger, endocineAcupuncture: 20 minAcupressure:100 press/session4 session/d2 times/wk3 wkCigarette consumption
He [29] (2001)RCTEA+Auricular acupuncture+Auricular acupressureLung, trachea, mouthAcupuncture: Not recordedAcupressure:4 session/d2 times/wk3 wkSmoking cessation rate

BDI, Beck Depression Inventory; EA, Electroacupuncture; FTND, Fagerstrom Nicotine Dependence Test; HHWQ, Hughes and Hatsukami’s Nicotine Withdrawal Symptom Score; HIS, Heaviness of Smoking Index; MNWS, Minnesota Nicotine Withdrawal Scale; QOL, Quality of Life; RCT, randomized controlled trials; SCL90, Symptom Checklist-90.


Acupoints Used for Smoking Withdrawal Symptoms Relief.

AcupointsN
Lung17
Ear Shenmen15
Mouth13
Sympathetic5
Hunger5
Stomach5
Subcortex4
Endocrine4
Trachea4
Thirst3
Kidney2
Brain2
Liver2
Adrenal1
Point zero1

Comparisons and Results of Studies.

Author [ref] (y)Intervetion (n)Comparison (n)Outcome measureResults (intervention vs. comparison)pAdverse events (intervemtion vs comparison)
Silva [9] (2014)Auricular acupressure (21)Sham auricular acupressure (9)1) FTND2) Cigarette consumption1) 2.2 ± 1.1 vs. 2.7 ± 1.62) 14.3 ± 7.0 vs. 16.7 ± 4.41) p = 0.5632) p = 0.114Not recorded

Kang [10] (2005)Auricular acupressure (159)Sham auricular acupressure (79)1) Smoking cessation rate2) Desire to Smoke1) 0.6% vs. 0%2) 1.83 ± 0.8432 vs. 1.84 ± 0.84661) Not recorded2) p = 0.1497Not recorded

Wu [11] (2007)Auricular acupuncture (59)sham auricular acupuncture (59)1) Smoking cessation rate2) HHWQ1) 27.1% vs. 20.3%2) 3.0 ± 2.7 vs. 3.7 ± 3.01) p = 0.5172) p = 0.0331 vs. 44

Lamontagne [12] (1980)Auricular acupuncture (25)Counseling (25)1) Smoking cessation rate1) 29% vs. 20%1) Not recorded0 vs. 0

Bier [13] (2002)Auricular acupuncture (12)Sham auricular acupuncture+education (20)1) Smoking cessation rate1) 21% vs. 22.4%1) p = 0.170 vs. 0

Zhang [14] (2013)Auricular acupressure (11)Sham auricular acupressure (8)1) Smoking cessation rate2) Cigarette consumption3) QOL1) 5% vs. 0%2) 10.61 ± 7.56 vs. 12.32 ± 5.473) 48.83 ± 5.44 vs.48.05 ± 4.551) p = 0.6352) p = 0.3973) p = 0.6121 vs. 5

Lee [15] 2017Auricular acupressure (27)Sham auricular acupressure (26)1) FTND2) Self efficacy for smoking cessation3) Cigarette consumption1) 2.56 ± 1.97 vs. 2.46 ± 1.482) 5.71 ± 5.81 vs. 3.00 ± 3.513) 12.33 ± 5.28 vs. 17.31 ± 6.731) p > 0.052) p < 0.053) p < 0.05Not recorded

Wing [16] (2010)Auricular acupressure (38)Sham auricular acupressure (32)1) MPSS1) 8.97 ± 3.06 vs. 8.93 ± 3.651) Not recorded0 vs. 0

Li [17] (2009)Auricular acupressure (69)Sham auricular acupressure (67)1) Effective rate1) 76.81 vs. 32.841) p < 0.010 vs. 0

Ayse [18] (2011)Auricular acupressure (24)Sham auricular acupressure (23)1) FTND2) BDI 3) Cigarette consumption1) 3.7 ± 2.9 vs. 3.9 ± 2.82) 6.9 ± 7.7 vs. 6.1 ± 9.03) 15.7 ± 9.6 vs. 12.8 ± 10.81) p < 0.052) p < 0.053) p < 0.05Not recorded

Kwon [19] (2015)Auricular acupressure (29)Sham auricular acupressure (27)1) Cigarette consumption2) Desire to Smoke1) 6.50 ± 4.78 vs. 8.15 ± 4.082) 2.07 ± 0.90 vs. 2.41 ± 1.021) p < 0.052) p < 0.05Not recorded

Machovec [20] (1978)Auricular acupressure (12)Sham auricular acupressure (12)1) Effective rate1) 66% vs. 25%1) Not recordedNot recorded


Untreated (12)1) 66% vs. 17%1) Not recorded

Seok [21] (2006)Auricular acupressure (45)Untreated (45)1) Cigarette consumption2) FTND3) Desire to Smoke1) 7.35 ± 3.03 vs. 27.53 ± 9.762) 3.57 ± 0.83 vs. 9.66 ± 1.083) 2.60 ± 0.49 vs. 4.66 ± 0.471) p < 0.052) p < 0.053) p < 0.05Not recorded

Li [22] (2011)Auricular acupressure (57)Counseling (62)1) Cigarette consumption1) 30.8 ± 9.6 vs. 24.2 ± 8.61) p > 0.050 vs. 0


Untreated (55)1) 30.8 ± 9.6 vs. 20.4 ± 11.81) p > 0.05

Chai [23] (2019)Auricular acupressure (100)Transcutaneous electrical nerve stimulation (100)1) Smoking cessation rate2) FTND3) HSI1) 23% vs. 19%2) 5.82 ± 3.22 vs. 5.55 ± 3.023) 3.41 ± 1.84 vs. 3.33 ± 1.761) p < 0.052) p < 0.053) p < 0.050 vs. 0


Nicotine replacement therapy (100)1) 23% vs. 18%2) 5.82 ± 3.22 vs.5.01 ± 3.033) 3.41 ± 1.84 vs. 3.01 ± 1.741) p < 0.052) p < 0.053) p < 0.05

Wang [24] (2018)Auricular acupressure (67)Nicotine replacement therapy (70)1) Smoking cessation rate2) FTND3) MNWS1) 32.00% vs. 46.00%2) 5.82 ± 3.22 vs. 5.55 ± 3.023) 8.64 ± 7.26 vs. 7.55 ± 6.701) Not recorded2) p < 0.053) p < 0.052 vs. 2

Waite [25] (1998)EA+Auricular acupuncture+Auricular acupressure (37)Sham EA+Sham auricular acupuncture+Sham auricular acupressure (35)1) Smoking cessation rate1) 12.5% vs. 0.0%1) p = 0.0558 vs. 3

Yeh [26] (2009)EA+Auricular acupuncture+Auricular acupressure (30)Sham EA+Sham auricular acupuncture+Sham auricular acupressure (29)1) Smoking cessation rate2) Cigarette consumption1) 13.3% vs. 13.7%2) 10.17 ± 8.28 vs. 13.41 ± 8.331) Not recorded2) p = 0.14Not recorded

Steiner [27] (1982)Acupuncture+Auricular acupressure (11)Sham acupuncture+Sham auricular acupressure (12)1) Cigarette consumption1) 13.9 ± 1.6 vs. 19.0 ± 2.91) p < 0.001Not recorded

He [28] (1997)EA+Auricular acupuncture+Auricular acupressure (22)Sham EA+Sham auricular acupuncture+Sham auricular acupressure (11)1) Cigarette consumption1) 12.3 ± 2.0 vs. 15.5 ± 2.81) p > 0.05Not recorded

He [29] (2001)EA+Auricular acupuncture+Auricular acupressure (26)Sham EA+Sham auricular acupuncture+Sham auricular acupressure (18)1) Smoking cessation rate1) 30.7% vs. 0%1) Not recordedNot recorded

BDI, Beck Depression Inventory; EA, Electroacupuncture; FTND, Fagerstrom Nicotine Dependence Test; HHWQ, Hughes and Hatsukami’s Nicotine Withdrawal Symptom Score; HIS, Heaviness of Smoking Index; MNWS, Minnesota Nicotine Withdrawal Scale; QOL, Quality of Life; RCT, randomized controlled trials; SCL90, Symptom Checklist-90


Outcome Domains of the Studies.

Outcome domainsN
Psychological scale15 [FTND (6), Desire to Smoke (3), HHWQ (1), QOL (1), MPSS (1), BDI (1), HIS (1), MNWS (1)]
Cigarette consumption10
Smoking cessation rate10
Effective rate2

BDI, Beck Depression Inventory; FTND, Fagerstrom Nicotine Dependence Test; HHWQ, Hughes and Hatsukami’s Nicotine Withdrawal Symptom Score; HIS, heaviness of smoking index; MNWS, Minnesota Nicotine Withdrawal Scale; MPSS, Mood and Physical Symptoms Scale; QOL, Quality of Life; SCL90, Symptom Checklist-90


  1. Kim, DH, and Suh, YS. Smoking as a disease. Korean J Fam Med 2009;30:494-502.
    CrossRef
  2. U.S. Department of Health and Human Servies. A Report of the Surgeon General. Rockville (MD): Department of Health and Human Servies; 2014. 443 p.
  3. Goodchild, M, Nargis, N, and D’Espaignet, ET. Global economic cost of smoking-attributable diseases. Tob Control 2018;27:58-64.
    Pubmed KoreaMed CrossRef
  4. Korea Disease Control and Prevention Agency [Internet]. Trends in prevalence of current cigarette smoking 2010. 2020 [cited 2022 May 26].
    Available from: https://www.kdca.go.kr/board/board.es?mid=a20602010000&bid=0034&act=view&list_no=719645.[in Korean]
  5. Korea Disease Control and Prevention Agency [Internet]. Number of deaths and socioeconomic costs in Korea due to smoking [cited 2022 May 24].
    Available from: https://www.kdca.go.kr/contents.es?mid=a20205010200.[in Korean]
  6. McCaffrey, AM, Pugh, GF, and O’Connor, BB. Understanding patient preference for integrative medical care: Results from patient focus groups. J Gen Intern Med 2007;22:1500-1505.
    Pubmed KoreaMed CrossRef
  7. Hughes, JR. Effects of abstinence from tobacco: Valid symptoms and time course. Nicotine Tob Res 2007;9:315-327.
    Pubmed CrossRef
  8. White, AR, Rampes, H, Liu, JP, Stead, LF, and Campbell, J. Acupuncture and related interventions for smoking cessation. Cochrane Database Syst Rev 2014:CD000009.
    CrossRef
  9. Silva, RP, Chaves, ECL, Pillon, SC, Silva, AM, Moreira, DS, and Iunes, DH. Contributions of auriculotherapy in smoking cessation: A pilot study. Rev da Esc Enferm 2014;48:879-886. [in Portuguese]
    Pubmed CrossRef
  10. Kang, HC, Shin, KK, Kim, KK, and Youn, BB. The effects of the acupuncture treatment for smoking cessation in high school student smokers. Yonsei Med J 2005;46:206-212.
    Pubmed KoreaMed CrossRef
  11. Wu, TP, Chen, FP, Liu, JY, Lin, MH, and Hwang, SJ. A randomized controlled clinical trial of auricular acupuncture in smoking cessation. J Chin Med Assoc 2007;70:331-338.
    Pubmed CrossRef
  12. Lamontagne, Y, Annable, L, and Gagnon, MA. Acupuncture for smokers: Lack of long-term therapeutic effect in a controlled study. Can Med Assoc J 1980;122:787-790.
  13. Bier, ID, Wilson, J, Studt, P, and Shakleton, M. Auricular acupuncture, education, and smoking cessation: A randomized, sham-controlled trial. Am J Public Health 2002;92:1642-1647.
    Pubmed KoreaMed CrossRef
  14. Zhang, AL, Di, YM, Worsnop, C, May, BH, Da Costa, C, and Xue, CCL. Ear acupressure for smoking cessation: A randomised controlled trial. Forsch Komplementmed 2013;20:290-294.
    KoreaMed CrossRef
  15. Lee, S, and Park, H. The Effects of Auricular Acupressure on Smoking Cessation for Male College Students. West J Nurs Res 2017;39:374-387.
    Pubmed CrossRef
  16. Wing, YK, Lee, A, Wong, ELY, Leung, PC, Zhang, L, and Pang, ESY. Auricular acupressure for smoking cessation: A pilot randomized controlled trial. Med Acupunct 2010;22:265-271.
    CrossRef
  17. Li, Y, Shen Te, L, Cao, LY, Zhang, W, and Wu, QH. Clinical study on 70 cases of smoking cessation with auricular sticking of Wangbuliuxingzi. Jilin J Tradit Chinese Med 2009;29:505-506. [in Chinese]
  18. Aycicegi-Dinn, A, and Dinn, W. Efficacy of an alternative smoking cessation treatment. J Addict Dis 2011;30:368-381.
    Pubmed CrossRef
  19. Kwon, OY, Song, JH, and Park, KS. Effect of Auricular Acupressure Therapy on Decreasing Smoking rates, Desire for Smoking, and Exhaled Carbon Monoxide in Male College Students. Korean J Rehabil Nurs 2015;18:88-97. [in Korean]
    CrossRef
  20. MacHovec, F, and Man, S. Acupuncture and Hypnosis Compared: Fifty-eight Cases. Am J Clin Hypn 1978;21:45-47.
    Pubmed CrossRef
  21. Sok, SH, and Kim, KB. Effect of Auricular Acupressure Therapy on Smoking Cessation for Male Adults in Rural Areas. J Korean Acad Soc Adult Nurs 2006;18:781-789. [in Korean]
  22. Li, LB, Sun, J, and Da, L. The Approach of Ear Acupuncture Combining to Psychological Intervention with the Health Belief Mode in Community Tobacco Control. Zhejiang J Prev Med 2011;23:23-25. [in Chinese]
  23. Chai, X, Yang, J, Liu, Z, Chen, F, Yuan, G, and Wu, Y. Effect of the different smoking cessation regimens with acupuncture on smoking withdrawal and their influence factors: A multi-center randomized controlled trial. Chin Acupunct Moxibustion 2019;39:1255-1261. [in Chinese]
  24. Wang, Y, Liu, Z, Wu, Y, Yang, L, Guo, L, and Zhang, H. Efficacy of Acupuncture Is Noninferior to Nicotine Replacement Therapy for Tobacco Cessation: Results of a Prospective, Randomized, Active-Controlled Open-Label Trial. Chest 2018;153:680-688.
    Pubmed CrossRef
  25. Waite, NR, and Clough, JB. A single-blind, placebo-controlled trial of a simple acupuncture treatment in the cessation of smoking. Br J Gen Pract 1998;48:1487-1490.
  26. Yeh, ML, Chang, CY, Chu, NF, and Chen, HH. A six-week acupoint stimulation intervention for quitting smoking. Am J Chin Med 2009;37:829-836.
    Pubmed CrossRef
  27. Steiner, RP, Hay, DL, and Davis, AW. Acupuncture therapy for the treatment of tobacco smoking addiction. Am J Chin Med 1982;10:107-121.
    Pubmed CrossRef
  28. He, D, Berg, JE, and Høstmark, AT. Effects of acupuncture on smoking cessation or reduction for motivated smokers. Prev Med 1997;26:208-214.
    Pubmed CrossRef
  29. He, D, Medbo, JI, and Hostmark, AT. Effect of acupuncture on smoking cessation or reduction: An 8-month and 5-year follow-up study. Prev Med 2001;33:364-372.
    Pubmed CrossRef
  30. World Health Organization [Internet]. Tobacco [cited 2022 May 24].
    Available from: https://www.who.int/news-room/fact-sheets/detail/tobacco.
  31. Hwang, J, and Lee, C. Recent Updates of Pharmacotherapy for Smoking Cessation. Korean J Fam Pract 2021;11:403-414. [in Korean]
    CrossRef
  32. Hayley, AC, Stough, C, and Downey, LA. DSM-5 Tobacco Use Disorder and Sleep Disturbance: Findings from the National Epidemiologic Survey on Alcohol and Related Conditions-III (NESARC-III). Subst Use Misuse 2017;52:1859-1870.
    Pubmed CrossRef
  33. Morrell, HER, Cohen, LM, and al’Absi, M. Physiological and psychological symptoms and predictors in early nicotine withdrawal. Pharmacol Biochem Behav 2008;89:272-278.
    Pubmed CrossRef
  34. Alimoradi, Z, Kazemi, F, Valiani, M, and Gorji, M. Comparing the effect of auricular acupressure and body acupressure on pain and duration of the first stage of labor: Study protocol for a randomized controlled trial. Trials 2019;20:766.
    Pubmed KoreaMed CrossRef
  35. Mehta, P, Dhapte, V, Kadam, S, and Dhapte, V. Contemporary acupressure therapy: Adroit cure for painless recovery of therapeutic ailments. J Tradit Complement Med 2017;7:251-263.
    Pubmed KoreaMed CrossRef
  36. He, W, Wang, X, Shi, H, Shang, H, Li, L, and Jing, X. Auricular acupuncture and vagal regulation. Evid Based Complement Alternat Med 2012;2012:786839.
    Pubmed KoreaMed CrossRef
  37. Liu, CT, Lai, JN, and Ko, YL. Effects of auricular acupressure on improving the sleep quality of puerperae. J Nurs 2016;63:39-48. [in Chinese]
  38. Shin, HY, Jang, YJ, Choe, CH, Lee, DH, and Lee, EJ. Effects of Auricular Acupressure on Quality of Sleep and Depression. J Korea Converg Soc 2021;12:509-518.
  39. Zhao, ZH, Zhou, Y, Li, WH, Tang, ZH, Xia, TW, and Li, H. Auricular Acupressure in Patients with Hypertension and Insomnia: A Systematic Review and Meta-Analysis. Evid Based Complement Alternat Med 2020;2020:7279486.
    Pubmed KoreaMed CrossRef
  40. Wang, H, Liu, XR, Wu, XJ, He, TZ, Miao, D, and Jiang, JF. Additional value of auricular intradermal acupuncture alongside selective serotonin reuptake inhibitors: A single-blinded, randomized, sham-controlled preliminary clinical study. Acupunct Med 2021;39:596-602.
    Pubmed CrossRef
  41. Sig, Kim Myung, and Jin, Paek Yu. Psychometric Tools for the Assessment of Nicotine Dependence and Withdrawal Symptoms. J Korean Acad Fam Med 2008;29:315-324. [in Korean]
  42. Sharp, LK, and Lipsky, MS. Screening for Depression across the lifespan: A review of measures for use in primary care settings. Am Fam Physician 2002;66:1001-1008.
  43. Derogatis, LR, Lipman, RS, and Covi, L. SCL-90: an outpatient psychiatric rating scale-preliminary report. Psychopharmacol Bull 1973;9:13-28.
  44. Zhao, ZQ. Neural mechanism underlying acupuncture analgesia. Prog Neurobiol 2008;85:355-375.
    Pubmed CrossRef
  45. Nielsen, A, Gereau, S, and Tick, H. Risks and Safety of Extended Auricular Therapy: A Review of Reviews and Case Reports of Adverse Events. Pain Med 2020;21:1276-1293.
    Pubmed CrossRef

Article

Review Article

Journal of Acupuncture Research 2022; 39(4): 258-266

Published online November 23, 2022 https://doi.org/10.13045/jar.2022.00185

Copyright © Korean Acupuncture & Moxibustion Medicine Society.

A Literature Review of Randomized Controlled Trials on Tobacco Cessation Using Auricular Acupuncture and Auricular Acupressure

Min-Gi Jo1, Jun-Yeong Jang1, Min-Jung Ko1, Sang-Yeup Chae1, Seungeun Lee2, Dongmin Lee2, Won Suk Sung3, Jung-Hyun Kim1, Bonhyuk Goo1, Yeon-Cheol Park1, Yong-Hyeon Baek1, Sang-Soo Nam1, Byung-Kwan Seo1*

1Department of Acupuncture and Moxibustion Medicine, Kyung Hee University Korean Medicine Hospital at Gangdong, Seoul, Korea;2Department of Clinical Korean Medicine, Graduate School, Kyung Hee University, Seoul, Korea;3Department of Acupuncture and Moxibustion Medicine, Dongguk University Bundang Oriental Hospital, Seongnam, Korea

Received: July 9, 2022; Revised: September 27, 2022; Accepted: October 12, 2022

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

This study aimed to analyze auricular acupressure and auricular acupuncture used in smoking cessation research by analyzing published randomized controlled trials. Eight databases (PubMed, Cochrane, EMBASE, CNKI, CiNII, KMbase, KISS, OASIS) were searched until December 2021, and 21 out of 1,919 studies met inclusion criteria. Data on the treatment site, time, frequency, period, and outcomes were analyzed. Lung (MA-IC1) and Ear Shenmen (MA-TF1) were the most used acupoints. The number of treatments varied between a minimum of 2 to a maximum of 24, and treatment duration varied between a minimum of 2 weeks to a maximum of 8 weeks. Cigarette consumption and smoking cessation rate were the most studied outcome, followed by multiple other psychological indications.

Keywords: acupuncture, acupressure, auricular acupuncture, randomized controlled trial, traditional medicine

Introduction

Smoking, referring to the act of smoking tobacco, is an activity that is considered a personal preference. However, since it was confirmed that smoking causes various conditions/diseases and that smokers who quit often experience withdrawal symptoms, smoking has been recognized as a chronic condition/disease facilitated by “nicotine dependence” [1]. Smoking is a major risk factor for cancer, cardiovascular disease, and respiratory disease [2]. The direct and indirect socioeconomic cost of smoking was reported to be 185.2 billion dollars in 2012, accounting for 1.8% of global gross domestic product (data from 152 countries) [3]. The incidence of smoking in Korea has been decreasing over the last decade from 27.5% of the national population in 2010, to 20.6% in 2020 [4]. Nevertheless, smoking is the cause of 58,000 deaths yearly in Korea, and its socioeconomic cost reaches 12 trillion won each year [5].

Smoking cessation is a recommendation the world over. In Korea, various anti-smoking campaigns have been implemented, including the use of health risk warning photos, increasing tobacco tax, and strengthening regulations on cigarette advertising and promotion. In the US, an approach welcomed by patient focus groups is a source of medical care including complementary medicine together with conventional medicine [6], whereby anti-smoking acupuncture should be considered an option covered by healthcare providers.

Quitting smoking is defined as the act of stopping smoking. Following smoke cessation, as the nicotine concentration in the body decreases, the effects of tobacco abstinence (anger, anxiety, depression, difficulty concentrating, impatience, insomnia, and restlessness) peak in the 1st week and last for 2–4 weeks [7].

In 2014, Cochrane published a systematic review related to various acupuncture therapies Among them, auricular acupuncture and auricular acupressure were determined to have the strongest effect on smoking cessation in a short period of time, however these studies were not free from bias [8].

This study reviewed anti-smoking acupuncture practices up to December 2021 by reviewing literature on auricular acupuncture and auricular acupressure.

Materials and Methods

Data sources and search strategy

A comprehensive literature search in domestic and foreign electronic databases was conducted up to December 2021. Records from PubMed, Excerpta Medica database (EMBASE), Cochrane Library, Citation Information by NII (CiNii), China National Knowledge Infrastructure (CNKI), Korean Medical database (KMBASE), Korean Studies Information Service System (KISS) and Oriental Medicine Advanced Searching Integrated System (OASIS) were analyzed.

The search terms were “smoking,” “quit,” and “ear,” “auricular,” and “acupressure,” “acupuncture” to cover the intervention methods. Depending on the characteristics of each search engine, additional languages were used. Details of the search strategy used in each electronic databases are described in Supplement 1.

Inclusion and exclusion criteria

Study selection

After performing database searches, duplicate literature was excluded by two Korean medicine doctors who also performed the process of selection by assessing the titles and abstracts. Then full paper texts were assessed and in cases without an agreement, a supervisor made the final decision.

Data analysis

Analysis of the characteristics of selected studies

The studies were analyzed according to their treatment method, time, frequency, and period. Acupoints that indicated treatment sites were also included. In the treatment method, not only were the types of treatment divided into auricular acupressure and auricular acupuncture, but the accompanying treatment was also described and classified.

Analysis by outcome measures

The outcome measures of acupuncture and acupressure treatments aimed to cease smoking including the comparison between the intervention group and the control group were analyzed. Only studies with numerical outcomes were included.

Results

Study selection and description

A total of 1,919 studies were retrieved from the databases and 1,357 articles were screened after duplicates were excluded. There were 1,133 studies excluded following screening of the abstracts and 203 articles were excluded following screening of the full text. There were 21 RCTs reviewed, and of these, 16 studies were written in English, 3 studies were written in Chinese, and 2 studies were written in Korean (Fig. 1). Extracted data such as treatment method, time, frequency, period, sites, and outcome measures are described in Table 1 [929].

Treatment groups of selected studies

There were 3 cases of auricular acupuncture alone, 13 cases of auricular acupressure alone, 1 case of acupuncture and auricular acupressure combined, and 4 cases of acupuncture plus auricular acupressure with electroacupuncture. In all studies using auricular acupuncture and auricular acupressure together, auricular acupressure was applied following auricular acupuncture treatment.

Fine acupuncture needles were used for auricular acupuncture treatment. For auricular pressure, treatment tools were classified in various ways including a sterile 36-gauge 0.5-inch (0.2 × 13 mm) acupuncture needle fixed with tape, ion pellets fixed with tape, and seeds of plants (such as Semen vaccaria, and Semen sinapis albae) fixed with tape. In all studies using auricular acupressure (in which the treatment method was mentioned), alternate targeting of the left and right auricle was adopted.

In the analysis for auricular acupuncture and auricular acupressure, MA-IC1 was used the most frequently (17 studies), MA-TF1 ranked second (15 studies), and Mouth (MA-IC5) ranked third (13 studies). When auricular acupuncture and auricular acupressure were analyzed separately, MA-IC1 was used the most in both groups, followed by MA-TF1. Detailed acupuncture points used for auricular acupuncture and auricular acupressure are described in Table 2.

Classification of the number of studies through treatment points, frequency, and period

Regarding the number of acupuncture points used for treatment, 6 points were the most common (5 studies). There were 4 studies that used 4 or 5 points. The maximum number of acupoints used was 7 and the minimum number was 1 point (Fig. 2A). As for the frequency of treatment, 6 studies used treatment once a week and 6 studies used treatment twice a week (Fig. 2B). The period of treatment was observed to be a minimum of 2 weeks and a maximum of 8 weeks. The largest proportion of studies treated for 8 weeks (5 studies; Fig. 2C).

Control group and outcome domains

As a control group, sham treatment was most often used. Psychological techniques such as counseling and education, Western medicine treatments such as nicotine replacement therapy, and transcutaneous electrical nerve stimulation are were also used. Studies with an untreated group as a control group were also included (Table 3 [929]). The results included smoking cessation rate, cigarette consumption based on daily smoking volume, efficacy rate and psychological indicators. Psychological indicators included smoking cessation questionnaires such as Fagerstrom Nicotine Dependence Test (FTND), Hughes and Hatsukami’s Nicotine Withdrawal Symptom Score (HHWQ), Heaviness of Smoking Index, and Minnesota Nicotine Withdrawal Scale were used. The Short Form Health Survey 36 was used to measure Quality of Life, the Beck Depression Inventory (BDI), a depression related questionnaire, and the Symptom Checklist-90 were employed to assess psychiatric symptoms. Among the psychological indicators, FTND was the most frequently used (6 cases). Overall, the tobacco consumption index and smoking cessation index were used most often (10 cases; Table 4).

Discussion

Smoking not only causes various conditions and diseases, but is also associated with high economic costs. Thus, global anti-smoking campaigns aim to prevent/stop people smoking. Nevertheless, many people smoke. A report released by the World Health Organization in 2020, determined that 22.3% of the world’s population were smokers and 36.7% were men and 7.8% were women [30]. The main reasons why quitting smoking is difficult are due to the withdrawal symptoms experienced by the individual and the desire to smoke because of their addiction to nicotine. To ease these withdrawal symptoms, nicotine replacement therapy (providing nicotine without using cigarettes), pharmacotherapy such as varenicline and bupropion (used to improve abstinence), and counseling are recommended [31].

In the Diagnostic and Statistical Manual of Mental Disorders, 5th edition, tobacco withdrawal criteria (for daily use of tobacco for several weeks or more) includes at least four of the following signs and symptoms: irritability, frustration, anger, anxiety, difficulty concentrating, increased appetite, restlessness, depressed mood, insomnia within 24 hours of abrupt cessation of tobacco use, or reduction in the amount of tobacco use [32]. Short-term smoking cessation has been reported to cause not only physical symptoms such as changes in systolic blood pressure, but also to induce negative mood and cognitive decline [33].

Auricular acupressure is a nonpharmacological intervention. It treats a wide range of conditions through the application of pressure to acupoints [34]. The various therapeutic effects can be delivered by pressing a specific acupuncture point in order to decrease tissue adhesion, promote relaxation and regional blood circulation, increase parasympathetic nerve activity and intramuscular temperature along with reduction in neuromuscular excitability [35].

There are many mechanisms responsible for the effect of auricular acupuncture and auricular acupressure. In the case of relaxation, the auricular branch of the vagus nerve is stimulated during treatment, leading to an increase in parasympathetic nerve activity and modification of both autonomic and central nervous system activity [36]. The representative acupoints for relaxation are MA-TF1 and Sympathetic (MA-AH6), and auricular acupressure applied to auricular acupoints has various positive effects including improvement in quality of sleep, and reduced blood pressure [3739]; auricular acupuncture also reduces symptoms of depression [40].

We believe the reason MA-TF1 and MA-AH6 are the most commonly used acupuncture points, besides the Lungs (MA-IC1) and MA-IC5, is because of the direct connection of these acupoints with breathing and relaxation which may be related to the treatment of the psychological symptoms associated with smoking withdrawal.

Various numerical psychological indicators were used in addition to the numbers which directly related to the amount of smoking. Among these indicators, questionnaires designed for smoking cessation such as FTND and HHWQ, and psychological indicators such as BDI and SCL-90, were used. Measuring tools related to smoking cessation not only measure amounts of smoked cigarettes per day, but also include psychometric indicators such as nicotine dependence, craving, withdrawal symptoms, self-efficacy, and quality of sleep [41]. BDI measures symptoms of depression [42] and SCL-90 is a questionnaire that evaluates the overall level of mental health, including depression [43]. This highlights the relationship between smoking cessation and mental status.

Treatment methods specifying the acupoints, treatment time, frequency of treatments, and duration of treatment period significantly influence the efficiency of acupuncture [44]. The treatment time of each study was different, but due to the characteristic of the auricular acupressure, it is considered that treatment was continuously performed except for the replacement time. Therefore, the stability of auricular acupressure can be determined due to the fact that there were no serious side effects (even though treatment has been continuously performed during the study period of up to 8 weeks). The side effects of auricular acupuncture are similar to those of body acupuncture, and the efficacy and stability of auricular acupuncture, and auricular acupressure have been previously reported [45].

Most of the RCT studies reported that auricular acupuncture and auricular acupressure were effective compared with the control group. However, only 9 of the 21 studies showed statistical significance i.e., p < 0.05. One study determined that nicotine replacement therapy was more effective than auricular acupressure [24], and one study reported that auricular acupressure was more effective than transcutaneous electrical nerve stimulation but less effective than nicotine replacement therapy [23].

This study has several limitations. Firstly, the risk of bias of the RCTs included in this review was not assessed. Secondly, due to linguistic limitations, the databases used were limited to English, Chinese, and Korean studies. Finally, we did not conduct quality evaluation to determine the level of the selected literature.

Conclusion

In the 21 RCT studies reviewed, many authors were aware of the importance of psychological aspects of smoking cessation treatment, and to treat tobacco withdrawal symptoms more studies used auricular acupressure than auricular acupuncture on auricular acupoints, and electronic acupuncture was typically an additional intervention. Auricular acupoints were mainly selected from two categories: directly related to breathing, such as MA-IC1, MA-IC5 and Trachea (MA-IC2), and related to mental health, such as Ear Shenmen (MA-TF1) and MA-AH6. The number of treatments varied between 2 and 24, and the treatment duration ranged from 2 weeks to 8 weeks. Cigarette consumption and smoking cessation rate were the most commonly used outcomes, but other psychological indicators were also assessed using scales such as FTND, HHWQ, QOL, MPSS, and BDI.

Supplementary Material

Author Contributions

Conceptualization: MGJ. Methodology: MGJ. Formal investigation: SL and DL. Data analysis: MJK, SYC, WSS, JHK and BG. Writing original draft: MGJ. Writing - review and editing: YCP, YHB, SSN and BKS.

Conflicts of Interest

There are no conflicts of interest regarding the publication of this manuscript.

Funding

This research was supported by a grant from the Korea Health Technology R&D Project through the Korea Health Industry Development Institute, funded by the Ministry of Health and Welfare, Republic of Korea (grant no.: HF21C0192). The funding did not affect the content of the study.

Ethical Statement

This research did not involve any human or animal experiments.

Data Availability

All relevant data are included in this manuscript.

Fig 1.

Figure 1.

Study selection and exclusion flow chart.

Journal of Acupuncture Research 2022; 39: 258-266https://doi.org/10.13045/jar.2022.00185

Fig 2.

Figure 2.

Classification of the number of studies. (A) According to the number of treatment points; (B) According to the treatment frequency and (C) According to the number of treatment period.

Journal of Acupuncture Research 2022; 39: 258-266https://doi.org/10.13045/jar.2022.00185

Table 1 . Characteristics of Selected Studies..

Author [ref] (y)Type of studyTreatment methodTreatment site (acupoints)Treatment timeTreatment frequencyTreatment periodOutcome measure
Silva [9] (2014)RCTAuricular acupressureEar shenmen, kidney, sympathetic, thirstNot recorded2 times/wk5 wkFTNDCigarette consumption
Kang [10] (2005)RCTAuricular acupressureEar shenmen, lung, mouthNot recordedNot recorded4 wkSmoking cessation rateDesire to Smoke
Wu [11] (2007)RCTAuricular acupunctureEar shenmen lung, mouth, sympatheticNot recorded1 time/wk8 wkSmoking cessation rateHHWQ
Lamontagne[12] (1980)RCTAuricular acupunctureLung, point zero20 min1 time/wk2 wkSmoking cessation rate
Bier [13] (2002)RCTAuricular acupunctureEar shenmen, sympathetic, lung, kidney, liver30 min4 times/wk5 wkSmoking cessation rateEffective rate
Zhang [14] (2013)RCTAuricular acupressureEar shenmen, lung, mouth, hunger, liver3 session/dNot recorded8 wkSmoking cessation rateCigarette consumptionQOL
Lee [15] 2017RCTAuricular acupressureEar shenmen, lung, subcortex, hunger, stomach, mouthNot recorded1 time/wk6 wkFTNDSelf efficacy for smoking cessationCigarette consumption
Wing [16] (2010)RCTAuricular acupressureEar shenmen, lung, mouth, brainAt least 3 times/d1 time/wk3 wkMPSS
Li [17] (2009)RCTAuricular acupressureEar shenmen, lung, stomach, mouth, adrenal, endocrine2–3 min/session, 3–5 session/d3 times/wk20dEffective rate
Ayse [18] (2011)RCTAuricular acupressureNot recordedNot recordedNot recorded3 wkFTNDBDICigarette consumption
Kwon [19] (2015)RCTAuricular acupressureEar shenmen, thirst, hunger, lung, mouth, subcortex5 d1 time/wk2 wkCigarette consumptionDesire to Smoke
Machovec [20] (1978)RCTAuricular acupressureNot recordedNot recordedNot recordedNot recordedEffective rate
Seok [21] (2006)RCTAuricular acupressureEar shenmen, thirst, hunger, trachea, brain3 d (frequently press)2 times/wk2 wkCigarette consumptionFTNDDesire to Smoke
Li [22] (2011)RCTAuricular acupressureEar shenmen, lung, trachea, mouth3–5 min/session2–3 session/d3 times/wk8 wkCigarette consumption
Chai [23] (2019)RCTAuricular acupressureEar shenmen, endocrine, subcortex sympathetic, lung, stomach3–5 min/d3 times/wk8 wkSmoking cessation rateFTNDHSI
Wang [24] (2018)RCTAuricular acupressureEar shenmen, endocrine, subcortex sympathetic, lung, stomach, mouth20 sec/1–2 h2 times/wk8 wkSmoking cessation rateFTNDMNWS
Waite [25] (1998)RCTEA+Auricular acupuncture+Auricular acupressureLungAcupuncture: 20 minAcupressure:As long as possible (press when experience the desire to smoke)Not recordedNot recordedSmoking cessation rate
Yeh [26] (2009)RCTEA+Auricular acupuncture+Auricular acupressureEar shenmen, lung, stomach, mouth, endocrineAcupuncture:20 minAcupressure:1 min/session3–5 session/d1 time/wk6 wkSmoking cessation rateCigarette consumption
Steiner [27] (1982)RCTAcupuncture+Auricular acupressureLung, mouthnot recorded2 times/wk2 wkCigarette consumption
He [28] (1997)RCTEA+Auricular acupuncture+Auricular acupressureEar shenmen, mouth, lung, trachea, hunger, endocineAcupuncture: 20 minAcupressure:100 press/session4 session/d2 times/wk3 wkCigarette consumption
He [29] (2001)RCTEA+Auricular acupuncture+Auricular acupressureLung, trachea, mouthAcupuncture: Not recordedAcupressure:4 session/d2 times/wk3 wkSmoking cessation rate

BDI, Beck Depression Inventory; EA, Electroacupuncture; FTND, Fagerstrom Nicotine Dependence Test; HHWQ, Hughes and Hatsukami’s Nicotine Withdrawal Symptom Score; HIS, Heaviness of Smoking Index; MNWS, Minnesota Nicotine Withdrawal Scale; QOL, Quality of Life; RCT, randomized controlled trials; SCL90, Symptom Checklist-90..


Table 2 . Acupoints Used for Smoking Withdrawal Symptoms Relief..

AcupointsN
Lung17
Ear Shenmen15
Mouth13
Sympathetic5
Hunger5
Stomach5
Subcortex4
Endocrine4
Trachea4
Thirst3
Kidney2
Brain2
Liver2
Adrenal1
Point zero1

Table 3 . Comparisons and Results of Studies..

Author [ref] (y)Intervetion (n)Comparison (n)Outcome measureResults (intervention vs. comparison)pAdverse events (intervemtion vs comparison)
Silva [9] (2014)Auricular acupressure (21)Sham auricular acupressure (9)1) FTND2) Cigarette consumption1) 2.2 ± 1.1 vs. 2.7 ± 1.62) 14.3 ± 7.0 vs. 16.7 ± 4.41) p = 0.5632) p = 0.114Not recorded

Kang [10] (2005)Auricular acupressure (159)Sham auricular acupressure (79)1) Smoking cessation rate2) Desire to Smoke1) 0.6% vs. 0%2) 1.83 ± 0.8432 vs. 1.84 ± 0.84661) Not recorded2) p = 0.1497Not recorded

Wu [11] (2007)Auricular acupuncture (59)sham auricular acupuncture (59)1) Smoking cessation rate2) HHWQ1) 27.1% vs. 20.3%2) 3.0 ± 2.7 vs. 3.7 ± 3.01) p = 0.5172) p = 0.0331 vs. 44

Lamontagne [12] (1980)Auricular acupuncture (25)Counseling (25)1) Smoking cessation rate1) 29% vs. 20%1) Not recorded0 vs. 0

Bier [13] (2002)Auricular acupuncture (12)Sham auricular acupuncture+education (20)1) Smoking cessation rate1) 21% vs. 22.4%1) p = 0.170 vs. 0

Zhang [14] (2013)Auricular acupressure (11)Sham auricular acupressure (8)1) Smoking cessation rate2) Cigarette consumption3) QOL1) 5% vs. 0%2) 10.61 ± 7.56 vs. 12.32 ± 5.473) 48.83 ± 5.44 vs.48.05 ± 4.551) p = 0.6352) p = 0.3973) p = 0.6121 vs. 5

Lee [15] 2017Auricular acupressure (27)Sham auricular acupressure (26)1) FTND2) Self efficacy for smoking cessation3) Cigarette consumption1) 2.56 ± 1.97 vs. 2.46 ± 1.482) 5.71 ± 5.81 vs. 3.00 ± 3.513) 12.33 ± 5.28 vs. 17.31 ± 6.731) p > 0.052) p < 0.053) p < 0.05Not recorded

Wing [16] (2010)Auricular acupressure (38)Sham auricular acupressure (32)1) MPSS1) 8.97 ± 3.06 vs. 8.93 ± 3.651) Not recorded0 vs. 0

Li [17] (2009)Auricular acupressure (69)Sham auricular acupressure (67)1) Effective rate1) 76.81 vs. 32.841) p < 0.010 vs. 0

Ayse [18] (2011)Auricular acupressure (24)Sham auricular acupressure (23)1) FTND2) BDI 3) Cigarette consumption1) 3.7 ± 2.9 vs. 3.9 ± 2.82) 6.9 ± 7.7 vs. 6.1 ± 9.03) 15.7 ± 9.6 vs. 12.8 ± 10.81) p < 0.052) p < 0.053) p < 0.05Not recorded

Kwon [19] (2015)Auricular acupressure (29)Sham auricular acupressure (27)1) Cigarette consumption2) Desire to Smoke1) 6.50 ± 4.78 vs. 8.15 ± 4.082) 2.07 ± 0.90 vs. 2.41 ± 1.021) p < 0.052) p < 0.05Not recorded

Machovec [20] (1978)Auricular acupressure (12)Sham auricular acupressure (12)1) Effective rate1) 66% vs. 25%1) Not recordedNot recorded


Untreated (12)1) 66% vs. 17%1) Not recorded

Seok [21] (2006)Auricular acupressure (45)Untreated (45)1) Cigarette consumption2) FTND3) Desire to Smoke1) 7.35 ± 3.03 vs. 27.53 ± 9.762) 3.57 ± 0.83 vs. 9.66 ± 1.083) 2.60 ± 0.49 vs. 4.66 ± 0.471) p < 0.052) p < 0.053) p < 0.05Not recorded

Li [22] (2011)Auricular acupressure (57)Counseling (62)1) Cigarette consumption1) 30.8 ± 9.6 vs. 24.2 ± 8.61) p > 0.050 vs. 0


Untreated (55)1) 30.8 ± 9.6 vs. 20.4 ± 11.81) p > 0.05

Chai [23] (2019)Auricular acupressure (100)Transcutaneous electrical nerve stimulation (100)1) Smoking cessation rate2) FTND3) HSI1) 23% vs. 19%2) 5.82 ± 3.22 vs. 5.55 ± 3.023) 3.41 ± 1.84 vs. 3.33 ± 1.761) p < 0.052) p < 0.053) p < 0.050 vs. 0


Nicotine replacement therapy (100)1) 23% vs. 18%2) 5.82 ± 3.22 vs.5.01 ± 3.033) 3.41 ± 1.84 vs. 3.01 ± 1.741) p < 0.052) p < 0.053) p < 0.05

Wang [24] (2018)Auricular acupressure (67)Nicotine replacement therapy (70)1) Smoking cessation rate2) FTND3) MNWS1) 32.00% vs. 46.00%2) 5.82 ± 3.22 vs. 5.55 ± 3.023) 8.64 ± 7.26 vs. 7.55 ± 6.701) Not recorded2) p < 0.053) p < 0.052 vs. 2

Waite [25] (1998)EA+Auricular acupuncture+Auricular acupressure (37)Sham EA+Sham auricular acupuncture+Sham auricular acupressure (35)1) Smoking cessation rate1) 12.5% vs. 0.0%1) p = 0.0558 vs. 3

Yeh [26] (2009)EA+Auricular acupuncture+Auricular acupressure (30)Sham EA+Sham auricular acupuncture+Sham auricular acupressure (29)1) Smoking cessation rate2) Cigarette consumption1) 13.3% vs. 13.7%2) 10.17 ± 8.28 vs. 13.41 ± 8.331) Not recorded2) p = 0.14Not recorded

Steiner [27] (1982)Acupuncture+Auricular acupressure (11)Sham acupuncture+Sham auricular acupressure (12)1) Cigarette consumption1) 13.9 ± 1.6 vs. 19.0 ± 2.91) p < 0.001Not recorded

He [28] (1997)EA+Auricular acupuncture+Auricular acupressure (22)Sham EA+Sham auricular acupuncture+Sham auricular acupressure (11)1) Cigarette consumption1) 12.3 ± 2.0 vs. 15.5 ± 2.81) p > 0.05Not recorded

He [29] (2001)EA+Auricular acupuncture+Auricular acupressure (26)Sham EA+Sham auricular acupuncture+Sham auricular acupressure (18)1) Smoking cessation rate1) 30.7% vs. 0%1) Not recordedNot recorded

BDI, Beck Depression Inventory; EA, Electroacupuncture; FTND, Fagerstrom Nicotine Dependence Test; HHWQ, Hughes and Hatsukami’s Nicotine Withdrawal Symptom Score; HIS, Heaviness of Smoking Index; MNWS, Minnesota Nicotine Withdrawal Scale; QOL, Quality of Life; RCT, randomized controlled trials; SCL90, Symptom Checklist-90.


Table 4 . Outcome Domains of the Studies..

Outcome domainsN
Psychological scale15 [FTND (6), Desire to Smoke (3), HHWQ (1), QOL (1), MPSS (1), BDI (1), HIS (1), MNWS (1)]
Cigarette consumption10
Smoking cessation rate10
Effective rate2

BDI, Beck Depression Inventory; FTND, Fagerstrom Nicotine Dependence Test; HHWQ, Hughes and Hatsukami’s Nicotine Withdrawal Symptom Score; HIS, heaviness of smoking index; MNWS, Minnesota Nicotine Withdrawal Scale; MPSS, Mood and Physical Symptoms Scale; QOL, Quality of Life; SCL90, Symptom Checklist-90.


References

  1. Kim, DH, and Suh, YS. Smoking as a disease. Korean J Fam Med 2009;30:494-502.
    CrossRef
  2. U.S. Department of Health and Human Servies. A Report of the Surgeon General. Rockville (MD): Department of Health and Human Servies; 2014. 443 p.
  3. Goodchild, M, Nargis, N, and D’Espaignet, ET. Global economic cost of smoking-attributable diseases. Tob Control 2018;27:58-64.
    Pubmed KoreaMed CrossRef
  4. Korea Disease Control and Prevention Agency [Internet]. Trends in prevalence of current cigarette smoking 2010. 2020 [cited 2022 May 26]. Available from: https://www.kdca.go.kr/board/board.es?mid=a20602010000&bid=0034&act=view&list_no=719645.[in Korean]
  5. Korea Disease Control and Prevention Agency [Internet]. Number of deaths and socioeconomic costs in Korea due to smoking [cited 2022 May 24]. Available from: https://www.kdca.go.kr/contents.es?mid=a20205010200.[in Korean]
  6. McCaffrey, AM, Pugh, GF, and O’Connor, BB. Understanding patient preference for integrative medical care: Results from patient focus groups. J Gen Intern Med 2007;22:1500-1505.
    Pubmed KoreaMed CrossRef
  7. Hughes, JR. Effects of abstinence from tobacco: Valid symptoms and time course. Nicotine Tob Res 2007;9:315-327.
    Pubmed CrossRef
  8. White, AR, Rampes, H, Liu, JP, Stead, LF, and Campbell, J. Acupuncture and related interventions for smoking cessation. Cochrane Database Syst Rev 2014:CD000009.
    CrossRef
  9. Silva, RP, Chaves, ECL, Pillon, SC, Silva, AM, Moreira, DS, and Iunes, DH. Contributions of auriculotherapy in smoking cessation: A pilot study. Rev da Esc Enferm 2014;48:879-886. [in Portuguese]
    Pubmed CrossRef
  10. Kang, HC, Shin, KK, Kim, KK, and Youn, BB. The effects of the acupuncture treatment for smoking cessation in high school student smokers. Yonsei Med J 2005;46:206-212.
    Pubmed KoreaMed CrossRef
  11. Wu, TP, Chen, FP, Liu, JY, Lin, MH, and Hwang, SJ. A randomized controlled clinical trial of auricular acupuncture in smoking cessation. J Chin Med Assoc 2007;70:331-338.
    Pubmed CrossRef
  12. Lamontagne, Y, Annable, L, and Gagnon, MA. Acupuncture for smokers: Lack of long-term therapeutic effect in a controlled study. Can Med Assoc J 1980;122:787-790.
  13. Bier, ID, Wilson, J, Studt, P, and Shakleton, M. Auricular acupuncture, education, and smoking cessation: A randomized, sham-controlled trial. Am J Public Health 2002;92:1642-1647.
    Pubmed KoreaMed CrossRef
  14. Zhang, AL, Di, YM, Worsnop, C, May, BH, Da Costa, C, and Xue, CCL. Ear acupressure for smoking cessation: A randomised controlled trial. Forsch Komplementmed 2013;20:290-294.
    KoreaMed CrossRef
  15. Lee, S, and Park, H. The Effects of Auricular Acupressure on Smoking Cessation for Male College Students. West J Nurs Res 2017;39:374-387.
    Pubmed CrossRef
  16. Wing, YK, Lee, A, Wong, ELY, Leung, PC, Zhang, L, and Pang, ESY. Auricular acupressure for smoking cessation: A pilot randomized controlled trial. Med Acupunct 2010;22:265-271.
    CrossRef
  17. Li, Y, Shen Te, L, Cao, LY, Zhang, W, and Wu, QH. Clinical study on 70 cases of smoking cessation with auricular sticking of Wangbuliuxingzi. Jilin J Tradit Chinese Med 2009;29:505-506. [in Chinese]
  18. Aycicegi-Dinn, A, and Dinn, W. Efficacy of an alternative smoking cessation treatment. J Addict Dis 2011;30:368-381.
    Pubmed CrossRef
  19. Kwon, OY, Song, JH, and Park, KS. Effect of Auricular Acupressure Therapy on Decreasing Smoking rates, Desire for Smoking, and Exhaled Carbon Monoxide in Male College Students. Korean J Rehabil Nurs 2015;18:88-97. [in Korean]
    CrossRef
  20. MacHovec, F, and Man, S. Acupuncture and Hypnosis Compared: Fifty-eight Cases. Am J Clin Hypn 1978;21:45-47.
    Pubmed CrossRef
  21. Sok, SH, and Kim, KB. Effect of Auricular Acupressure Therapy on Smoking Cessation for Male Adults in Rural Areas. J Korean Acad Soc Adult Nurs 2006;18:781-789. [in Korean]
  22. Li, LB, Sun, J, and Da, L. The Approach of Ear Acupuncture Combining to Psychological Intervention with the Health Belief Mode in Community Tobacco Control. Zhejiang J Prev Med 2011;23:23-25. [in Chinese]
  23. Chai, X, Yang, J, Liu, Z, Chen, F, Yuan, G, and Wu, Y. Effect of the different smoking cessation regimens with acupuncture on smoking withdrawal and their influence factors: A multi-center randomized controlled trial. Chin Acupunct Moxibustion 2019;39:1255-1261. [in Chinese]
  24. Wang, Y, Liu, Z, Wu, Y, Yang, L, Guo, L, and Zhang, H. Efficacy of Acupuncture Is Noninferior to Nicotine Replacement Therapy for Tobacco Cessation: Results of a Prospective, Randomized, Active-Controlled Open-Label Trial. Chest 2018;153:680-688.
    Pubmed CrossRef
  25. Waite, NR, and Clough, JB. A single-blind, placebo-controlled trial of a simple acupuncture treatment in the cessation of smoking. Br J Gen Pract 1998;48:1487-1490.
  26. Yeh, ML, Chang, CY, Chu, NF, and Chen, HH. A six-week acupoint stimulation intervention for quitting smoking. Am J Chin Med 2009;37:829-836.
    Pubmed CrossRef
  27. Steiner, RP, Hay, DL, and Davis, AW. Acupuncture therapy for the treatment of tobacco smoking addiction. Am J Chin Med 1982;10:107-121.
    Pubmed CrossRef
  28. He, D, Berg, JE, and Høstmark, AT. Effects of acupuncture on smoking cessation or reduction for motivated smokers. Prev Med 1997;26:208-214.
    Pubmed CrossRef
  29. He, D, Medbo, JI, and Hostmark, AT. Effect of acupuncture on smoking cessation or reduction: An 8-month and 5-year follow-up study. Prev Med 2001;33:364-372.
    Pubmed CrossRef
  30. World Health Organization [Internet]. Tobacco [cited 2022 May 24]. Available from: https://www.who.int/news-room/fact-sheets/detail/tobacco.
  31. Hwang, J, and Lee, C. Recent Updates of Pharmacotherapy for Smoking Cessation. Korean J Fam Pract 2021;11:403-414. [in Korean]
    CrossRef
  32. Hayley, AC, Stough, C, and Downey, LA. DSM-5 Tobacco Use Disorder and Sleep Disturbance: Findings from the National Epidemiologic Survey on Alcohol and Related Conditions-III (NESARC-III). Subst Use Misuse 2017;52:1859-1870.
    Pubmed CrossRef
  33. Morrell, HER, Cohen, LM, and al’Absi, M. Physiological and psychological symptoms and predictors in early nicotine withdrawal. Pharmacol Biochem Behav 2008;89:272-278.
    Pubmed CrossRef
  34. Alimoradi, Z, Kazemi, F, Valiani, M, and Gorji, M. Comparing the effect of auricular acupressure and body acupressure on pain and duration of the first stage of labor: Study protocol for a randomized controlled trial. Trials 2019;20:766.
    Pubmed KoreaMed CrossRef
  35. Mehta, P, Dhapte, V, Kadam, S, and Dhapte, V. Contemporary acupressure therapy: Adroit cure for painless recovery of therapeutic ailments. J Tradit Complement Med 2017;7:251-263.
    Pubmed KoreaMed CrossRef
  36. He, W, Wang, X, Shi, H, Shang, H, Li, L, and Jing, X. Auricular acupuncture and vagal regulation. Evid Based Complement Alternat Med 2012;2012:786839.
    Pubmed KoreaMed CrossRef
  37. Liu, CT, Lai, JN, and Ko, YL. Effects of auricular acupressure on improving the sleep quality of puerperae. J Nurs 2016;63:39-48. [in Chinese]
  38. Shin, HY, Jang, YJ, Choe, CH, Lee, DH, and Lee, EJ. Effects of Auricular Acupressure on Quality of Sleep and Depression. J Korea Converg Soc 2021;12:509-518.
  39. Zhao, ZH, Zhou, Y, Li, WH, Tang, ZH, Xia, TW, and Li, H. Auricular Acupressure in Patients with Hypertension and Insomnia: A Systematic Review and Meta-Analysis. Evid Based Complement Alternat Med 2020;2020:7279486.
    Pubmed KoreaMed CrossRef
  40. Wang, H, Liu, XR, Wu, XJ, He, TZ, Miao, D, and Jiang, JF. Additional value of auricular intradermal acupuncture alongside selective serotonin reuptake inhibitors: A single-blinded, randomized, sham-controlled preliminary clinical study. Acupunct Med 2021;39:596-602.
    Pubmed CrossRef
  41. Sig, Kim Myung, and Jin, Paek Yu. Psychometric Tools for the Assessment of Nicotine Dependence and Withdrawal Symptoms. J Korean Acad Fam Med 2008;29:315-324. [in Korean]
  42. Sharp, LK, and Lipsky, MS. Screening for Depression across the lifespan: A review of measures for use in primary care settings. Am Fam Physician 2002;66:1001-1008.
  43. Derogatis, LR, Lipman, RS, and Covi, L. SCL-90: an outpatient psychiatric rating scale-preliminary report. Psychopharmacol Bull 1973;9:13-28.
  44. Zhao, ZQ. Neural mechanism underlying acupuncture analgesia. Prog Neurobiol 2008;85:355-375.
    Pubmed CrossRef
  45. Nielsen, A, Gereau, S, and Tick, H. Risks and Safety of Extended Auricular Therapy: A Review of Reviews and Case Reports of Adverse Events. Pain Med 2020;21:1276-1293.
    Pubmed CrossRef
JAR
May 31, 2024 Vol.41 No.2, pp. 75~142

Stats or Metrics

Share this article on

  • line

Related articles in JAR

Journal of Acupuncture Research

pISSN 2586-288X
eISSN 2586-2898
qr-code Download