Evidence-based Evaluation Of Acupoint Therapy For Smoking Cessation And Interview Study On Factors Affecting Smoking Cessation In Patients With Chronic Obstructive Pulmonary Diseas

BackgroundSmoking is closely related to the onset,progression,and prognosis of chronic obstructive pulmonary disease(COPD),smoking cessation is the key intervention for COPD.Although the current existing smoking cessation therapies have achieved certain effects,there are still limitations in the promotion and application.Quitting smoking is a complicated process involving both psychology and physiology characteristics of smokers.Achieving smoking cessation depends not only on effective smoking cessation interventions,but also on smokers’willingness to quit.To explore the COPD smokers’ willingness to quit,experiences,needs,as well as their attitudes and preferences towards different smoking cessation interventions are the breakthrough points to improve their smoking cessation rate.Acupuncture has been used for smoking cessation for nearly 50 years.Limited evidence suggests that traditional filiform acupuncture has a certain effect on smoking cessation.Several special therapies of acupoint have also been used for smoking cessation in recent years,which refers to the method of using physical and chemical factors alone or in combination with traditional acupuncture therapy to act on acupoints to prevent and treat diseases,included acupressure,Chinese herbal medicine(CHM)acupoint external use,TEAS,laser acupuncture,intradermal needle,and acupoint catgut embedding.Which are more convenient,less painful than traditional filiform acupuncture,and are popular with smokers.However,there is a lack of independent and comprehensive evaluation of the effect of special therapies of acupoint on smoking cessation.ObjectivesTo screen out effective and convenient special therapies of acupoint for smoking cessation,providing reliable evidence for clinical practice.To identify related factors that influence successful quitting in Chinese smokers with COPD,and eventually,combining with effective special therapies of acupoint to develop comprehensive smoking cessation programs to improve abstinence rate for Chinese COPD smokers.Methods1.Special therapies of acupoint for smoking cessation:a systematic review and meta-analysis of randomized controlled trialsRandomized controlled trials(RCTs)comparing special therapies of acupoint with sham special therapies of acupoint or conventional therapies for smoking cessation were included.The study population were smokers without serious illness or pregnancy.We searched CNKI.Wanfang.VIP.Sino-Med,PubMed.the Cochrane Library.EMBASE.Web of Science from their inception to November 10th,2021.The Cochrane ROB tool was employed to assess the risk of bias of each trial.The primary outcome was abstinence rate.Data were synthesized using risk ratios(RR)or mean differences(MD)with 95%confidence intervals(CI).Meta-analysis was conducted by Cochrane Revman 5.4 software.GRADE approaches were applied to evaluate the certainty of the evidence of abstinence rate.The protocol of this systematic review was registered on INPLASY(202120054).2.Study on smoking cessation programmes in special therapies of acupoint and evaluation of reporting quality.The studies were 30 RCTs included in study 1.The characteristics of smoking cessation programmes in special therapies of acupoint were summarized,the frequency of acupoints selection and compatibility were counted,and the law of acupoints compatibility was also summarized.The reporting quality were evaluated according to the international standard for reporting interventions in clinical trials of acupuncture—STRICTA items.We calculated the number and percentage of trials reporting each item.We also evaluated the outcomes reported in these trials from three follow-up periods.3.Bibliometric analysis of smoking cessation intention among smokersStudies that reported the outcome of smoking cessation intention within one year were eligible,study types were not limited.We searched CNKI,Wanfang,VIP,Sino-Med,PubMed,the Cochrane Library,EMBASE,Web of Science from their inception to August 19th.2021.After screening,the bibliographic data were exported.The study population,study types,and factors that influence the intention to quit were also extracted.Excel2016,Spss20.0,Origin2015,and R language softwares were employed for bibliometric analysis and visual presentation.Studies on smokers with or without diseases were classified in detail,we also summarized the factors that affect smokers’ willingness to quit smoking.4.An interview study on factors that affecting smoking cessation in patients with chronic obstructive pulmonary diseaseThe current smokers or ex-smokers diagnosed with COPD in stage Ⅰ-Ⅲ were eligible,they can be inpatients or outpatients.A semi-structured interview was employed to encourage participants to adequately express their feelings,attitudes,or experiences regarding smoking cessation and smoking cessation interventions.A combination of convenience and purposive sampling was used.The interview received ethical approval,and a pilot interview was also conducted,the duration of each interview lasted approximately 25-30minutes.The coding process was conducted by NVivo12.0,thematic analysis was applied to analyze the data,and the capability,opportunity,and motivation-behavior(COM-B)framework was also applied to guide the data analysis.The reporting of this interview followed COREQ checklists.Results1.Special therapies of acupoint for smoking cessation:a systematic review and meta-analysis of randomized controlled trialsThirty RCTs on special therapies of acupoint for smoking cessation were identified,involving 4022 smokers,and included 16 Chinese studies and 14 English studies.There were 11,5,5,2,2,and 5 RCTs on acupressure,intradermal needle,TEAS,laser acupuncture,acupoint catgut embedding,and CHM external use respectively.The methodological quality of these RCTs were of high or unclear risk of bias due to insufficient reporting of random sequence generation or allocation concealment.The outcome of abstinence rate suggested that acupressure was more effective than sham acupressure in achieving short-term smoking cessation(RR 2.01,95%CI[1.10,3.67];low certainty;2 trials,n=210);Acupressure was also superior to both sham acupressure(RR2.44,95%CI[1.13,5.25];low certainty;2 trials,n=210)and conventional therapy(RR 1.52,95%CI[1.17,1.98];I2=18%;low certainty;6 trials,n=539)in achieving mid-term smoking cessation.Laser acupuncture was superior to sham control for long-term abstinence(RR 2.25,95%CI[1.23,4.11];moderate certainty;n=160,2 trials).Acupoint catgut embedding was comparable to bupropion for mid-term smoking cessation(RR 0.99,95%CI[0.70,1.40];low certainty;2 trials,n=177).CHM acupoints external use was superior to CHM placebo in decreasing short-term relapse rate(RR 0.38,95%CI[0.18,0.84];2 trials,n=115).2.Study on smoking cessation programmes in special therapies of acupoint and evaluation of reporting quality.The studies were 30 RCTs included in study 1,there were 11,5,5,2,2,and 5 RCTs on acupressure,intradermal needle,TEAS,laser acupuncture,acupoint catgut embedding,and CHM external use respectively.Except for acupoint catgut embedding and CHM external use,the treatment sites were all on the ear.The acupoints used for smoking cessation were mainly auricular acupoints,the number of acupoints in prescriptions varied from 1 acupoint to 7 acupoints.The three most frequently used auricular points were:lung(19 times),Shenmen(18times),and mouth(8times).The combination with the highest frequency of the two acupoints were lung and Shenmen(17 times),and the most frequent combination of three acupoints were lung,shenmen and mouth.The reporting quality were evaluated according to the STRICTA checklists.In terms of acupuncture rationale(1b),43.3%(13)studies reported the rationale for acupoints selection.In terms of details of needling(2a),83.3%(25)studies have adopted international standard acupoints with clear nomenclature and location,however,some new auricular acupoints were also used in 4 English studies,13.3%(4)studies reported de qi response(2d).In tems of practioner background(5a),only 23.3%(7)studies reported qualifications or trainings of practioner.Referring to the reporting of outcomes,97.7%(29)of studies reported the the abstinence rate at 3 follow-up periods,but only 16.7%(5)over 6 months.The total report rate of withdrawal symptoms was 40%,while the mid-term and long-term report rate was 6.7%and 3.3%respectively.3.Bibliometric analysis of smoking cessation intention among smokersA total of 416 studies were identified,included 262 English studies and 154 Chinese studies,and these studies were published between 1990 and 2021.Including 3 05 cross-sectional studies,76 clinical trials,28 interviews,and 7 reviews.The number of published studies has been increasing year by year.These studies were conducted in 42 countries,and the top three countries were the United States(81),the United Kingdom(19),and China(15).There were 188 studies on smokers with diseases,195 studies on smokers without diseases.Among the studies of sick smokers,COPD was the most studied and ranked first(51).63 and 138 categories of factors affecting smokers’ intention to quit were identified from Chinese and English studies respectively.4.An interview study on factors that affecting smoking cessation in patients with chronic obstructive pulmonary diseaseOverall 32 smokers diagnosed with COPD participated in this interview,17 ex-smokers and 15 current smokers.Three inter-related themes were generated:smokers’ motivation was a prerequisite for quitting,maintaining capability to quit smoking,and opportunities that facilitated smokers to quit.Motivation to quit for most participants were activated by COPD related symptoms.Physical benefits from quitting,and strong willpower were facilitators for maintaining quitting,while exposure to smoking environment,and strong addiction to nicotine induced relapse.Most ex-smokers quitted smoking by their own willpower,smokers’ attitude towards these interventions depended on their effectiveness and convenience,most smokers preferred auricular acupressure to quit smoking.ConclusionsLow to moderate certainty evidence suggests that acupressure,acupoint catgut embedding,and laser acupuncture maybe effective in achieving short-term,middle-term or long-term smoking cessation.Acupressure also appears to be beneficial to relieve short-term withdrawal symptoms,and CHM acupoints external use potentially reduce the short-term relapse rate.Auricular acupoints and Tianmei acupoint are mostly used,and the acupoints selection is usually few but accurate.The most common combination of acupoints is lung,mouth and Shenmen.However,large sample size,fully reported and long-term follow up RCTs are warranted to confirm these effects.The motivation to quit smoking is a prerequisite for achieving successful cessation,more and more studies focuse on smoking cessation intentions of sick smokers.The motivation to quit among smokers with COPD is usually initiated by COPD related symptoms,gifting cigarettes to each other and nicotine dependence often lead to replase;their attitude towards smoking cessation therapies depend on effectiveness and convenience,and they preferred auricular acupressure to quit smoking.