Visual abstract

Introduction

The World Health Organization defined smoking tobacco as one of the biggest public health threats, killing more than 8 million people in the world [1]. There are estimated globally to be 1 billion current smokers in 2020 [2]. In a community health survey in 2022 in South Korea, 19.3% of respondents were current smokers [3]. When compared with nonsmokers, smoking is reported to cause 2–3 times higher mortality in association with 5 major conditions/diseases: lung cancer, chronic obstructive pulmonary disease, ischemic heart disease, and stroke (including ischemic and hemorrhagic) [4].

Since the first smoking cessation (SC) clinical practice guideline (CPG) in the US in 1996 [5], the initial SC CPGs mainly recommended behavioral therapy and nicotine replacement treatment (NRT) [6]. However, national health insurance services recently recommend medication rather than NRT [7]. Since 2004, in South Korea, SC has been managed mainly by public health centers (PHCs) [8], and several articles have reported the effectiveness of PHCs and have investigated the factors associated with the success of SC [9–11].

Regarding Korean Medicine (KM) treatments, acupuncture and herbal medicine have been used [12,13]. Korean medicine doctors (KMDs), who work in PHC due to mandatory military service, have helped smokers successfully stop smoking by using various interventions. However, there are few articles on KMDs in public health sector reporting their treatment of SC. Therefore, this study aimed to investigate the current KM treatment for SC clinic through feedback from PHDKMs.

Materials and Methods

Before conducting the survey, the following items were prepared; (1) development of questions; (2) ethical approval; and (3) modification of a web-survey platform. Regarding the development of questions, GEP and JHM retrieved previous surveys on SC and other diseases [14–17], and literature on KM treatment for SC from several databases [MEDLINE, EMBASE, Cochrane library, China National Knowledge Infrastructure (Chinese database), CiNii, KoreaMed, Korean Medical Database, Korean Studies Information Service System, ScienceOn, Korea Institute of Science and Technology Information, and Oriental Medicine Advanced Searching Integrated System].

After drafting the survey and following 2 conferences, other KMDs (EJK and WSS), who are specialized in SC, participated in revision of the survey. After this process, 39 questions were proposed with the main 5 sections: (1) clinical practice status; (2) SC participants; (3) KM treatments for SC; (4) progress and prognosis; and (5) perception of KM on SC. Questions were modified online on the web-survey platform (Moaform). There were no conflicts of interest in collecting responses. Regarding ethics, this survey was approved by the institutional review board of Dongguk University Bundang Oriental Hospital in South Korea (no.: DUBOH IRB 2022-0006).

The survey was emailed to 621 KMDs in public health sector on April 6 to 20, 2022 and contained the survey link. The survey was emailed twice through the association of KMDs in public health sector. In the email, the information in the survey was explained (including the objectives, estimated time to complete, and an email address was given for inquiries and for returning the respondent data), it was mentioned that we would use the survey data for academic research, and participants were reminded that they could stop the survey any time.

Regarding statistics, the raw data was obtained using Microsoft Excel. The number of responses in each question was checked and percentages were calculated (except for questions which were ranked). When necessary, frequencies and percentages were calculated and ranked. For the objectivity, 1 independent researcher, who did not participate in the survey, rechecked the results.

Results

Of the 621 PHDKMs, 28 PHDKMs participated in the survey. Survey questionnaires and results are presented in the Supplementary section. Most of the respondents acquired their KM license in 2020 and 2021 (N = 19; 2020: n = 10, 35.7%; 2021: n = 9. 32.1%) and worked in a rural area (N = 26; Gyeongsang-do: n = 8, 28.6%; Jeolla-do: n = 7, 25.0%; Gangwon-do: n = 5, 17.9%; and Chungcheong-do: n = 5, 17.9%).

1. Clinical practice status

Regarding the status of clinical practice, more than 90% of PHDKMs treated ≤ 10 SC participants in the last year (5: n = 23, 82.1%; 6–10: n = 3, 10.7%). About 10% of respondents answered that they had treated 11–20 SC participants (n = 2, 7.1%). Regarding abstinence rate, the number of cigarettes smoked before treatment (A) minus the number of cigarettes smoked after treatments (B), divided by the number of cigarettes smoked before treatment (A) was calculated [i.e., abstinence rate = (A−B)/A]. Then respondents were asked to score abstinence rate using a 10-point Likert scale. We indirectly measured the abstinence rate at 56.8% by averaging respondents’ answers. About 60% of respondents were distributed between a score of 5 and 7 (N = 17, 5: n = 7, 25.0%; 6: n = 4, 14.3%; 7: n = 6, 21.4%). More than 60% of respondents reported that smokers showed more than a 50% level of satisfaction (N = 18; 6: n = 3, 10.7%; 7: n = 8, 28.6%; 8: n = 4, 14.3%; 9: n = 1, 3.6%; 10: n = 2, 7.1%) and the average score for satisfaction that PHDKMs identified was 63.2%.

2. SC participants

Regarding age distribution of SC participants, respondents were asked to answer the age of their participants, and multiple responses was the 3^rd most popular answer for age range. In the SC participants, most respondents answered that their SC participants were in the age range of 40–50. The 51–60 age range, and the 31–40 age range ranked 2^nd and 3^rd, respectively, (41–50: n = 18, 51–60: n = 15, 31–40: n = 13). Most SC participants started smoking before their 30s. For the smoking starting age, teenagers and 20s age range ranked the 1^st, answered by each 22 respondents. Regarding the period of smoking, SC participants smoked for 11–20 years or more than 21 years (each item: n = 16). SC participants consumed regular cigarettes, and about half of them used electronic cigarettes as well as cigarettes. Regarding the number of SC attempts, most participants tried 2–3 times (each item: n = 17), followed by 4 attempts (n = 11) and one attempt at SC (n = 10). Most SC participants visited PHCs due to worries about their health (students: n = 5, adults: n = 26) and by recommendations made by other people (students: n = 10, adults: n = 19; Table 1).

3. KM treatments for SC

Regarding treatment, most respondents used auricular acupuncture (AA), (n = 23, 82.1%), and acupuncture (n = 17, 60.7%), followed by education (n = 11, 39.3%), and herbal medicine (n = 8, 28.6%). Regarding the importance of KM treatment for SC, respondents were asked to use a 7-point scale; (1) not at all; (2) not important; (3) not very important; (4) usually; (5) somewhat important; (6) important; or (7) very important) to register their opinion (convenience was changed from “important” to “convenient).” The convenience of KM treatment for SC was counted as the number of “somewhat important,” “important,” or “very important” responses. Over 50% of respondents emphasized AA, acupuncture, herbal medicine, and education was important, and selected AA, acupuncture, and education as convenient (Table 2). Regarding the frequency of treatments, KMDs in public health sector conducted treatment 1–2 times a week (each item: n = 12, 42.9%). The duration of intervention was 1–2 months (n = 11, 39.3%) followed by 0.5–1 month (n = 6, 21.4%), 2–3 months (n = 4, 14.3%), and 3–6 months (n = 4, 14.3%).

In detail, among 22 respondents who answered using AA, the most frequently used AA points were lung (CO14, n = 18, 81.8%), endocrine (CO18, n = 18, 81.8%), shenmen (TF4, n = 17, 77.3%), and throat (TF3, n = 13, 59.1%). Of the 28 respondents, acupuncture points were chosen in accordance with the latest knowledge from published studies and CPGs (n = 21, 75%), and diagnosis based on traditional KM theory (n = 13, 46.4%). We also asked about the use of herbal medicine, only 5 respondents answered, and there was no tendency to use the herbal medicine to aid SC.

4. Perception about KM on SC

Regarding perception of KM treatment, respondents were asked to check 1 option using a 5-point scale: (1) not at all; (2) no; (3) usually; (4) yes; or (5) it really is, and the number of “yes” and “it really is” items were counted. The survey asked about the feasibility of KM for SC and withdrawal symptoms and whether KM alone would be sufficient treatment for SC. Respondents did not think that KM treatments alone were sufficient for SC or superior to other therapies (KM effectiveness alone on SC: n = 11, 39.3%; comparison with other medications: n = 12, 42.9%). Instead, they thought that KM treatments could control the withdrawal symptoms and be used in combination with other treatment (n = 26, 92.9%). The other therapies that respondents preferred to use in combination (ranking question) were behavior therapy (n = 23), education (n = 21), and NRT (n = 18; Table 3).

Discussion

Addiction (including drugs, alcohol, and nicotine) has emerged as a major problem in society. It has caused numerous socioeconomic burdens and physicians have demanded effective treatment strategies [18]. KM treatments exert an antiaddiction effect. Several reviews on acupuncture and herbal medicine suggest the possibility of complementary options to conventional treatment for addiction [19,20].

Regarding SC, PHCs in South Korea have carried out most of the work, and many articles have reported on the success rate of SC in PHCs [21,22]. However, research into the clinical status of SC following KM treatment in PHCs is lacking. Therefore, this survey investigated the clinical practice of SC, demographic characteristics of SC participants, and the possibility of KM treatment as the alternative option for SC.

Most smokers who received KM treatment in PHCs were in their 40–50s, had around 20 years of smoking experience, and had tried to stop smoking 2–3 times. The characteristics of smokers were similar to the previous reports which have been reviewed by Wang et al [12]. This systematic review of 24 randomized controlled trials using acupuncture for SC reported the characteristics of the included studies. Among them, 11 out of 18 studies showed 40s–50s mean age, and 9 out of 19 studies showed 20-year history of smoking.

The most used KM treatment for SC observed in this survey was acupuncture. AA ranked 1^st and manual acupuncture ranked 2^nd. In clinical practice, studies have reported the clinical efficacy of acupuncture on SC [12,23]. In addition, the effectiveness and safety acupuncture point stimulating techniques such as acupressure, transcutaneous electrical acupoint stimulation, laser acupuncture, and acupoint catgut embedding has been reported with few adverse events [24–26]. Regarding the mechanism by which acupuncture facilitates SC, it has been reported (using functional magnetic resonance imaging) that acupuncture can regulate brain activation, nerves, and connective tissue and can decrease cue-induced cravings during SC [27,28].

Among KM treatments, AA was selected as the most frequently used treatment. AA is a treatment method that is convenient (easy to hold and perform) and versatile (can be used for a variety of conditions including addiction, pain, obesity, anxiety, nausea, and sleep disorders) [29]. In SC, various designs for studies using AA have been conducted. One study reported the efficacy of AA compared with sham AA, and other studies have used NRT or behavior education as an add-on to acupuncture, and acupuncture has been used as monotherapy [30–32]. Regarding AA points, previous trials [33–35], and randomized controlled trials [36] have used various points including shenmen (TF4), endocrine (CO18), lung (CO14), and throat (TG3).

The abstinence rate in this survey was 56.8%, with an average 63.2% level of satisfaction in the treatment. Similarly in substance-use disorders, acupuncture and herbal medicines have been proposed as safe and feasible options to reduce drug usage and alleviate craving symptoms [37,38]. These results may show the possibility of KM treatments playing a diverse role in substance-use disorder rehabilitation programs, including SC, with considerable patient satisfaction and adherence.

Through this survey, there is a glimpse of the KM treatments used for SC in PHCs, their effectiveness, and satisfaction with those treatments which was considered excellent. However, this survey has some limitations. Firstly, less than 30 KMDs in public health sector participated in this survey. Therefore, any results from this study may not be generalizable and there may be a possibility of statistical bias. Secondly, use of other KM treatments including herbal medicine was not common. We asked the respondents to write the name of decoction used for SC with a short-ended answer, but there were only 4 responses. Thirdly, there was discrepancy between the respondents’ actual treatment use and their thoughts. Due to the circumstances of the workplace, respondents may not have access to laser acupuncture or pharmacopuncture. So, even though these treatments are highly valued but not used, but the importance of these treatments was observed in the survey. This implies the need for further studies involving general KMDs in various clinical environments. Furthermore, the survey was limited to KMDs in public health sector and the results could be overestimated, resulting in recall bias. The opinions of SC participants regarding abstinence rate and satisfaction level also need to be considered. Based on this, more surveys and high-quality related research needs to be conducted.

Conclusion

This survey aimed to investigate the clinical practice and the perception of PHDKMs on KM treatments for SC. Although the study size was small, clinical effectiveness of KM, the satisfaction of SC participants, and the emphasis on KM treatment combined with other therapies was observed. Based on this study, further clinical research would be needed.

Supplementary Material

Article information

Author Contributions

Conceptualization: WSS. Methodology: EJK. Formal investigation: JHM. Data analysis: GEP and JHM. Writing original draft: GEP. Writing - review and editing: WSS, EJK, BKS, and YHB.

Conflicts of Interest

The authors have no conflicts of interest to declare.

Funding

None

Ethical Statement

This study was approved by the institutional review board of Dongguk University Bundang Oriental Hospital in Republic of Korea (no.: DUBOH IRB 2022-0006).

Data Availability

References

• [1] World Health Organization [Internet]. Tobacco - fact sheets: Geneva (Switzerland); World Health Organization: 2022 Available from: https://www.who.int/news-room/fact-sheets/detail/tobacco
• [2] World Health Organization [Internet]. Health at a glance: Asia/Pacific 2022: Geneva (Switzerland); World Health Organization: 2022 Available from: https://www.who.int/westernpacific/publications/m/item/health-at-a-glance-asia-pacific-2022
• [3] Korea Disease Control and Prevention Agency [Internet]. 2022 community health survey: Available from: https://chs.kdca.go.kr/chs/stats/statsMain.do
• [4] Carter BD, Abnet CC, Feskanich D, Freedman ND, Hartge P, Lewis CE, et al. Smoking and mortality-beyond established causes. N Engl J Med 2015;372(7):631−40.ArticlePubMed
• [5] Fiore MC, Jorenby DE, Baker TB. Smoking cessation: principles and practice based upon the AHCPR guideline, 1996. Agency for health care policy and research. Ann Behav Med 1997;19(3):213−9.ArticlePubMed
• [6] Wetter DW. Addiction specialists and the AHCPR smoking cessation clinical practice guideline. Addiction 1997;92(6):653−5.ArticlePubMed
• [7] Seo YB, Paek YJ, Lee CM, Lee ES, Kang HS, Kim SY, et al. Korean clinical practice guideline for smoking cessation provided by the national health insurance services. J Korean Soc Res Nicotine Tob 2023;14(2):41−8. [in Korean].Article
• [8] Song TM. Changes in smoking rates of male adults in Korea and smoking cessation policy: focus on smoking cessation clinics. Health Welfare Policy Forum 2011;173:55−63. [in Korean].Article
• [9] Suh KH, Kim KH, Jun ID. The effect of cognitive behavioral therapy and nicotine replacement therapy centered smoking intervention and abstention factors. Korean J Health Psychol 2008;13(3):705−26. [in Korean].Article
• [10] Lee NA, Lee ES, Yun JM, Lee CM, Oh SW, Choi YL, et al. Behavioral therapy and pharmacotherapy for relapse prevention in abstinent smokers: a rapid review and meta-analysis for the Korea preventive service task force. Osong Public Health Res Perspect 2021;12(4):244−53.ArticlePubMedPMCPDF
• [11] Jun YW, Ji NJ, Lee BY. Factors associated with success of smoking cessation for 6 months at smoking-cessation clinic of public health center in urban area. Korean J Health Educ Promot 2008;25(1):25−38. [in Korean] https://koreascience.kr/article/JAKO200827651801383.page.
• [12] Wang JH, van Haselen R, Wang M, Yang GL, Zhang Z, Friedrich ME, et al. Acupuncture for smoking cessation: a systematic review and meta-analysis of 24 randomized controlled trials. Tob Induc Dis 2019;17:48. ArticlePubMedPMC
• [13] Mitra R, Rai A, Kumar A, Mitra JK. Role of herbal medication in tobacco cessation treatment: A systematic review and meta-analysis. Addict Health 2019;15(1):63−70.ArticlePubMedPMCPDF
• [14] Yun WJ, Shin MH, Kweon SS, Ryu SY, Rhee JA. Association of smoking status, cumulative smoking, duration of smoking cessation, age of starting smoking, and depression in Korean adults. BMC Public Health 2012;12:724. ArticlePubMedPMCPDF
• [15] Ahn SG, Kim SC, Lee MH, Kim KS. A clinical research of the auricular acupuncture therapy on stop - smoking. J Acupuncture Res 1993;10(1):175−90. https://www.e-jar.org/journal/view.html?pn=vol&uid=155&vmd=Full.
• [16] Sung WS, Choi SK, Jo HR, Park SH, Lee SH, Lee YJ, et al. A survey of the clinical practice followed by Korean medicine doctors for scoliosis: Preliminary data for clinical practice guidelines. Medicine (Baltimore) 2022;101(34):e30047. ArticlePubMedPMC
• [17] Choi SK, Moon JH, Kim JH, Kim EJ, Seo BK, Sung WS. A survey on the clinical practice of rheumatoid arthritis management by Korean medicine doctors. Eur J Integr Med 2023;58:102227. Article
• [18] Sturgess JE, George TP, Kennedy JL, Heinz A, Müller DJ. Pharmacogenetics of alcohol, nicotine and drug addiction treatments. Addict Biol 2011;16(3):357−76.ArticlePubMed
• [19] Pinto JW, Bradbury K, Newell D, Bishop FL. Lifestyle and health behavior change in traditional acupuncture practice: A systematic critical interpretive synthesis. J Altern Complement Med 2021;27(3):238−54.ArticlePubMed
• [20] Zhu W, Zhang Y, Huang Y, Lu L. Chinese herbal medicine for the treatment of drug addiction. Int Rev Neurobiol 2017;135:279−95.ArticlePubMed
• [21] Ahn YM, Lee HJ, Kim YH, Lee SM, Cho JA, Sohn M. Predictors of institution level of smoking cessation rate and job satisfaction of counselors in smoking cessation clinics of community health centers. J Korean Public Health Nurs 2022;36(2):184−95. [in Korean].Article
• [22] Kim JS, Kang SJ, Kim DJ, Choi IY, Choi BS. Success factors of new enrollees at smoking cessation clinics in the nationwide public health centers in Korea based on gender differences. Korean Public Health Res 2018;44(1):17−30. [in Korean] https://koreascience.kr/article/JAKO201820748944206.page.
• [23] Ma E, Chan T, Zhang O, Yang JS, Wang YY, Li YC, et al. Effectiveness of acupuncture for smoking cessation in a Chinese population. Asia Pac J Public Health 2015;27(2):NP2610−22.ArticlePubMedPDF
• [24] Zhang YY, Yu ZY, Lan HD, Liang SB, Fang M, Robinson N, et al. Non-traditional acupuncture therapies for smoking cessation: a systematic review of randomized controlled trials. Eur J Integr Med 2021;47:101390. Article
• [25] Jang SB, Park SJ, Jang BH, Park YL, Lee JA, Cho CS, et al. Study protocol of a pragmatic, randomised controlled pilot trial: clinical effectiveness on smoking cessation of traditional and complementary medicine interventions, including acupuncture and aromatherapy, in combination with nicotine replacement therapy. BMJ Open 2017;7(5):e014574.. ArticlePubMedPMC
• [26] Yavagal PC, Nagesh L. Efficacy of laser auricular acupuncture for smoking cessation: a randomised controlled trial. Sultan Qaboos Univ Med J 2021;21(2):e275−81..ArticlePubMedPMCPDF
• [27] Kang OS, Kim SY, Jahng GH, Kim HJ, Kim JW, Chung SY, et al. Neural substrates of acupuncture in the modulation of cravings induced by smoking-related visual cues: an FMRI study. Psychopharmacology (Berl) 2023;228:119−27.ArticlePDF
• [28] White AR, Rampes H, Liu JP, Stead LF, Campbell J. Acupuncture and related interventions for smoking cessation. Cochrane Database Syst Rev 2014;2014(1):CD000009. ArticlePubMedPMC
• [29] Hou PW, Hsu HC, Lin YW, Tang NY, Cheng CY, Hsieh CL. The history, mechanism, and clinical application of auricular therapy in traditional Chinese medicine. Evid Based Complement Alternat Med 2015;2015:495684. ArticlePubMedPMCPDF
• [30] Wu TP, Chen FP, Liu JY, Lin MH, Hwang SJ. A randomized controlled clinical trial of auricular acupuncture in smoking cessation. J Chin Med Assoc 2007;70(8):331−8. [in Chinese].ArticlePubMed
• [31] Hyun SH, Huh H, Kang NG. Effectiveness of auricular acupuncture combined with nicotine replacement therapy for smoking cessation. Tob Induc Dis 2018;16:40. ArticlePubMedPMC
• [32] Bier ID, Wilson J, Shakleton M. Auricular acupuncture, education, and smoking cessation: a randomized, sham-controlled trial. Am J Public Health 2002;92(10):1642−7.ArticlePubMedPMC
• [33] Kim PW, Kum MH, Yoon HM, Kim JH. Effects of auricular acupuncture therapy at adult men on smoking cessation. J Acupuncture Res 2013;30(2):55−63.Article
• [34] Lee EJ. Effects of auriculotherapy on addiction: a systematic review. J Addict Dis 2022;40(3):415−27.ArticlePubMed
• [35] Lee GH, Jeon SW, Kang SY. Observation of the effects of auricular acupressure on smoking cessation in male high school students from 2015 to 2017. J Intern Korean Med 2019;40(6):1202−9. [in Korean].ArticlePDF
• [36] Sung WS, Choi IS, Moon JH, Chae SY, Jo MG, Kim JH, et al. Efficacy and safety evaluation of adjuvant auricular acupuncture for smoking cessation: A study protocol of randomized, assessor-blinded, pragmatic pilot trial. Medicine (Baltimore) 2022;101(43):e31456.. ArticlePubMedPMC
• [37] Kitzman JM, Bowman LC, Lin YC. Acupuncture in addiction medicine: its history, evidence, and possibilities. Med Acupunct 2023;35(3):111−6.ArticlePubMed
• [38] Zhu W, Zhang Y, Luang Y, Lu L. Chinese herbal medicine for the treatment of drug addiction. Int Rev Neurobiol 2017;135:279−95.ArticlePubMed

Figure & Data

References

Citations

Citations to this article as recorded by