Bier and coauthors are to be congratulated for the rigor with which they approached their study of auricular acupuncture, education, and smoking cessation. The comparison to sham acupuncture, the use of well-trained acupuncturists, the inclusion of an educational component, the careful attempts to minimize bias, and the long-term follow-up mark important advances over many previous acupuncture cessation studies. However, serious methodological problems with the study remain. Even the slim positive conclusions are unwarranted, including the Journal’s front cover headline “Acupuncture Helps Smokers Quit.”
As the authors note, the wide range of smoking intensity (6–80 cigarettes/day) and duration (5–154 pack years) spread across a small number of subjects suggests immense, perhaps qualitative, variations in patterns of use and levels of dependence. Moreover, the report does not describe the main outcome measure, abstinence from smoking. Is it continuous abstinence, abstinence that week, or that day? Whatever the duration, there was no biochemical validation.
Of most concern, however, are the very high dropout rates and the use of the dwindling number of subjects remaining in the study as a denominator in calculating successful quitting. Two thirds of 141 subjects were lost to follow-up by the study’s end. Most of those left the study in the first 3 months. The authors appear to calculate the “percentage nonsmoking” by dividing the remaining nonsmokers in each arm by the total remaining in that arm. Hence their claim that acupuncture combined with education “demonstrated an effectiveness rate of 40% cessation.”
This is an unusual and inappropriate calculation. A much more suitable approach would have been an intention-to-treat analysis2 that assumes that those lost to follow-up resumed smoking. Given that approach, the cessation rate drops to 13%. Even this number may be high, depending on the definition and validation of abstinence.
Twenty acupuncture treatments are costly and may be quite uncomfortable. This study presents little evidence to encourage either acupuncture’s use for smoking cessation or to deviate from the consensus expressed in the US Public Health Service’s Clinical Practice Guideline: Treating Tobacco Use and Dependence that “[e]vidence . . . did not support the efficacy of acupuncture as a smoking cessation treatment.”2
References
- 1.Bier ID, Wilson J, Studt P, Shakleton M. Auricular acupuncture, education, and smoking cessation: a randomized, sham controlled trial. Am J Public Health. 2000;10:1642–1647. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Clinical Practice Guideline: Treating Tobacco Use and Dependence. Rockville, Md: US Dept of Health and Human Services, Public Health Service; June 2000.