Use of Acupuncture in Smoking Cessation
Use of Acupuncture in Smoking Cessation
June 1998; Volume 1: 64-67
By Jay Udani MD, and Joshua Ofman MD, MSHS, with an introduction by Dennis deLeon, MD
The medical treatment of nicotine addiction and of smokers who wish to quit, is similar to the treatment of other addictions in one way: consistently low efficacy rates are the norm. Certainly, many new approaches and significant data have been added to physicians’ armamentarium to help patients stop smoking. These include nicotine replacement via gum, skin patches, and even sprays; and medication adjuncts, most recently the antidepressant bupropion (Wellbutrin or Zyban). Other techniques studied and practiced in smoking cessation clinics include behavior modification training, meditation, counseling, hypnosis, and acupuncture. Nicotine replacement seems to result in one-year successful abstinence rates of 10-20%. Simple one-time physician advice has been shown to approximately double this baseline abstinence rate in any given group of smokers. The most successful clinics provide nicotine replacement plus bupropion in a setting that includes the other nonpharmacologic methods, raising the one-year abstinence rate to 25-45%. Of course, the additive cost of all these interventions is high. A 25% one-year success rate after costly interventions seems modest, but compares favorably to the 1-5% chance of one-year smoking cessation faced by smokers who try to quit entirely on their own.
Background
Tobacco is the leading cause of preventable death and disability in the United States. The prevalence of tobacco use is 25% of the U.S. adult population, and there are 3000 new smokers every day; 1000 of these people will die prematurely of a smoking-related illnesses. The direct medical costs attributable to smoking are estimated to be $50 billion per year, and the loss of human life in earnings and premature death result in another $50 billion per year.1
Acupuncture has long been touted as a useful adjunct in the treatment of addiction. According to the U.S. Food and Drug Administration, Americans spent $500 million and made 12 million patient visits for acupuncture treatment in 1993. In addition to nicotine replacement, counseling, and the use of antidepressants, acupuncture is used in approximately 300 U.S. government-supported and private clinics as adjunctive therapy for the treatment of nicotine dependence.2
History
Part of the ancient Chinese medical system, acupuncture dates to prehistoric times—even before the discovery of metal—as evidenced by the finding of acupuncture needles made of flint.3
The earliest documentation of acupuncture is in The Yellow Emperor’s Classic of Internal Medicine from the 3rd century BC.
There are two postulated rationales for the inception of acupuncture. The first is that ancient Chinese warriors noticed the disappearance of long-standing pains when pierced by enemy arrows in a variety of anatomic locations. The other rationale is that the analgesic effects of massage therapy were translated into specific acupuncture points to bring about relaxation and alleviate pain.3
Europe became acquainted with acupuncture in the 17th and 18th centuries as trade and colonization brought Europeans in contact with the Far East. However, it wasn’t until 1972, when James Reston, then a correspondent for the New York Times, accompanied President Richard Nixon on his historic visit to China, that acupuncture came to the West. Reston developed acute appendicitis, underwent an appendectomy, and received acupuncture for post-operative pain relief. Impressed with its effectiveness and simplicity, he wrote about the technique, and it has been studied and used here since.
Mechanism of Action
In traditional acupuncture theory, the Yin (negative) and Yang (positive) are opposing life forces that exist within the body. The traditional explanation for the mechanism of action of acupuncture is based on meridians or channels of energy that run in regular patterns through the body and over its surface. These patterns of flow are referred to as Qi (pronounced "chee"), and any obstruction to the free flow of movement of energy through these channels may lead to illness and disease. The theory is that acupuncture needles unblock obstruction and re-establish regular flow through the meridians.4 Meridians are pathways in which bioelectrons (negative and positive electrons that comprise the cells of the body) move more frequently than other parts of the body. When these bioelectrons are not balanced, the cells will act abnormally, resulting in "disease."4 It is an imbalance of these forces that creates the disease states. Acupuncture forces the bioelectrons back to their normal movement patterns and thus restores the balance between the body’s Yin and Yang and treats the disease.
An alternative neurophysiological explanation is that acupuncture needling releases endogenous neurohormones that regulate the perception of pain. It is thought that acupuncture accelerates the release of five different neuropeptides that bind to the delta, mu, and kappa opioid receptors in the central nervous system.5
This theory is further strengthened by the finding that opioid antagonists, such as naloxone, reverse the analgesic effect of acupuncture. Nicotine use triggers the mesolimbic reward pathway via two mechanisms. The first is presynaptically via the neurohumoral CNS pathways, and the second is by postsynaptic nicotinic cholinergic receptors. These pathways both lead to the release of endogenous opioids that bind to mu opioid receptors.6
A recent review of the role of opioid receptors in nicotine addiction concluded that the role of opioid antagonism on smoking cessation, although likely, is not yet clearly defined, and that further study with mu specific antagonists is necessary.6
The meridian system consists of 400 acupuncture points and 20 meridians that connect some of the points.7 Acupuncture points have a significantly higher calcium ion concentration than nonacupuncture points, leading to speculation that calcium ion flux may play a role in the mechanism of action of acupuncture.7
Meridians do not follow the anatomy of the circulatory or nervous systems. Superconducting Quantum Interference Devices (SQUIDs) are used to detect neuromagnetic fields evoked in the peripheral and central nervous systems.8 This technology has been used to map out patterns of magnetic fields along the body, and these fields seem to follow the major acupuncture meridians.7
Clinical Studies
The National Academy of Acupuncture and Oriental Medicine published a summary on the efficacy of acupuncture in 1996.9 This review acknowledged the following five problems that may interfere with the interpretation of results of clinical trials involving acupuncture:
• There is no national standard for acupuncture and no way of assessing the level of training of the acupuncturists in the studies;
• There is inadequate description of the points needled and the frequency and duration of the treatments;
• Sham acupuncture (needling control sites) is likely to produce some effect, such as local or systemic response to microtrauma;
• Underenrollment and dropout of patients bias the results of some trials; and
• Acupuncture may be given as either a fixed set of treatment points or as completely individualized therapy.9
A meta-analysis published in 1990 reviewed the medical literature on acupuncture and addiction and found 21 studies that met strict inclusion criteria.10 Fifteen studies evaluated acupuncture for tobacco addiction compared to a placebo group that received sham acupuncture, but only three studies found acupuncture more effective than placebo. The authors concluded that the overwhelming evidence opposed the use of acupuncture for smoking cessation, as there were scant data supporting its effectiveness in the treatment of tobacco addiction. The authors also concluded that the trials comprising the analysis suffered from poor study design, and called for studies addressing important patient subgroups.
A recent study randomized 46 adult smokers to acupuncture or sham acupuncture (placebo).11 The design of this study addressed many of the problems that plagued the studies used in the meta-analysis. This study evaluated the effect of acupuncture on smoking cessation by measuring patient attitudes and motivations via a questionnaire and measured biochemical markers of tobacco addiction including serum cotinine, thiocyanate, peroxides, and fibrinogen in addition to measuring daily cigarette consumption. The acupuncture group had a significant reduction in daily cigarette consumption compared to placebo (P < 0.002), significant reductions in serum cotinine and thiocyanate levels (P < 0.001), and a 31% cessation rate compared to the placebo group (0% cessation rate). This is a well-designed study, addressing both clinical and biochemical issues, that demonstrates a significant effect on smoking cessation due to acupuncture.
The NIH recently formed a consensus panel to investigate the efficacy of acupuncture.5 A systematic search of the world’s literature yielded 2302 studies, of which very few were controlled clinical trials. In November 1997, the panel concluded that the evidence suggests acupuncture is not effective for smoking cessation and should not be used as monotherapy for smoking cessation. Acupuncture may be an acceptable adjunct to a comprehensive smoking cessation program including behavioral modification and pharmacotherapy.5
Adverse Effects
A 1996 systematic review of the world’s acupuncture literature revealed 78 papers reporting 193 adverse events related to acupuncture over 14 years.12 The most common mechanical injury was pnuemothorax, and the most common infectious injury was viral hepatitis. There were three deaths reported, one from pneumothorax, one from hepatitis, and one from endocarditis. The majority of these adverse effects were related to poor hygiene and poor medical training and knowledge of the acupuncturists. In the era of universal precautions, the use of sterile needles is necessary. Even with these potential harmful effects, acupuncture is still considered a safe and low-risk treatment.12
Conclusion
Acupuncture in the United States has matured from a curiosity to a legitimate component of medical practice for a subset of specific disease entities. However, acupuncture has not demonstrated a clear or consistent beneficial effect in the treatment of nicotine addiction. Until stronger evidence from well-designed clinical trials is available to support the use of acupuncture for smoking cessation, we recommend against the use of acupuncture as monotherapy for smoking cessation. We instead recommend the use of pharmacotherapy and behavior modification programs for the treatment of nicotine addiction.13 The use of acupuncture as an adjunct to these programs may be acceptable given its low-risk profile.
Dr. Udani is Chief Resident, Internal Medicine, Cedars-Sinai Medical Center, Los Angeles.
References
1. Ferri L. Biology of smoking addiction. Los Angeles: Cedars-Sinai Medical Center Grand Rounds; 1998.
2. Brewington V, et. al. Acupuncture as a detoxification treatment: An analysis of controlled research. J Subst Abuse Treatment 1994;11:289-307.
3. Tan L. Acupuncture Therapy. Current Chinese Practice. Philadelphia: Temple University Press; 1973:3-5.
4. Chinese Pain Center. How Does Acupuncture Work? Available: http://www.acupuncture.com /Acup/ Works.htm. Jan 29, 1998.
5. Childs N. NIH Consensus on Acupuncture: It Works. Internal Medicine News 1997:Dec 1.
6. Ismail Z, et al. Nicotine and endogenous opioids: Toward specific pharmacotherapy. Can J Psychiatry 1998;43:37-42.
7. Shang C. The Mechanism of Acupuncture. Available: http://www.acupuncture.com/Acup/Mech.htm. Jan 29, 1998.
8. Curio G, et al. Magnetometry of evoked fields from human peripheral nerve, brachial plexus, and primary somatosensory cortex using a liquid nitrogen cooled superconducting quantum interference device. Neurosci Lett 1996;206:204-206.
9. Birch S, et al. Acupuncture Efficacy: A Summary of Controlled Clinical Trials. New York: National Academy of Acupuncture and Oriental Medicine; 1996:12-14.
10. Riet G, et al. A meta-analysis of studies into the effect of acupuncture on addiction. Br J Gen Pract 1990;40:379-382.
11. He D, et al. Effects of acupuncture on smoking cessation or reduction for motivated smokers. Prev Med 1997;26:208-214.
12. Norheim, AJ. Adverse effects of acupuncture: A study of the literature for the years 1981-1994. J Altern Complement Med 1996;2:291-297.
13. Hurt RD, et al. A comparison of sustained-release bupropion and placebo for smoking cessation. N Engl J Med 1997;17:1195-1202.
June 1998; Volume 1: 64-67
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