Ho et al.

Chinese Medicine (2022) 17:92

https://doi.org/10.1186/s13020-022-00649-w Chinese Medicine

RESEARCH Open Access

Acupuncture combined with auricular

acupressure for smoking cessation and its
effects on tobacco dependence and smoking
behavior among Hong Kong smokers:
a multicenter pilot clinical study
Lai Fun Ho1* , Wai Kwan Ho1, Ling Ling Wong1, Sze Wan Chiu1, Shuk Yu Tang1, Chun Ming Wong1,
Kin San Chan1, Chi Lan Lam1, Min Chen1, Kam Leung Chan2,3, Guohua Lin4, Bacon Fung‑Leung Ng5 and
Zhi Xiu Lin2,3

Abstract
Background: Acupuncture combined with auricular acupressure has been used as a complementary and alterna‑
tive treatment for smoking cessation in Hong Kong for over 10 years. This study aimed to investigate the success rates
of smoking cessation posttreatment, and to evaluate treatment effects on tobacco dependence, smoking behavior,
anxiety levels, and sleep disturbances between successful and unsuccessful quit smokers in Hong Kong.
Methods: This prospective, multicenter clinical study conducted between September 2020 and February 2022 in
Hong Kong was part of the Guangdong-Hong Kong-Macau Greater Bay Area project on smoking cessation. Thirty eli‑
gible current smokers (mean age 47.10 years; 40% female) were recruited and received a combination of standardized
acupuncture and auricular acupressure treatments twice weekly for 8 weeks. The primary outcome was the success
rate of smoking cessation at week 24. The secondary outcomes were the success rates of smoking cessation at weeks
8 and 16, exhaled carbon monoxide (CO) levels, and changes in scores on the Fagerström Test for Nicotine Depend‑
ence (FTND), Autonomy Over Smoking Scale (AUTOS), Hamilton Anxiety Rating Scale (HAM-A), Self-rating Anxiety
Scale (SAS), and Pittsburgh Sleep Quality Index (PSQI). Adverse events were also recorded.
Results: Of 30 eligible participants, 28 completed 6 or more treatment sessions; all completed follow-up assess‑
ments. At week 24, the success rate of smoking cessation was 46.67%. The successfully quit rates at weeks 8 and 16
were 36.67% and 43.33%, respectively. The overall change in mean FTND scores from baseline improved significantly
from weeks 2 to 24 (P < 0.05), with the successful quit group showing significantly greater improvement between
weeks 8 and 24 (P < 0.01). Compared with baseline values, there were significant reductions in mean AUTOS scores
from weeks 6 to 24 (P < 0.001), with the successful quit group showing greater improvement at weeks 16 (P = 0.04)
and 24 (P < 0.001). No significant changes were detected in exhaled CO levels or HAM-A, SAS, and PSQI scores. No
study-related adverse events were observed.

*Correspondence: holaifun@gmail.com
1
Chinese Medicine Services, Pok Oi Hospital, G/F, Shatin (Taiwai) Clinic, 2 Man
Lai Road, Taiwai, Shatin, NT, Hong Kong, SAR, China
Full list of author information is available at the end of the article

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Ho et al. Chinese Medicine (2022) 17:92 Page 2 of 12

Conclusions: Acupuncture combined with auricular acupressure could be an effective alternative treatment for
smoking cessation and reduction of tobacco dependence among Hong Kong smokers.
Trial registration Chinese Clinical Trial Registry, No. ChiCTR2000033650. Registered on June 7, 2020. http://​www.​chictr.​
org.​cn/​showp​roj.​aspx?​proj=​54866
Keywords: Acupuncture, Auricular acupressure, Clinical trial, Smoking cessation, Tobacco dependence

Background abstinence phase of smoking cessation through the regu-

Tobacco smoking is a challenging public health problem lation of brain activation in areas involved in attention,
worldwide. The global prevalence of smoking among motivation, and reward [6]. A study exploring the neural
people aged greater than 15 years was 17.5% in 2019 [1]. mechanisms of acupuncture indicated that the imme-
In Hong Kong, the Census and Statistics Department diate effects of acupuncture on smoking cravings were
Survey Report for 2019 showed that cigarette smoking significant and identified the anterior cingulate cortex,
prevalence was 11.1% among those aged 15 years and insula, prefrontal cortex, visual cortex, and cerebellum
older [2]. Smoking is a major cause of and associated as the key brain areas involved in the response [7]. Previ-
with many preventable diseases and premature deaths ous clinical studies have also shown that acupuncture is
internationally [1]. According to the Global Burden of effective for smoking cessation [8, 9], its treatment effect
Diseases, Injuries, and Risk Factors Study 2019, smoking is noninferior to that of nicotine replacement therapy [9],
was the second leading risk factor for attributable deaths, and said effect may last for at least 5 years [10]. Acupunc-
accounting for 8.71 million deaths worldwide [3]. ture is also safe and can relieve withdrawal symptoms [8]
Tobacco smoking increases the risk of contracting a and reduce daily cigarette consumption [11, 12].
wide range of diseases, including lung and heart diseases, Auricular acupressure works by continuously stimu-
chronic respiratory diseases, cancers, and diabetes, many lating acupoints to regulate and relieve disease symp-
of which are fatal. In general, there is a positive associa- toms; consequently, auricular acupressure has also been
tion between average daily cigarette consumption and adopted as a simple and effective noninvasive interven-
the risk of most smoking-related diseases, and cigarette tion to help quit smoking, as it may help relieve with-
use can also harm non-smokers who are exposed to envi- drawal symptoms and decrease levels of exhaled carbon
ronmental tobacco smoke [4]. monoxide (CO) [13]. The results from a previous sys-
Quitting tobacco smoking has a profound effect on tematic review and meta-analysis suggested that ear acu-
improving health and quality of life and significantly pressure is beneficial to achieving smoking cessation and
reduces the risk of tobacco-related diseases and death. could be a clinical alternative to established smoking ces-
Stopping smoking at any age is more beneficial than sation interventions [14]. However, this result was based
continuing to smoke. Reducing tobacco use is critical on data without biochemical confirmation.
for reducing the burden of noncommunicable diseases, In view of the above, acupuncture, auricular acupres-
which account for 71% of deaths globally [1]. Many coun- sure, or a combination of both could be effective treat-
tries have adopted smoke-free legislative measures for ments for smoking cessation; however, their efficacy
tobacco control. In addition, various methods, including remains controversial, and high-quality scientific evi-
but not limited to pharmacotherapy, nicotine replace- dence is currently lacking [15]. An earlier systematic
ment therapy, and behavioral therapy, are available to review and Bayesian network meta-analysis showed that
help smokers achieve abstinence. Bupropion and vareni- the probability rankings of auricular acupressure and
cline are non-nicotine medications used for smoking acupuncture plus auricular acupressure were superior to
cessation. Nicotine replacement therapy helps reduce other interventions in smoking cessation [16]. Nonethe-
the motivation to smoke and is accepted as an essential less, substantial uncertainty remains as other previous
treatment for people who want to stop smoking. Numer- studies showed conflicting results, and no firm conclu-
ous trials attempting to evaluate these treatments have sions can yet be made regarding the effectiveness of acu-
resulted in different levels of evidence; however, no single puncture as a single treatment for smoking cessation.
best treatment method has been identified [5]. In Hong Kong, a free community-based smoking ces-
Acupuncture has been used for smoking cessation for sation service utilizing body acupuncture and auricular
years, with increasing research into acupuncture’s effect acupressure has been provided since April 2010, with
on nicotine dependence leading to more widespread favorable results [8, 12]. This study aimed to investigate
acceptance. A previous clinical study found that acupunc- the success rates of smoking cessation among Hong
ture alleviates cue-induced cravings during the initial Kong smokers who underwent 8 weeks of acupuncture
Ho et al. Chinese Medicine (2022) 17:92 Page 3 of 12

combined with auricular acupressure treatments. In (8) had a history of smoking cessation treatments, such as
addition, we evaluated changes in tobacco dependence, acupuncture, auricular acupressure, or nicotine replace-
smoking behavior, anxiety levels, and sleep disturbances ment therapy, within the previous month.
between successful and unsuccessful quit smokers. After eligibility assessment by the research team, the
participants were enrolled and underwent baseline pre-
Methods treatment evaluations. Routine biochemical and hema-
Study design and setting tological tests and electrocardiography were performed
This prospective, multicenter, open-label clinical study before treatment administration.
was conducted between September 24, 2020, and Feb-
ruary 22, 2022. The trial sites included Pok Oi Hospital‒
The Chinese University of Hong Kong Chinese Medicine Intervention
Clinic cum Training and Research Centre (Shatin Dis- All participants received standardized acupuncture and
trict), and two community-based mobile clinics. The trial auricular acupressure treatments twice weekly for 8
consisted of 8 weeks of treatment and 16 weeks of follow- consecutive weeks. The treatments were performed by
up (an 8-week treatment period with follow-up at weeks Hong Kong Registered Chinese Medicine Practitioners
16 and 24). The trial was approved by the Joint Chinese who had over 3 years of practice experience and received
University of Hong Kong‒New Territories East Cluster training to execute standard protocol procedures prior to
Clinical Research Ethics Committee (No. 2020.116) and study initiation. The treatment protocol was developed
registered in the Chinese Clinical Trial Registry (No. based on the neural mechanism of acupuncture [6, 7],
ChiCTR2000033650). The trial adhered to the Declara- previous clinical studies [19, 20], and the clinical experi-
tion of Helsinki and Good Clinical Practice guidelines. ence of acupuncture experts.
The study was conducted in accordance with the STand- For acupuncture treatments, the acupoints Baihui
ards for Reporting Interventions in Clinical Trials of (GV20), Yintang (GV29), bilateral Lieque (LU7), and
Acupuncture recommendations [17]. All participants bilateral Hegu (LI4) [21, 22] were used based on the
provided written informed consent prior to participation. methodology of an earlier smoking cessation study [20].
Treatments were provided free, and no subjects were During each treatment session, the participants were
paid for their participation. in a supine position exposing the acupoints. After skin
disinfection, sterile, single-use acupuncture needles
Participants (0.25 mm × 25/40 mm; Suzhou Medical Appliance Fac-
Current smokers who wanted to quit smoking were tory, Suzhou, China) were inserted obliquely into GV20
recruited and underwent eligibility assessment by cross- (depth, 0.8–1.0 cun) and bilateral LU7 (depth, 0.5–1.0
referral from all Chinese medicine service units under cun until it reached Yangxi [LI5]), inserted transversely
the management of Pok Oi Hospital (covering all districts into GV29 (depth, 0.8 cun), and inserted perpendicularly
in Hong Kong) between September 2020 and August into bilateral LI4 (depth, 0.5–0.8 cun). The needles were
2021. manipulated using the lifting and thrusting method [23]
Eligible participants had to meet the following inclu- until deqi sensation [24] was achieved for each acupoint
sion criteria: (1) voluntarily quit smoking; (2) aged whenever possible, and retained in situ for 30 min before
18‒65 years; (3) smoked for ≥ 1 year; (4) consumed ≥ 20 removal. During retention, the needles were manipulated
cigarettes per day in the previous year; (5) positive sali- by lifting and thrusting 20 times every 10 min.
vary cotinine test; (6) nicotine dependence score (Fager- Auricular acupressure was administered unilaterally,
ström Test for Nicotine Dependence, FTND [18]) of ≥ 4 alternating between the left and right ear in each treat-
points; (7) provided written informed consent and vol- ment session. The auricular acupoints used were Shen-
unteered to participate; and (8) undergone a washout men ­(TF4), Fei (­CO14), Wei (­CO4), Neifenmi ­ (CO18),
period of more than 1 month if other smoking cessation Pizhixia ­(AT4), Jiaogan (­ AH6a), and Kou (­ CO1) [25]. After
treatments were previously conducted. skin disinfection, Vaccariae seeds (Wang Bu Liu Xing)
Participants were excluded if they: (1) had severe and 2 mm in diameter were adhered with adhesive tape to the
unstable cardiac, pulmonary, cerebral, or hematologic surface of the 7 auricular acupoints and maintained for
diseases or diabetes with other complications; (2) had 3 days. Participants were instructed to press each auricu-
mental illness or drug abuse; (3) had apoplexy or other lar acupoint via the central plastered seed 3–5 times per
nervous system diseases; (4) had unknown diseases; (5) day for 30–60 s.
had blood coagulation disturbances or were undergoing During the study period, the research team advised
treatment with anticoagulant drugs; (6) had moderate or each participant to avoid any other treatments for smok-
severe liver or kidney impairment; (7) were pregnant; or ing cessation but to continue medications for diseases
Ho et al. Chinese Medicine (2022) 17:92 Page 4 of 12

such as hypertension, diabetes, hyperlipidemia, and coro- We used the statistical package IBM SPSS Statistics
nary heart disease. version 27.0 (IBM Corp, Armonk, NY, USA) for conduct-
ing statistical analyses, and all participants’ data were
included. Analyses were performed by a statistician not
Outcome measures involved in treatment provision or data collection. All
Evaluations in this study were performed at baseline and statistical tests were two-sided, with a significance level
at weeks 2, 4, 6, and 8 after the start of treatment and of 0.05.
again at weeks 16 and 24 when follow-up was performed. To analyze the data, appropriate parametric or non-
The primary outcome measure was the success rate parametric statistical tests were used in accordance with
of smoking cessation at week 24. Success was defined the nature of the data. Baseline participant characteris-
as self-reported quitting and verified by an exhaled CO tics were reported as mean and standard deviation for
level < 10 parts per million (ppm) within 24 h of self- continuous variables and as count and percentage for cat-
reported abstinence, measured using CO Check Pro (MD egorical variables.
Diagnostics Ltd, Chatham, UK), and a negative test result To investigate changes in the mean scores for all con-
for salivary cotinine, measured using the Oral Fluid Coti- tinuous outcome variables from baseline to week 24,
nine Test Mini Cube (TestCountry, San Diego, CA, USA). linear mixed-effects model (LMM) analyses were con-
Secondary outcomes were the success rates of smok- ducted. The fundamental assumptions of the LMM
ing cessation at weeks 8 and 16, exhaled CO levels at each (including normality, validity of the model, and inde-
evaluation time point, efficacy indicators of the FTND pendence of data points) were tested to ensure the accu-
and Autonomy Over Smoking Scale (AUTOS) at each racy of the test results.
evaluation time point, and scale evaluations of the Ham- The overall and individual group changes for each
ilton Anxiety Rating Scale (HAM-A), Self-rating Anxiety continuous outcome from baseline across all measure-
Scale (SAS), and Pittsburgh Sleep Quality Index (PSQI) at ment points were analyzed using LMM analyses. In
each evaluation time point. The FTND (score, 0–10) is a addition, LMM analyses were performed to compare
validated 6-item instrument devised to evaluate the num- treatment effects between the successful and unsuccess-
ber and strength of cigarettes smoked as well as smok- ful quit groups across all study time points from baseline
ing behavior, with higher scores indicating higher levels to week 24 (group-by-time interaction effects). Post-hoc
of nicotine dependence [18]. AUTOS (score, 0–36) is a between-group and within-group differences were com-
validated 12-item theory-based instrument with three puted using the Bonferroni adjustment for multiple com-
subscales to assess withdrawal symptoms, psychological parisons (six time points).
dependence, and cue-induced craving [26, 27]. HAM-A Furthermore, binary logistic regression was adopted
(score, 0–56) is a validated 14-item (symptom-defined to analyse the relationship between a series of baseline
elements) clinician-rated instrument for quantifying characteristics that could act as possible predictors and
anxiety symptoms, with higher scores indicating greater the success rate of smoking cessation at week 24 and was
symptom severity [28, 29]. The SAS (index, 25–100) is a reported as odds ratio and 95% confidence interval (OR
validated 20-item rating instrument for anxiety disorders, and 95% CI). Adverse events and additional information
with higher scores indicating greater anxiety [30]. PSQI were descriptively analyzed and reported.
(score, 0–21) is a validated 19-item self-rated question-
naire for assessing sleep quality and disturbances, with
higher scores indicating poorer sleep quality [31]. Possi- Results
ble predictors for smoking cessation were evaluated, and Participant flow and baseline characteristics
all adverse events or reactions were monitored, appro- From September 2020 to August 2021, a total of 33 cur-
priately managed, and recorded throughout the study rent smokers who expressed interest in the study were
period. screened. Of these 33 smokers, 3 declined participation
before the start of treatment. The remaining 30 par-
ticipants were enrolled and treated; none were lost to
Statistical analysis follow-up. Of these 30 participants, 15 completed all 16
This study was part of the Guangdong-Hong Kong- treatment sessions, and only 2 received less than 6 treat-
Macau Greater Bay Area Smoking Cessation Project, and ment sessions. All pretreatment salivary cotinine test
the Hong Kong site was assigned to recruit 30 subjects. results were positive. The study flowchart is shown in
Therefore, no additional formal sample size calculations Fig. 1.
were performed. This sample size is similar to that rec- The demographic and clinical characteristics of
ommended by previous research on sample size determi- the participants are presented in Table 1. All partici-
nation for pilot trials [32]. pants were Chinese, 40.00% were female, and 76.67%
Ho et al. Chinese Medicine (2022) 17:92 Page 5 of 12

Fig. 1 Study flowchart

were aged 40 years and above. The mean age was those who successfully quit smoking had a lower level of
47.10 ± 10.74 years, and most participants were between exhaled CO before treatment.
40 and 49 years old (43.33%). The mean duration of
smoking was 24.10 ± 11.43 years, and 70.00% of the par-
ticipants smoked at least 10 cigarettes per day. In addi- Primary outcome
tion, 46.67% of participants had tried to quit smoking in Regarding the primary outcome, the success rate of
the past. The mean scores for FTND and AUTOS were smoking cessation at week 24 was 46.67% (Fig. 2). Thir-
5.06 ± 1.87 and 19.33 ± 7.99, respectively. Moreover, we teen out of the 14 participants who successfully quit
presented the baseline data of participants by categoriz- smoking attended 6 or more treatment sessions. Among
ing them into successful and unsuccessful quit smokers those who did not quit smoking (n = 16), 11 (68.75%)
(based on smoking cessation at week 24). The baseline reported a reduction in the number of cigarettes smoked
characteristics of the two groups were similar, except that per day at week 24.
Table 1 Baseline participant characteristics
Characteristic Total (n = 30) Successful Quit (n = 14) Unsuccessful Quit (n = 16) P value

Age, y 47.10 ± 10.74 49.50 ± 13.11 45.00 ± 8.01 0.26

Sex 0.76
Female 12 (40.00) 6 (42.86) 6 (37.50)
Ho et al. Chinese Medicine

Male 18 (60.00) 8 (57.14) 10 (62.50)

Body mass index, kg/m2 25.10 ± 3.69 25.24 ± 3.08 24.98 ± 4.26 0.85
Marital status 0.76
Married 18 (60.00) 8 (57.14) 10 (62.50)
(2022) 17:92

Single or divorced 12 (40.00) 6 (42.86) 6 (37.50)

Education level 0.35
Secondary 26 (86.67) 13 (92.86) 13 (81.25)
Post-secondary or higher 4 (13.33) 1 (7.14) 3 (18.75)
Occupation 0.51
Currently employed 19 (63.33) 8 (57.14) 11 (68.75)
Unemployed/retired/other 11 (36.67) 6 (42.86) 5 (31.25)
Family type 0.58
Two-parent family 23 (76.67) 11 (78.57) 12 (75.00)
Single-parent family 7 (23.33) 3 (21.43) 4 (25.00)
Living condition 0.75
Living alone 3 (10.00) 2 (14.29) 1 (6.25)
With family members 25 (83.33) 11 (78.57) 14 (87.50)
With others 2 (6.67) 1 (7.14) 1 (6.25)
Smoking duration 24.10 ± 11.43 22.85 ± 14.81 25.18 ± 7.73 0.60
Daily cigarette consumption* 14.41 ± 7.16 13.28 ± 8.18 15.46 ± 6.16 0.42
Previous quit attempts 0.06
None 16 (53.33) 10 (71.43) 6 (37.50)
≥1 14 (46.67) 4 (28.57) 10 (62.50)
Reason to quit smoking 0.26
Own health 21 (70.00) 9 (64.29) 12 (75.00)
Family suggestion 3 (10.00) 1 (7.14) 2 (12.50)
Medical suggestion 1 (3.33) 0 (0.00) 1 (6.25)
Other reasons 5 (16.67) 4 (28.57) 1 (6.25)
Exhaled CO Level (ppm) 0.001
< 10 ppm 18 (60.00) 13 (92.86) 5 (31.25)
≥ 10 ppm 12 (40.00) 1 (7.14) 11 (68.75)
FTND 5.06 ± 1.87 5.14 ± 2.17 5.00 ± 1.63 0.83
Page 6 of 12
 Ho et al. Chinese Medicine
(2022) 17:92

Table 1 (continued)
Characteristic Total (n = 30) Successful Quit (n = 14) Unsuccessful Quit (n = 16) P value

AUTOS
Withdrawal symptoms 6.33 ± 3.20 6.78 ± 2.75 5.93 ± 3.60 0.48
Psychological dependence 5.83 ± 3.20 6.35 ± 3.20 5.37 ± 3.24 0.41
Cue-induced craving 7.16 ± 2.50 7.85 ± 2.31 6.56 ± 2.58 0.16
Total 19.33 ± 7.99 21.00 ± 7.53 17.87 ± 8.34 0.29
HAM-A 16.06 ± 9.02 18.85 ± 9.33 13.62 ± 8.26 0.11
SAS 50.80 ± 7.82 50.92 ± 8.84 50.68 ± 7.10 0.93
PSQI 7.43 ± 4.05 7.35 ± 4.03 7.50 ± 4.21 0.92
Data are expressed as mean ± standard deviation or as number (%)
CO, carbon monoxide; ppm, parts per million; FTND, Fagerström Test for Nicotine Dependence; AUTOS, Autonomy Over Smoking Scale; HAM-A, Hamilton Anxiety Rating Scale; SAS, Self-rating Anxiety Scale; PSQI,
Pittsburgh Sleep Quality Index
*One participant in the unsuccessful quit group used electronic cigarettes
Page 7 of 12
Ho et al. Chinese Medicine (2022) 17:92 Page 8 of 12

the successful quit group and at weeks 8 and 16 in the

unsuccessful quit group exhibited significant improve-
ments (Table 2).
Improvements were detected in HAM-A, SAS, and
PSQI scores for both successful and unsuccessful quit
groups over time, but their changes were not significant
(all P > 0.05, Table 2). Moreover, between-group compari-
sons showed no significant differences in HAM-A, SAS,
or PSQI scores across all study time points (all P > 0.05,
Table 2).
In addition, binary regression analysis revealed that
the exhaled CO level was a possible factor impacting
smoking cessation success at week 24. Participants with
higher exhaled CO levels at baseline were less likely to
Fig. 2 Successful quit rates at different time points. Wk, Week be successful in quitting smoking (OR = 0.72; 95% CI:
0.56‒0.92, P < 0.01).Throughout the study period, no
study-related adverse events were reported.
Secondary outcomes
The success rates for smoking cessation at weeks 8 Discussion
and 16 were 36.67% and 43.33%, respectively (Fig. 2). Smoking is an important global public health problem,
Among those who did not quit smoking, 63.16% and and many countries have taken numerous measures to
70.59% reported a reduction in daily cigarette con- address it. Various therapeutic approaches, including
sumption at weeks 8 and 16, respectively. acupuncture, have been used to help people quit smok-
Overall, the mean exhaled CO levels for all partici- ing. In Hong Kong, a free community-based smoking
pants showed a gradual reduction over time; however, cessation service combining acupuncture and auricular
no significant changes were detected (P > 0.05). The acupressure has been provided since 2010, with positive
mean exhaled CO levels at each time point for the suc- results [8, 12, 33]. Our findings from the Hong Kong site
cessful and unsuccessful quit groups are illustrated in in this Guangdong-Hong Kong-Macau Greater Bay Area
Fig. 3, and no significant changes over time were found project provide updated and additional evidence on the
in either group (P > 0.05). effects and safety of combined acupuncture and auricular
The mean FTND scores for both the successful and acupressure for smoking cessation.
unsuccessful quit groups at each time point are shown
in Fig. 4. LMM analysis indicated significant effects of
group (P < 0.001), time (P < 0.001), and group-by-time Main findings
interaction (P = 0.003) for FTND. Significant between- The 30 participants involved in this clinical trial were
group differences were identified between weeks 8 and moderate to heavy smokers living in Hong Kong. Our
24, with the successful quit group having a significantly study showed that the successful quit rate improved
greater reduction in mean FTND scores. In the suc- gradually from weeks 8 to 23. After combined acupunc-
cessful quit group, the FTND scores from weeks 4 to ture and auricular acupressure treatments, the success
24 were significantly lower than those at baseline; how- rates of smoking cessation achieved at weeks 8 (post-
ever, these improvements were not observed in the treatment) and 24 (follow-up period) were 36.67% and
unsuccessful quit group (Table 2). 46.67%, respectively. Among those who did not quit
The mean AUTOS scores at different time points for smoking, 63.16% and 68.75% reductions in cigarette con-
the successful and unsuccessful quit groups are shown sumption were recorded at weeks 8 and 24, respectively.
in Fig. 5. LMM analysis of changes in the mean AUTOS Regarding efficacy scales, the FTND scores in the suc-
scores between both groups over time revealed sig- cessful quit group were significantly decreased from
nificant effects of group (P = 0.012), time (P < 0.001), weeks 4 to 24 when compared to baseline; however, these
and group-by-time interaction (P = 0.002). Post-hoc improvements were not observed in the unsuccessful quit
between-group comparisons showed significantly group. As for AUTOS, the mean scores at weeks 6–24 in
greater improvement in mean AUTOS scores in the the successful quit group and at weeks 8 and 16 in the
successful quit group at weeks 16 (P = 0.04, Table 2) unsuccessful quit group were significantly improved rela-
and 24 (P < 0.001, Table 2). Relative to the baseline tive to the baseline.
score, the mean AUTOS scores at weeks 6 to 24 in No significant improvements were detected over time
in exhaled CO levels or in HAM-A, SAS, and PSQI scores
Ho et al. Chinese Medicine (2022) 17:92 Page 9 of 12

lower levels of exhaled CO on day 8 of a 22-day interven-

tion program than their unsuccessful counterparts [34].
Smoking cessation requires a strong will and a deter-
mined attempt to stop for most smokers. The careful and
intense follow-up schedule employed in our study may
have provided continuous support to smokers aiming to
achieve smoking cessation.
Regarding FTND, a previous clinical trial reported
improvements in mean scores over time, from week 8
(posttreatment) to week 24 (follow-up), for both acu-
puncture and auricular point pressing [9]. Our results
indicated a greater improvement in FTND scores over
Fig. 3 Changes in mean exhaled CO levels over time. CO, carbon time, which revealed that acupuncture combined with
monoxide; ppm, parts per million; Wk, Week acupressure might have an effect on nicotine depend-
ence. Further randomized controlled trials are warrented
to confirm these findings.
Similar to previous study findings, the HAM-A scores
in our study did not show any significant changes over
time after treatment [35]. Moreover, SAS scores in our
study declined over time, as was similarly observed in a
previous clinical trial [36]. However, our results did not
detect any significant reduction.

Study strengths and limitations

The major aim of our study was to investigate the suc-
cess rates of smoking cessation posttreatment. It has
been reported that receiving sufficient and qualified acu-
puncture is a leading factor for short-term smoking ces-
sation [33]. The more acupuncture treatment received,
Fig. 4 Changes in mean FTND scores over time. FTND, Fagerström the greater the possibility of quitting tobacco dependence
Test for Nicotine Dependence; Wk, Week. * denotes a significant
with acupuncture [8, 33]. A previous clinical trial in Nor-
between-group difference; # denotes a significant within-group
difference compared with the pretreatment value way reported that six acupuncture sessions might help
motivate smokers to quit smoking completely, and the
effect might last for five years [10]. In addition, another
earlier study in Hong Kong demonstrated that 6 or more
for both the successful and unsuccessful quit groups (all
sessions of acupuncture were strongly associated with a
P > 0.05). Finally, no study-related adverse events were
higher chance of successful quitting [8]. In our study, over
observed.
90% of participants received 6 or more treatments, which
may be one of the factors contributing to our higher rate
Comparisons with previous studies of successful smoking cessation.
In general, our findings on abstinence rates were consist- Moreover, measuring exhaled CO levels may provide
ent with the previous multicenter observational study on an immediate, noninvasive method for assessing smoking
acupuncture combined with auricular acupressure from status [37], and cotinine is the best indicator of tobacco
Hong Kong (34.01% at week 8) [12] and the previous smoke exposure [38]. Our study’s use of self-reported
randomized controlled trial on acupuncture from China smoking cessation confirmed by exhaled CO levels and
(36.00% at week 8 and 43.00% at week 24) [9]. Our study’s cotinine test results ensured objectivity and correctness
smoking cessation rates were noninferior to 8-week nico- and reduced the possibility of false claims.
tine replacement therapy as reported in an earlier clinical Furthermore, this study’s use of validated and reli-
trial in China (46.00% at week 8 and 44.00% at week 24). able measurement tools increased the reliability of the
The higher abstinence rates recorded in our study may be reported outcomes. FTND is a convenient and valid
because most of our participants possessed lower base- self-reported measure of nicotine dependency, and loss
line exhaled CO levels. In a previous cohort study, suc- of autonomy is a good predictor of success at smoking
cessful quit smokers with 1-year abstinence exhibited cessation [26]. The improved FTND and AUTOS scores
Ho et al. Chinese Medicine (2022) 17:92 Page 10 of 12

Table 2 Change from baseline for secondary outcome measures at different time points
Outcome Total P ­valuea Successful Quit (n = 14) Unsuccessful Quit (n = 16) P ­valueb

FTND
Week 2 − 0.80 (− 3.51 to − 0.08) 0.03 − 2.57 (− 5.44 to 0.30) − 1.12 (− 3.27 to 1.02) 0.18
Week 4 − 2.06 (− 3.77 to − 0.35) 0.006 − 3.07 (− 6.01 to − 0.12)* − 1.18 (− 3.17 to 0.79) 0.06
Week 6 − 2.50 (− 4.16 to − 0.84) < 0.001 − 3.35 (− 6.21 to − 0.50)* − 1.75 (− 3.70 to 0.20) 0.08
Week 8 − 2.73 (− 4.49 to − 0.97) < 0.001 − 4.35 (− 6.98 to − 1.72)‡ − 1.31 (− 3.48 to 0.85) 0.006
Week 16 − 2.73 (− 4.51 to − 0.95) < 0.001 − 4.42 (− 7.02 to − 1.83)‡ − 1.25 (− 3.44 to 0.94) 0.004
Week 24 − 2.76 (− 4.48 to − 1.05) < 0.001 − 4.78 (− 7.04 to − 2.52)‡ − 1.00 (− 3.05 to 1.05) < 0.001
AUTOS
Week 2 − 3.30 (− 9.83 to 3.23) 1.00 − 4.85 (− 14.43 to 4.72) − 1.93 (− 11.18 to 7.31) 0.90
Week 4 − 5.83 (− 12.22 to 0.55) 0.11 − 9.07 (− 18.80 to 0.65) − 3.00 (− 11.74 to 5.74) 0.10
Week 6 − 8.93 (− 14.82 to − 3.04) < 0.001 − 12.14 (− 21.65 to − 2.62)† − 6.12 (− 13.62 to 1.37) 0.24
Week 8 − 10.73 (− 16.55 to − 4.91) < 0.001 − 14.00 (− 23.48 to − 4.51)† − 7.87 (− 15.54 to − 0.20)* 0.46
‡
Week 16 − 12.56 (− 18.10 to − 7.02) < 0.001 − 17.50 (− 25.99 to − 9.00) − 8.25 (− 15.71 to − 0.78)* 0.04
Week 24 − 13.03 (− 19.10 to − 6.96) < 0.001 − 20.28 (− 27.89 to − 12.67)‡ − 6.68 (− 15.09 to 1.72) < 0.001
HAM− A
Week 2 − 0.86 (− 8.64 to 6.91) 1.00 − 2.00 (− 13.48 to 9.48) 0.12 (− 10.29 to 10.54) 0.40
Week 4 − 4.13 (− 11.69 to 3.42) 1.00 − 5.78 (− 17.48 to 5.91) − 2.68 (− 12.35 to 6.97) 0.60
Week 6 − 6.20 (− 13.54 to 1.14) 0.20 − 7.14 (− 19.51 to 5.23) − 5.37 (− 13.85 to 3.10) 0.55
Week 8 − 6.53 (− 13.82 to 0.75) 0.12 − 8.14 (− 20.17 to 3.89) − 5.12 (− 14.00 to 3.75) 0.80
Week 16 − 4.96 (− 12.13 to 2.20) 0.66 − 6.07 (− 17.98 to 5.84) − 4.00 (− 12.62 to 4.62) 0.36
Week 24 − 5.80 (− 13.08 to 1.48) 0.29 − 9.14 (− 20.44 to 2.15) − 2.87 (− 12.80 to 7.05) 0.97
SAS
Week 2 − 2.40 (− 8.61 to 3.81) 1.00 − 1.00 (− 11.45 to 9.45) − 3.62 (− 11.52 to 4.27) 0.23
Week 4 − 4.16 (− 9.97 to 1.64) 0.55 − 3.28 (− 13.06 to 6.48) − 4.93 (− 12.41 to 2.54) 0.26
Week 6 − 3.60 (− 8.82 to 1.62) 0.66 − 3.21 (− 12.43 to 6.01) − 3.93 (− 10.54 to 2.67) 0.47
Week 8 − 5.03 (− 10.95 to 0.89) 0.19 − 5.57 (− 16.06 to 4.92) − 4.56 (− 11.92 to 2.79) 0.86
Week 16 − 3.66 (− 8.99 to 1.65) 0.67 − 3.00 (− 12.28 to 6.28) − 4.25 (− 11.06 to 2.56) 0.27
Week 24 − 2.33 (− 7.58 to 2.91) 1.00 − 1.71 (− 10.77 to 7.34) − 2.87 (− 9.71 to 3.96) 0.37
PSQI
Week 2 − 0.80 (− 3.79 to 2.19) 1.00 − 1.00 (− 5.66 to 3.66) − 0.62 (− 4.70 to 3.45) 0.64
Week 4 − 1.26 (− 4.43 to 1.90) 1.00 − 1.57 (− 6.56 to 3.41) − 1.00 (− 5.38 to 3.38) 0.52
Week 6 − 1.53 (− 4.69 to 1.62) 1.00 − 1.85 (− 6.76 to 3.05) − 1.25 (− 5.62 to 3.12) 0.44
Week 8 − 1.60 (− 4.68 to 1.48) 1.00 − 1.85 (− 6.61 to 2.89) − 1.37 (− 5.67 to 2.92) 0.41
Week 16 − 1.53 (− 4.75 to 1.68) 1.00 − 2.00 (− 6.91 to 2.91) − 1.12 (− 5.70 to 3.45) 0.45
Week 24 − 1.66 (− 5.06 to 1.73) 1.00 − 2.85 (− 7.64 to 1.93) − 0.62 (− 5.61 to 4.36) 0.14
Data are presented as estimated mean (95% CI) from the linear mixed-effects model
FTND, Fagerström Test for Nicotine Dependence; AUTOS, Autonomy Over Smoking Scale; HAM-A, Hamilton Anxiety Rating Scale; SAS, Self-rating Anxiety Scale; PSQI,
Pittsburgh Sleep Quality Index
a
P values were calculated using a linear mixed-effects model to illustrate pre- and posttreatment differences
b
P values were calculated using a linear mixed-effects model to illustrate between-group differences
*
P < 0.05, compared with pretreatment within-group
†
P < 0.01, compared with pretreatment within-group
‡
P < 0.001, compared with pretreatment within-group

reported in our results showed the positive therapeutic Although no significant changes were found in these
effects of acupuncture on tobacco dependence in smok- scores, our study still provided preliminary insight into
ers. Furthermore, HAM-A is a reliable and valid anxiety the effects of combined acupuncture and auricular acu-
evaluation questionnaire, and SAS is a rating instrument pressure on smokers’ anxiety status and sleep quality.
for measuring anxiety disorders, while PSQI provides Our study also has several limitations. This was a
a standardized, quantitative measure of sleep quality. single-arm clinical trial without control group, which
Ho et al. Chinese Medicine (2022) 17:92 Page 11 of 12

Abbreviations
CO: Carbon monoxide; ppm: Parts per million; FTND: Fagerström Test for
Nicotine Dependence; AUTOS: Autonomy Over Smoking Scale; HAM-A:
Hamilton Anxiety Rating Scale; SAS: Self-rating Anxiety Scale; PSQI: Pittsburgh
Sleep Quality Index; LMM: Linear mixed-effects model; OR: Odds ratio; CI:
Confidence interval.

Acknowledgements
We thank all participants for their contributions to the study. We also thank
the Hospital Authority Chinese Medicine Department of Hong Kong for their
expert advice and monitoring of the trial’s progress.

Author contributions
LFH, WKH, GHL, and ZXL conceived and contributed to the study design. LFH,
WKH, and KLC obtained ethical approval. MC, GHL, BN, and ZXL supervised the
study. LFH and WKH contributed to the study collaboration. LLW, ZWC, SYT,
CMW, KSC, and CLL participated in clinical treatment and data collection. LFH
Fig. 5 Changes in mean AUTOS scores over time. AUTOS, and WKH were responsible for data management and analysis. LFH drafted
Autonomy Over Smoking Scale; Wk, Week. * denotes a significant the manuscript. MC, KLC, BN, and ZXL reviewed the manuscript. All authors
between-group difference; # denotes a significant within-group read and approved the final manuscript.
difference compared with the pretreatment value
Funding
This study was supported and funded by the reserve of Pok Oi Hospital‒The
Chinese University of Hong Kong Chinese Medicine Clinic cum Training and
affected the quality of our study design and results. All Research Centre (Shatin District). Funding played no role in the study design,
30 smokers in our study received combined acupunc- collection, management, or analysis, nor in the interpretation of the data, writ‑
ing of the report, or decision to submit the report for publication.
ture and auricular acupressure treatments, and no con-
trols were used for comparison. This small and relatively Availability of data and materials
homogenous sample size may prevent the extrapolation The datasets used and/or analyzed during the current study are available from
the corresponding author upon reasonable request.
of the findings and may be insufficient to generate pre-
cise results. Further large-scale, high-quality randomized
controlled trials with proper comparison groups are war- Declarations
ranted to verify our findings. In addition, we investigated Ethics approval and consent to participate
the therapeutic effects of combined acupuncture and This study was reviewed and approved by the Joint Chinese University of
Hong Kong‒New Territories East Cluster Clinical Research Ethics Committee
auricular acupressure for smoking cessation in moderate (CREC Ref. No. 2020.116) in April 2020. Written informed consent was obtained
and heavy smokers. Future studies focusing on light and from all participants.
intermittent smokers would be useful since light smok-
Consent for publication
ing also carries substantial health risks [39]. Moreover, Not applicable.
our follow-up period was only up to week 24. A longer
follow-up period will provide more insights into the Competing interests
The authors declare that they have no competing interests.
therapeutic effects of combined acupuncture and auricu-
lar acupressure for long-term smoking cessation, help- Author details
ing smokers to maintain a longer-term or even life-long 1
Chinese Medicine Services, Pok Oi Hospital, G/F, Shatin (Taiwai) Clinic, 2 Man
Lai Road, Taiwai, Shatin, NT, Hong Kong, SAR, China. 2 School of Chinese Medi‑
smoke-free life. Therefore, more research is required to cine, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong,
verify the exact role of acupuncture and auricular acu- SAR, China. 3 Hong Kong Institute of Integrative Medicine, Faculty of Medicine,
pressure treatments for smoking cessation and to provide The Chinese University of Hong Kong, Hong Kong, SAR, China. 4 The First Affili‑
ated Hospital, Guangzhou University of Chinese Medicine, Guangzhou, China.
more robust and precise scientific evidence. 5
Chinese Medicine Department, Hospital Authority, Hong Kong, SAR, China.

Conclusions Received: 13 May 2022 Accepted: 29 July 2022

The findings of this study indicated that acupuncture
combined with auricular acupressure might help smokers
to quit smoking. The intervention is safe and may help
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