Abstract

Introduction:

China has the highest number of tobacco smokers among the world’s nations; however, no systematic review has been conducted of clinical trials on the efficacy of smoking cessation interventions in China. This paper summarizes findings of studies in order to compare the effect of pharmacotherapy, counseling, and Traditional Chinese Medicine (TCM) approaches on the abstinence rate.

Methods:

Clinical trials of smoking cessation interventions published in English or Chinese were extracted from an electronic search of PubMed and WanFang databases. The search yielded 234 studies from the PubMed and 78 studies from the WanFang.

Results:

Twenty-nine studies were included in this review. Of these, 11 (37.9%) were randomized controlled trials (RCTs) that assessed the following approaches: counseling (5 studies), TCM (3 studies), pharmacotherapy (1 study), a combination of pharmacotherapy and counseling (1 study), and physician advice (1 study). Pharmacotherapy alone or in combination with counseling generally resulted in a higher abstinence rate than counseling alone. TCM techniques such as acupuncture and ear point seed pressure yielded a much higher abstinence rate than pharmacotherapy and counseling. Findings are inconclusive, however, because most of the TCM studies were noncontrolled trials and did not provide a definition of “abstinence.” Findings on the effectiveness of physician advice to quit smoking were also inconclusive.

Conclusions:

A review of smoking cessation studies revealed that pharmacotherapy was effective in China. More RCTs of TCM approaches and physician advice are needed with long-term follow-up assessments and biochemical verification of self-reported abstinence before these approaches are adopted as evidence-based smoking cessation interventions in China.

Introduction

China is the world’s largest consumer of tobacco products, consuming one third of the world’s cigarettes (Gu et al., 2009; Liu et al., 1998; Yang et al., 1999; Zhang & Cai, 2003). The Global Adult Survey conducted in 2010 found that 52.9% of men and 2.4% of women in China report current smoking (World Health Organization [WHO], 2011). In China, smoking is portrayed as a sign of masculinity for men (Ma et al., 2008) and they are about 22 times more likely to smoke than women (WHO, 2011). Of note, the rates of smoking among male physicians in China were also reported to be high, ranging from 30% to 66% (Ceraso et al., 2009; Dong, Lan, Yang, Luo, & Mao, 2005; Jiang et al., 2007; Li et al., 2008; Yao, Ong, Lee, Jiang, & Mao, 2009; Yu et al., 2009).

Quitting is not the norm for smokers in China, and the majority of current smokers (83.9%) report having no intention to quit smoking (WHO, 2011). Quit rate as a proportion of former smokers among ever-smokers had remained low from 10.1% in 1998 to 8.6% in 2008 (L. Yang, Sung, Mao, Hu, & Rao, 2011). Ma et al. (2008) identified four key barriers to changing smoking habits in China: (1) the identification of smoking as a symbol of personal freedom, (2) the importance of tobacco in social and cultural interaction, (3) belief in the ability to control the health effects of smoking through “reasonable” and “measured” use, and (4) the importance of tobacco to the economy. These authors asserted that “China will be able to curb its tobacco epidemic only when it challenges the value it gives to smoking in everyday social interactions” (Ma et al., 2008, p. 660).

To our knowledge, there has been no systematic review of the efficacy of smoking cessation interventions in mainland China. Findings will be helpful in expanding tobacco control initiatives, including the delivery of medical education to physicians and other health care specialists in China. Tobacco control specialists can use this information to influence national policy development and design organizational change strategies for hospitals and other health care settings. Liu & Chen (2011) have observed, “Unfortunately, smoking is as imbedded in China’s medical culture as it is in broader Chinese society” (p. 1219). There is an urgent need for change in the social norm of smoking and a better understanding of the barriers to implementing smoking cessation interventions in medical practice.

Smoking cessation in China will help reduce environmental tobacco smoke (ETS) exposure to nonsmokers. Most ETS exposures occur at home, with women and children as the primary victims (Abdullah, Yang, & Beard, 2010; Gu et al., 2004; Han et al., 2006; Wang et al., 2008). Exposure to ETS in the home is common in both urban and rural areas, with 71% of people in urban areas and 81% of people in rural areas reporting such an exposure (Yang et al., 1999). In a 2004 survey, only 6% of participants reported a complete smoking ban in their house (Wang et al., 2009b). Dr. G. Yang, a pioneer against the tobacco epidemic in China, observes that gender inequality plays a role in the high rate of the exposure to ETS (WHO, 2010). According to her, women often feel powerless to stop men’s smoking at home and social gatherings.

Exposure to ETS can also occur in hospitals and other public settings, despite clean indoor air policies. In April 2000, 14 provinces and 88 cities in China passed local bans forbidding smoking in public places, including hospitals, schools, government offices, traffic stations, and transportation vehicles (Stillman, Yang, Figueiredo, Hernandez-Avila, & Samet, 2006). Yet, enforcement and public compliance with smoking bans reportedly have been poor (Li, Cui, Rao, & Sun, 2007).

Currently, about 15% of annual deaths (1.2 million people) in China are caused by tobacco-related diseases, and the rate is expected to double in the next 20 years (Gu et al., 2009). There is an urgent need to explore the current status of smoking cessation interventions in China and to delineate interventions that are likely to curb this country’s tobacco epidemic. Therefore, the main purpose of this article is to critically review clinical trials of smoking cessation interventions, including interventions designed to motivate smokers to quit. The review includes studies of pharmacotherapy, counseling, and Traditional Chinese Medicine (TCM; e.g., acupuncture and ear point seed pressure). Of note, we attempted to identify the full range of TCM approaches (e.g., herbal treatments and qi gong) in use for this purpose. Based on this review, we make suggestions for further research on the effectiveness of smoking cessation interventions in China.

Methods

Clinical trials of smoking cessation interventions that were published in English or Chinese journals through December 31, 2010, were retrieved from an electronic search of the PubMed database with a combination of keywords such as “smoking cessation,” “treatment,” “Traditional Chinese Medicine,” and “China.” We also used the “WanFang” database, which is an affiliate of Chinese Ministry of Science &Technology and has been the leading provider of this type of information in China since the 1950s. In addition to the terms used to search the PubMed database (with the exception of “China,” which could be assumed), more specific forms of TCM were used as search terms. Examples include “acupuncture,” “acupoint stimulation,” “acupressure,” “massage therapy,” and “herbal treatment.” Two authors (WC and VJW) who are fluent in Mandarin and English translated materials from Mandarin to English.

Eligibility Criteria

To be included in our review, a study had to (1) be a study of smoking cessation interventions or an intervention to enhance motivation to quit, (2) be conducted in China, (3) assess abstinence after the intervention and/or at follow-ups, and (4) report specific data about the subjects of Chinese ethnicity so that studies involving subjects who were not ethnically Chinese could be eliminated (for example, studies conducted with persons who were recruited in China but who were not ethnically Chinese were not included). Manual search was also conducted to identify studies from references in the studies identified by the electronic searches.

Data Collection Process

A total of 234 study abstracts were identified from the PubMed search. Two authors (SSK and MK) judged the eligibility of each study independently based on the inclusion criteria. First, smoking cessation interventions were selected (there were no studies of other forms of tobacco usage in this population, such as chewing tobacco). Second, where several articles were published from the same study, the articles with the largest sample size were selected. Third, intervention studies conducted in multiple nations including China were excluded if no Chinese-specific data were presented. For example, two randomized controlled trials (RCTs) of Varenicline were excluded because findings were reported in aggregated data from several countries (Fagerström et al., 2010; Wang et al., 2009a).

The two authors then met together and compared their selections, which showed good agreement (Kappa = .82, p < .001). They reconciled discrepancies through discussion. Two additional studies were identified from references in selected articles (see Figure 1). Two authors (WC and XW) independently searched the Chinese database WanFang and identified 78 studies. Of these, 29 studies were clinical trials of smoking cessation interventions and 13 met inclusion criteria (see Figure 1).

Figure 1.

A decision tree of article inclusion and exclusion.

Figure 1.

A decision tree of article inclusion and exclusion.

Data Synthesis and Analysis

The odds ratio (OR) and 95% CI at each follow-up period were either abstracted or calculated from study data. If discrepancies were found between self-reported and biochemically verified abstinence rates, ORs were based on the latter. We analyzed data on an intention-to-treat basis and synthesized data qualitatively in a narrative format. None of the studies implemented the same intervention with the same follow-up time-point. Thus, the Mantel–Haenszel pooled OR was not calculated.

Results

Description of Studies

Twenty-nine studies were included in this review; 27 were retrieved from the databases (14 from the PubMed and 13 from the WanFang) and two from references in selected articles. Supplementary Table 1 presents a brief summary of the studies grouped by type of intervention. Of these, 11 (37.9%) were RCTs and examined the following interventions: counseling (five studies), TCM (three studies), pharmacotherapy (one study), a combination of pharmacotherapy and counseling (one study), and physician advice (one study). Among the remaining studies, only two (Ding et al., 2010; Han, 2006) were non-RCTs. The rest were noncontrolled single group studies.

The only study of pharmacotherapy alone (Sun et al., 2009) was a double-blind placebo-controlled trial. Of the eight counseling studies, three (Abdullah, Mak, Loke, & Lam, 2005; Chan et al., 2005; Chan, Leung, Wong, & Lam, 2008) were implemented to address harms associated with secondhand smoke among young children. All the four studies that examined the effect of a combination of pharmacotherapy and counseling were conducted in Hong Kong.

Of 14 TCM studies (see Supplementary Table 1), four involved comparisons between two groups. Of these, three were RCTs; the study by Han (2006) was not an RCT. The remaining studies were noncontrolled single group studies. With two exceptions (Fu, Du, Yu, Wang, & Chen, 2002; Yan et al., 2010), all the TCM studies examined the effectiveness of acupuncture, ear point see pressure, or a combination of the two. Most reported an abstinence rate based on self-report without biochemical verification and did not provide a definition of abstinence in terms of point prevalence versus prolonged abstinence.

The study by Yan et al. (2010) was a double-blind placebo-controlled trial comparing the efficacy of a tea filter that was made to look identical to a regular cellulose filter. The authors stated that the tea contains theanine, and its chemical effect is very similar to nicotinic acetylcholine receptor inhibitor. Yang & Li (2010) found a high abstinence rate (83.3%) at 12-month follow-up; yet, the sample size (N = 30) was small, and the rate was based on self-report without biochemical verification.

Effects of Interventions

Of 29 studies reviewed, 11 (37.9%) were RCTs. Their abstinence rates and ORs are presented in Table 1. Adjusted odds ratios (AORs) could not be calculated due to insufficient information in many studies. In general, the intervention condition obtained a higher abstinence rate than its comparative condition, which resulted in a significant OR. In particular, the placebo-controlled drug trial (Sun et al., 2009), two counseling studies (Chen, Zheng, Zeng, & Luo, 2010; Zheng et al., 2007), and two TCM studies (Tian & Chu, 1996; Yan et al., 2010) obtained a large effect size, indicating the practical significance of the intervention being delivered. Below is a brief summary of the studies listed in Table 1.

Table 1.

Odds Ratio for Individual Randomized Controlled Trials of Smoking Cessation Interventions by Type of Intervention (N = 11)

Study Participants Follow-up Intervention abstinence/N Control abstinence/N OR (95% CIp valuea 
Pharmacotherapy (n = 1)       
    Sun et al., 2009 Smokers ≥ 10 cigarettes 3 months 52/101 21/110 4.5 (2.4–8.3) <.001 
Counseling (n = 5)       
    Abdullah et al., 2005 Parents of young children 6 months 40/444 19/459 2.3 (1.3–4.0) .004 
    Chan et al., 2005 Parents of sick children 1 month 3/40 1/40 3.2 (0.3–31.8) .305 
    Chan et al., 2008 Mothers of sick children 3 months 56/752 35/731 1.6 (1.0–2.5) .033 
Married to a smoker 12 months 85/752 68/731 1.3 (0.9–1.8) .205 
    Chen et al., 2010 Smokers with Type 2 diabetes 1 month 29/72 8/58 4.2 (1.7–10.2) .001 
3 months 66/72 12/58 42.2 (14.8–120.5) <.001 
    Zheng et al., 2007 Current smokers 6 months 47/118 5/107 13.5 (5.1–35.6) <.001 
6 months 33/118 3/107 13.5 (4.0–45.4) <.001 
Combination of pharmacotherapy  and counseling (n = 1)       
    Chan et al., 2010 Patients with  erectile dysfunction 6 months 57/501 12/218 2.2 (1.2–4.2) .014 
Physician advice (n = 1)       
    Loke & Lam, 2005 Husbands of nonsmoking  pregnant women 3–5 months 32/380 18/378 1.8 (1.0–3.3) .042 
23/380 16/378 1.5 (0.8–2.8) .257 
Traditional Chinese medicine (n = 3)       
    Huang, 2001 Smokers ≥ 15 cigarettes 6 months 66/158 41/159 2.1 (1.3–3.3) .003 
    Tian & Chu, 1996 Smokers > 10 cigarettes 12 months 26/60 2/60 22.2 (5.0–99.3) <.001 
    Yan et al., 2010 Current smokers After therapy 11/35 0/35 Infinity  
Study Participants Follow-up Intervention abstinence/N Control abstinence/N OR (95% CIp valuea 
Pharmacotherapy (n = 1)       
    Sun et al., 2009 Smokers ≥ 10 cigarettes 3 months 52/101 21/110 4.5 (2.4–8.3) <.001 
Counseling (n = 5)       
    Abdullah et al., 2005 Parents of young children 6 months 40/444 19/459 2.3 (1.3–4.0) .004 
    Chan et al., 2005 Parents of sick children 1 month 3/40 1/40 3.2 (0.3–31.8) .305 
    Chan et al., 2008 Mothers of sick children 3 months 56/752 35/731 1.6 (1.0–2.5) .033 
Married to a smoker 12 months 85/752 68/731 1.3 (0.9–1.8) .205 
    Chen et al., 2010 Smokers with Type 2 diabetes 1 month 29/72 8/58 4.2 (1.7–10.2) .001 
3 months 66/72 12/58 42.2 (14.8–120.5) <.001 
    Zheng et al., 2007 Current smokers 6 months 47/118 5/107 13.5 (5.1–35.6) <.001 
6 months 33/118 3/107 13.5 (4.0–45.4) <.001 
Combination of pharmacotherapy  and counseling (n = 1)       
    Chan et al., 2010 Patients with  erectile dysfunction 6 months 57/501 12/218 2.2 (1.2–4.2) .014 
Physician advice (n = 1)       
    Loke & Lam, 2005 Husbands of nonsmoking  pregnant women 3–5 months 32/380 18/378 1.8 (1.0–3.3) .042 
23/380 16/378 1.5 (0.8–2.8) .257 
Traditional Chinese medicine (n = 3)       
    Huang, 2001 Smokers ≥ 15 cigarettes 6 months 66/158 41/159 2.1 (1.3–3.3) .003 
    Tian & Chu, 1996 Smokers > 10 cigarettes 12 months 26/60 2/60 22.2 (5.0–99.3) <.001 
    Yan et al., 2010 Current smokers After therapy 11/35 0/35 Infinity  

Note.OR = odds ratio.

a

Uncorrected two-tailed chi-square test.

Pharmacotherapy

Sun et al. (2009) found that a nicotine sublingual tablet was more effective in achieving abstinence than a placebo at the end of the treatment (i.e., 3 months after quitting). Results from longer-term follow-up assessments were not available.

Counseling

All but two studies (Chan et al., 2005, 2008) found the intervention had a significant treatment effect over the comparative condition (e.g., usual care or simple advice). Parents who received counseling along with self-help materials were more likely to be abstinent at 6-month follow-up than were those who received the self-help materials only (Abdullah et al., 2005). A one-time motivational counseling intervention showed no treatment effect on smoking cessation as compared with diet counseling (Chan et al., 2005). In contrast, intense individual counseling was effective among smokers with Type 2 diabetes compared with simple advice (Chen et al., 2010). Interventions by mothers of sick children who had received counseling to help them advocate for their spouses’ smoking cessation had a small treatment effect at 3-month follow-up compared with no intervention (Chan et al., 2008). However, no difference was found between the two conditions at 12-month follow-up. The study of a group-based social cognitive therapy showed a significant treatment effect over brief advice (Zheng et al., 2007).

Combination Therapy

Nicotine replacement therapy (NRT) plus counseling showed a relatively high abstinence rate compared with NRT only (Chan et al., 2010). However, only half of the participants who reported abstinence were available for a urinary cotinine test. Many participants refused to come for the test at the 6-month follow-up, which caused the large discrepancy between self-report and biochemical verification (S. Chan, personal communication, February 16, 2011).

Physician Advice

Physician advice provided to nonsmoking pregnant women to help them assist husbands’ smoking cessation was found to be effective compared with no intervention when the outcome was assessed in terms of 7-day point prevalence abstinence (Loke & Lam, 2005). However, no difference was found in 1-month abstinence between physician advice and no intervention. Abstinence rates were based on self-report without biochemical verification.

Traditional Chinese Medicine

Abstinence rates were significantly higher with ear point seed pressure versus acupuncture (Huang, 2001) or simple advice (Tian & Chu, 1996). Of note, abstinence rates among those who received ear point seed pressure in these two studies were very similar to each other, although one study assessed the rate (41.8%) at 6-month follow-up and the other one (40.0%) at 12-month follow-up. Those who smoked with a tea filter were much more likely to achieve abstinence than those using a regular filter (Yan et al., 2010). However, the exact OR could not be calculated due to the nil abstinence rate of the regular filter group.

Assessment of the Risk of Bias

Risk of bias was assessed using parallel criteria for RCTs adapted from the Cochrane Handbook for Systematic Reviews of Interventions (Higgins & Gree, 2008). Five of the 11 RCT studies provided sufficient information to determine the adequate generation of a random allocation sequence (Abdullah et al., 2005; Loke & Lam, 2005; Sun et al., 2009; Tian & Chu, 1996; Zheng et al., 2007). Two of these studies also provided sufficient information to determine the adequacy of allocation concealment (Loke & Lam, 2005; Zheng et al., 2007).

Five studies (Chan et al., 2005, 2008, 2010; Chen et al., 2010; Loke & Lam, 2005) presented comparable characteristics among participants between intervention and control conditions at baseline. On the other hand, three studies (Abdullah et al., 2005; Sun et al., 2009; Zheng et al., 2007) showed a significant difference in some baseline characteristics that could have affected study outcomes. In the study by Abdullah et al. (2005), participants in the two conditions differed in age distribution, number of years smoked, and alcohol dependence. The OR of 7-day abstinence was changed to 2.2 (95% CI = 1.2%–3.9%) when it was adjusted for those baseline differences (Abdullah et al.), although the change was not remarkable. In the study by Sun et al. (2009), participants in the NRT were older than those in the placebo condition, which might have affected outcomes of the two interventions. Yet, AOR was not reported by the authors. In the study by Zheng et al. (2007), participants in the intervention condition were more likely to be older and to have smoked more years than those in the control condition. The AOR of 6-month (continuous) abstinence was reduced to 6.4 (95% CI = 2.5%–13.3%; Zheng et al., 2007). The remaining three studies (Huang, 2001; Tian & Chu, 1996; Yan et al., 2010) did not provide information on any baseline characteristics of participants in each of the two conditions.

All abstinence rates presented in Supplementary Table 1 and Table 1 were based on an intention-to-treat analysis. This method assumes that those who dropped out of treatment or were lost to follow-up all relapsed to smoking. Thus, the ORs reported in Table 1 might have been biased toward the null. In contrast, inclusion of participants who had been abstinent prior to the study (Chan et al., 2005, 2008) could have produced findings biased toward a better treatment effect. Abdullah et al. (2005) also included smokers who had been abstinent at baseline; yet, they reported the outcome only with those who were smoking at baseline. Of the 11 RCT studies listed in Table 1, six (54.5%) used a biochemical measure such as exhaled carbon monoxide or urinary cotinine levels to verify self-reported abstinence.

Discussion

This review of clinical trials conducted in China revealed a paucity of RCTs of pharmacotherapy, particularly in mainland China. Abstinence rates were generally high in studies with pharmacotherapy alone or with combined interventions of pharmacotherapy and counseling compared with those in studies with counseling alone. However, two counseling therapy studies (Chen et al., 2010; Zheng et al., 2007) obtained a much higher abstinence rate than combined intervention studies. We did not identify any studies that compared smoking cessation medication and TCM. Furthermore, there were no smoking cessation intervention studies of physicians who smoke.

Most Chinese pharmacotherapy studies were conducted in Hong Kong; only one (Sun et al., 2009) was from mainland China. In this review, we did not include the study by Wang et al. (2009a), which was a double-blind, placebo-controlled trial of Varenicline, and about 75% of participants (n = 254) were from mainland China. However, results were reported in aggregated data with smokers outside of China, and we were not able to obtain additional unpublished information from the authors. In this study, Varenicline yielded a significantly high abstinence rate at 24-week follow-up compared with placebo (OR = 1.9, 95% CI = 1.2%–3.1%; Wang et al., 2009a).

Abstinence rates obtained in studies of combined treatments that provided counseling along with NRT were somewhat lower than those reported in studies of similar treatment modalities conducted in the United States (Fiore et al., 2008). However, these findings are likely due to the fact that studies conducted in China administered nicotine patches and other NRT medications for only 1–4 weeks, which is a shorter time period than is typical in studies in the United States and less than the time period recommended by the U.S. Public Health Services Guideline (Fiore et al., 2008). Therefore, more RCT studies are needed to examine the efficacy of NRT while adhering to the recommended duration of the treatment in the guideline. In addition, there is a need for new studies that do long-term (one year or more) follow-up assessments. For example, in the study of multicomponent treatments, including counseling provided to mothers of sick children who had smoking spouses, Chan et al. (2008) found a significant difference in spouses’ abstinence favoring the intervention compared with usual care (i.e., simple advice) at 3 months but not at 12 months.

Several researchers (Gu et al., 2009; Kenkel, Lillard, & Liu, 2009; Qian et al., 2010) mentioned that NRT and other cessation medications are expensive and not readily available in most regions of mainland China. Limited access to NRT might have resulted in the paucity of pharmacotherapy studies in China; however, the lack of published studies done with Chinese smokers may also be a factor in why few health care providers prescribe NRT. Given the limited resources of cessation medications, results of the study by Zheng et al. (2007) may be particularly important to motivate Chinese clinicians who worry about the barrier of lack of medications. The research team implemented group-based behavioral counseling without any smoking cessation medications and found a relatively high rate of abstinence, with a long-term treatment effect as compared with brief advice. They delivered group therapy guided by the social cognitive theory that has shown effectiveness in smoking cessation in other countries as well (Hendricks, Delucchi, & Hall, 2010; Le Foll, Aubin, & Lagrue, 2002; Segaar, Bolman, Willemsen, & Vries, 2006).

Two studies utilized an intervention component of family (spouse) support in smoking cessation. These studies are important in demonstrating a cultural adaptation (i.e., engaging the family in smoking cessation interventions). The study by Chan et al. (2008) tested the efficacy of counseling provided to nonsmoking mothers of sick children who lived with smoking husbands to help them advocate for their spouses’ smoking cessation. The second study (Loke & Lam, 2005) used physician advice provided to nonsmoking pregnant women related to their role in helping their spouses quit smoking. Yet, findings were inconclusive. Sun et al. (2009) stated that family support and employment were significant predictors of smoking cessation. However, the study did not have any intervention components of family support. The authors believed that family support might have played a role because married participants had a better abstinence rate than their counterparts. More studies are needed to explore the role of family support, particularly spouse support, in smoking cessation outcomes.

Finally, TCM approaches, particularly ear point seed pressure, used alone or in combination with other treatments, seemed to yield a promising result in smoking cessation. The intervention had a significant treatment effect in smoking cessation over acupuncture (Huang, 2001) and simple advice (Tian & Chu, 1996). TCM has been practiced in China for more than 2,000 years and used in the treatment of drug addiction for the past 200 years (Shi et al., 2006). However, studies of acupuncture and its derivatives conducted in the United States had inconclusive findings. It is noteworthy that five TCM (two of acupuncture, two of auricular pressure, and one of a combination of acupuncture and auricular pressure) studies conducted exclusively with smokers of Chinese ethnicity in a neighboring country (Russia and Taiwan: Cai, Zhao, Wong, Zhang, & Lim, 2000; Chen, Yeh, & Chao, 2006; Song, 2008; Wu, Chen, Liu, Lin, & Hwang, 2007; Yeh, Chang, Chu, & Chen, 2009) yielded findings very similar to those of the U.S. studies. The study of theanine tea filter (Yan et al., 2010) seemed to hold a promise in smoking cessation, although its long-term treatment effect was not available in the published article.

The findings from this review also help to frame some of the barriers to smoking cessation interventions in China and are comparable to certain populations and treatment settings in the United States (Ziedonis et al., 2007). The limited scientific literature on smoking cessation studies in China may be associated with limited interest to study this issue, the ongoing smoking rates of physicians and other male health care providers, and lack of available resources for pharmacotherapy or counseling.

The lack of studies also may affect the choices of policy makers and health care providers. Policy change in China occurs on a national and local level, and not having data from China or specific regions of China on smoking cessation outcomes to inform recommendations may deter the creation of guidelines for Chinese health care providers. The high number of male physicians and other health care workers who are smokers is a major barrier to tobacco-free hospitals and to implementing smoking cessation interventions (Dong et al., 2005; Li et al., 2008). Lack of staff training is also a barrier to integrating smoking cessation strategies into hospital settings (Yao et al., 2009; Ziedonis, Guydish, Williams, Steinberg, & Foulds, 2006). The limited implementation of tobacco control policies that restrict smoking in hospital settings and other public places perpetuates the behavior among men in China.

Suggestions for future research

More studies are urgently needed to investigate the efficacy and acceptability of smoking cessation medications among smokers in China. Anecdotal reports indicate that many smokers in major cities now purchase the medications to quit smoking. Therefore, epidemiological surveys on the use of the medications and data on abstinence rates among those who have used the medications could provide valuable information on these areas. Moreover, studies are needed to examine whether the dosage and tapering schedule of NRT medications should be adjusted for people in China, given the difference in nicotine metabolism between Chinese Americans and White Americans (Benowitz, Perez-Stable, Herrera, & Jacob, 2002).

More studies are needed to investigate the efficacy of group-based counseling (Sun et al., 2009) and use of the tea filter (Yan et al., 2010). In particular, studies with long-term follow-up assessments are needed. Future research should be geared toward tailoring the type of intervention to smokers’ profiles in order to deliver the interventions efficiently in China. Pharmacotherapy could be reserved for a certain group of smokers who have high nicotine dependence. More studies are also needed on utilizing family support to motivate smokers to quit, since most ETS exposures occur at home (Yang et al., 1999) and women and children are primary victims of the exposure. It has been found that some Asian men are more likely to make a quit attempt if they are informed about the effect of smoking on children than its effect on their own health (Kim, Kwon, Klessig, & Ziedonis, 2008). Future studies need to explore intervention strategies such as involving nonsmoking family members in counseling to help them convey their personalized antismoking messages to smokers. In addition, more studies are needed to examine the effectiveness of mass-media campaigns against exposures to secondhand smoke in promoting the adoption of and adherence to smoking ban in the home.

More RCT studies are needed to examine the efficacy and cost effectiveness of ear point seed pressure and acupuncture. A meta-analysis of ten studies showed auricular acupuncture at “correct” points to be more effective than sham therapy (White & Moody, 2006). The latest Cochran Review suggested that more rigorous studies are needed before any conclusions can be made about the efficacy of acupuncture in smoking cessation (White, Rampes, & Campbell, 2006). Given its wide availability with relatively low cost in China, more clinical trials are needed to identify most effective stimulus points of the approach and frequency and interval of the stimulation. The promising preliminary findings of the two studies (Fu et al., 2002; Yang & Li, 2010) with herbal patches suggest more studies are needed to investigate the efficacy of the patch in a large clinical trial. In addition, qi gong and other unique approaches may provide direct or supplemental support. TCM medical schools should consider their role in research and in the development of innovative approaches in smoking cessation.

Overall, this literature review points to an array of studies that are likely to lead to more intervention options for smoking cessation in China. More rigorous methods are necessary to investigate these options effectively. Moreover, our review suggests that there remain opportunities for greater exploration of whether and how TCM approaches may be used in smoking cessation efforts, especially among those who are unlikely to make use of NRT and counseling therapy. Finally, attention is needed to policy changes that will facilitate access to NRT and promote effective training for health care providers in the areas of pharmacotherapy and behavioral interventions. Undertaking these efforts will be crucial to curb the tobacco epidemic in China.

Supplementary Material

Supplementary Table 1 can be found online at http://www.ntr.oxfordjournals.org

Funding

None declared.

Declaration of Interests

None declared.

The authors thank Professor Guang Du and his student Linging Shen at Department of Pharmacy,Tongji Hospital, Tongji Medical College, Huazhong University of  Science and Technology as well as Professor Yu Liu and her Dian Team, particularly student Lipeng Liu, at Huazhong University of Science and Technology, Department of Electronic and Information Engineering, for their assistance in obtaining and transferring an e-copy of articles retrieved from the Chinese database WanFang.

References

Abdullah
AS
Mak
YW
Loke
AY
Lam
TH
Smoking cessation intervention in parents of young children: A randomized controlled trial
Addiction
 , 
2005
, vol. 
100
 (pg. 
1731
-
1740
doi:10.1111/j.1360-0443.2005.01231.x
Abdullah
AS
Yang
T
Beard
J
Predictors of women's attitudes toward world health organization framework convention on tobacco control policies in urban China
Journal of Women's Health (Larchmt)
 , 
2010
, vol. 
19
 (pg. 
903
-
909
doi:10.1089/jwh.2009.1613
Benowitz
NL
Perez-Stable
EJ
Herrera
B
Jacob
P
III
Slower metabolism and reduced intake of nicotine from cigarette smoking in Chinese-Americans
Journal of the National Cancer Institute
 , 
2002
, vol. 
94
 (pg. 
108
-
115
doi:10.1093/jnci/94.2.108
Cai
Y
Zhao
C
Wong
SU
Zhang
L
Lim
SK
Laser acupuncture for adolescent smokers—A randomized double-blind controlled trial
American Journal of Chinese Medicine
 , 
2000
, vol. 
25
 (pg. 
443
-
449
doi:10.1142/S0192415X00000520
Ceraso
M
McElroy
JA
Kuang
X
Vila
PM
Du
X
Lu
L
, et al.  . 
Smoking, barriers to quitting, and smoking-related knowledge, attitudes, and patient practices among male physicians in China
Preventing Chronic Disease
 , 
2009
, vol. 
6
 pg. 
A06
  
Chan
SS
Lam
TH
Salili
F
Leung
GM
Wong
DC
Botelho
RJ
, et al.  . 
A randomized controlled trial of an individualized motivational intervention on smoking cessation for parents of sick children: A pilot study
Applied Nursing Research
 , 
2005
, vol. 
18
 (pg. 
178
-
181
doi:10.1016/j.apnr.2005.01.002
Chan
SS
Leung
DY
Abdullah
AS
Lo
SS
Yip
AW
Kok
WM
, et al.  . 
Smoking-cessation and adherence intervention among Chinese patients with erectile dysfunction
American Journal of Preventive Medicine
 , 
2010
, vol. 
39
 (pg. 
251
-
258
doi:10.1016/j.amepre.2010.05.006
Chan
SS
Leung
GM
Wong
DC
Lam
TH
Helping Chinese fathers quit smoking through educating their nonsmoking spouses: A randomized controlled trial
American Journal of Health Promotion
 , 
2008
, vol. 
23
 (pg. 
31
-
34
doi:10.4278/ajhp.07043040
Chen
HH
Yeh
ML
Chao
YH
Comparing effects of auricular acupressure with and without an internet-assisted program on smoking cessation and self-efficacy of adolescents
Journal of Alternative and Complementary Medicine
 , 
2006
, vol. 
12
 (pg. 
147
-
152
doi:10.1089/acm.2006.12.147
Chen
X
Zheng
P
Zeng
J
Luo
J
[A short-term outcome study of different health education interventions for smoking behavior in patients with type 2 diabetes.]
Chinese Journal of Modern Nursing
 , 
2010
, vol. 
16
 (pg. 
799
-
801
)
Ding
RJ
Fu
YY
Wang
GL
Zhao
H
Lu
PN
Hu
DY
[The smoking status of patients with acute coronary syndrome and effect of simple intervention on smoking cessation]
Chinese Journal of Internal Medicine
 , 
2010
, vol. 
49
 (pg. 
32
-
34
)
Dong
CT
Lan
YJ
Yang
Q
Luo
Y
Mao
ZZ
[Investigation on smoking status of medical professionals in Chengdu City and on intervention for tobacco control]
Journal of Sichuan University
 , 
2005
, vol. 
36
 (pg. 
709
-
712
)
Fagerström
K
Nakamura
M
Cho
HJ
Tsai
ST
Wang
C
Davies
S
, et al.  . 
Varenicline treatment for smoking cessation in Asian populations: A pooled analysis of placebo-controlled trials conducted in six Asian countries
Current Medical Research & Opinion
 , 
2010
, vol. 
26
 (pg. 
2165
-
2173
doi:10.1185/03007995.2010.505130
Fiore
MC
Jaen
CR
Baker
TB
Bailey
WC
Bennett
G
Benowitz
NL
, et al.  . 
Treating tobacco use and dependence: 2008 Update. Clinical practice guideline
 , 
2008
Rockville, MD
U.S. Department of Health and Human Services, U.S. Public Health Services
Fu
L
Du
T
Yu
H
Wang
Z
Chen
Z
[Chinese herbal patches affects on chronic smokers’ cortisol and β-endorphin]
Chinese Magazine of Drug Abuse Prevention and Treatment
 , 
2002
, vol. 
2002
 (pg. 
9
-
11
)
Gu
D
Kelly
TN
Wu
X
Chen
J
Samet
JM
Huang
J
, et al.  . 
Mortality attributable to smoking in China
New England Journal of Medicine
 , 
2009
, vol. 
360
 (pg. 
150
-
159
doi:10.1056/NEJMsa0802902
Gu
D
Wu
X
Reynolds
K
Duan
X
Xin
X
Reynolds
RF
Cigarette smoking and exposure to environmental tobacco smoke in China: The international collaborative study of cardiovascular disease in Asia
American Journal of Public Health
 , 
2004
, vol. 
94
 (pg. 
1972
-
1976
Han
JX
Ma
L
Zhang
HW
Liu
X
Zheng
SH
Gan
DK
, et al.  . 
[A cross sectional study of passive smoking of non-smoking women and analysis of influence factors on women passive smoking]
Journal of Hygiene Research
 , 
2006
, vol. 
35
 (pg. 
609
-
611
)
Han
Y
[Smoking withdrawal syndrome among 42 cases of acupuncture and auricular acupressure treatment]
Journal of Clinical Acupuncture and Moxibustion
 , 
2006
, vol. 
22
 pg. 
16
 
Hendricks
PS
Delucchi
KL
Hall
SM
Mechanisms of change in extended cognitive behavioral treatment for tobacco dependence
Drug and Alcohol Dependence
 , 
2010
, vol. 
109
 (pg. 
114
-
119
doi:10.1016/j.drugalcdep.2009.12.021
Higgins
JPT
Gree
S
Cochrane handbook for systematic reviews of interventions
 , 
2008
Chichester, UK
Wiley-Blackwell
Huang
W
[Smoking cessation with ear point vaccaria seed pressure in 158 cases]
Journal of Guangxi Medical University
 , 
2001
, vol. 
18
 pg. 
430
 
Jiang
Y
Ong
MK
Tong
EK
Yang
Y
Nan
Y
Gan
Q
, et al.  . 
Chinese physicians and their smoking knowledge, attitudes, and practices
American Journal of Preventive Medicine
 , 
2007
, vol. 
33
 (pg. 
15
-
22
doi:10.1016/j.amepre.2007.02.037
Kenkel
D
Lillard
DR
Liu
F
An analysis of life-course smoking behavior in China
Health Economics
 , 
2009
, vol. 
18
 (pg. 
S147
-
S156
doi:10.1002/hec.1507
Kim
SS
Kwon
M
Klessig
YC
Ziedonis
D
Adapting tobacco dependence group therapy treatment for Korean Americans: A case report of a pilot treatment program
Journal of Group Therapy in Addiction and Recovery
 , 
2008
, vol. 
3
 (pg. 
93
-
108
doi:10.1080/15560350802157544
Le Foll
B
Aubin
HJ
Lagrue
G
[Behavioral and cognitive therapy to break the smoking habit. Review of the literature]
Annales De Medecine Interne (Paris)
 , 
2002
, vol. 
153
 
3 Suppl.
(pg. 
1S32
-
1S40
)
Li
CY
Cui
XB
Rao
YS
Sun
XG
[Study on the rates of smoking among the residents of Beijing, from 1997 to 2004]
Chinese Journal of Epidemiology
 , 
2007
, vol. 
28
 (pg. 
453
-
456
)
Li
HZ
Sun
W
Cheng
F
Wang
X
Liu
W
Wang
A
Cigarette smoking status and smoking cessation counseling of Chinese physicians in Wuhan, Hubei province
Asia-Pacific Journal of Public Health
 , 
2008
, vol. 
20
 (pg. 
183
-
192
doi:10.1177/1010539508317821
Liu
BQ
Peto
R
Chen
ZM
Boreham
J
Wu
YP
Li
JY
, et al.  . 
Emerging tobacco hazards in China: 1. Retrospective proportional mortality study of one million deaths
British Medical Journal
 , 
1998
, vol. 
317
 (pg. 
1411
-
1422
doi:10.1136/bmj.317.7170.1411
Liu
Y
Chen
L
New medical data and leadership on tobacco control in China
Lancet
 , 
2011
, vol. 
377
 (pg. 
1218
-
1220
doi:10.1016/S0140-6736(10)61391-8
Loke
AY
Lam
TH
A randomized controlled trial of the simple advice given by obstetricians in Guangzhou, China, to non-smoking pregnant women to help their husbands quit smoking
Patient Education and Counseling
 , 
2005
, vol. 
59
 (pg. 
31
-
37
doi:10.1016/j.pec.2004.08.018
Ma
S
Hoang
MA
Samet
JM
Wang
J
Mei
C
Xu
X
, et al.  . 
Myths and attitudes that sustain smoking in China
Journal of Health Communication
 , 
2008
, vol. 
13
 (pg. 
654
-
666
doi:10.1080/10810730802412222
Qian
J
Cai
M
Gao
J
Tang
S
Xu
L
Critchley
JA
Trends in smoking and quitting in China from 1993 to 2003: National Health Service Survey data
Bulletin of the World Health Organization
 , 
2010
, vol. 
88
 (pg. 
769
-
776
doi:10.2471/BLT.09.064709
Segaar
D
Bolman
C
Willemsen
MC
Vries
H
Determinants of adoption of cognitive behavioral interventions in a hospital setting: Example of a minimal-contact smoking cessation intervention for cardiology wards
Patient Education and Counseling
 , 
2006
, vol. 
61
 (pg. 
262
-
271
doi:10.1016/j.pec.2005.04.004
Shi
J
Liu
YL
Fang
YX
Xu
GZ
Zhai
HF
Lu
L
Traditional Chinese medicine in treatment of opiate addiction
Acta Pharmacologica Sinica
 , 
2006
, vol. 
27
 (pg. 
1303
-
1308
doi:10.1111/j.1745-7254.2006.00431.x
Song
LZ
[Acupuncture combined with auricular point sticking and pressing for smoking cessation of 53 cases in Russia]
Chinese Acupuncture & Moxibustion
 , 
2008
, vol. 
28
 (pg. 
133
-
134
)
Stillman
F
Yang
G
Figueiredo
V
Hernandez-Avila
M
Samet
JM
Building capacity for tobacco control research and policy
Tobacco Control
 , 
2006
, vol. 
15
 
Suppl. 1
(pg. 
i18
-
i23
doi:10.1136/tc.2005.014753
Sun
HQ
Guo
S
Chen
DF
Jiang
ZN
Liu
Y
Di
XL
, et al.  . 
Family support and employment as predictors of smoking cessation success: A randomized, double-blind, placebo-controlled trial of nicotine sublingual tablets in Chinese smokers
American Journal of Drug and Alcohol Abuse
 , 
2009
, vol. 
35
 (pg. 
183
-
188
doi:10.1080/00952990902839794
Tian
Z
Chu
W
Treating smoking addiction with the ear point seed pressuring method
Journal of Chinese Medicine
 , 
1996
, vol. 
52
 (pg. 
5
-
6
Wang
C
Xiao
D
Chan
KP
Pothirat
C
Garza
D
Davies
S
Varenicline for smoking cessation: A placebo-controlled, randomized study
Respirology
 , 
2009
, vol. 
14
 (pg. 
384
-
392
doi:10.1111/j.1440-1843.2008.01476.x
Wang
CP
Ma
SJ
Xu
XF
Wang
JF
Mei
CZ
Yang
GH
The prevalence of household second-hand smoke exposure and its correlated factors in six counties of China
Tobacco Control
 , 
2009
, vol. 
18
 (pg. 
121
-
126
doi:10.1136/tc.2008.024836
Wang
CP
Xu
XF
Ma
SJ
Mei
CZ
Wang
JF
Chen
AP
, et al.  . 
[The current status of passive smoking in Chinese families and associated factors]
Chinese Journal of Preventive Medicine
 , 
2008
, vol. 
42
 (pg. 
186
-
191
)
White
A
Moody
R
The effects of auricular acupuncture on smoking cessation may not depend on the point chosen—An exploratory meta-analysis
Acupuncture in Medicine
 , 
2006
, vol. 
24
 (pg. 
149
-
156
doi:10.1136/aim.24.4.149
White
AR
Rampes
H
Campbell
JL
Acupuncture and related interventions for smoking cessation
Cochrane Database of Systematic Reviews
 , 
2006
1
 
CD000009
 
doi:10.1002/14651858.CD000009.pub2
World Health Organization
China wrestles with tobacco control. An interview with Dr Yang Gonghuan
 , 
2010
 
World Health Organization
Global Adult Tobacco Survey (GATS). Fact Sheet China: 2010
 , 
2011
 
Wu
TP
Chen
FP
Liu
JY
Lin
MH
Hwang
SJ
A randomized controlled clinical trial of auricular acupuncture in smoking cessation
Journal of the Chinese Medical Association
 , 
2007
, vol. 
70
 (pg. 
331
-
338
doi:10.1016/S1726-4901(08)70014-5
Yan
J
Di
X
Liu
C
Zhang
H
Huang
X
Zhang
J
, et al.  . 
The cessation and detoxification effect of tea filters on cigarette smoke
Science China: Life Science
 , 
2010
, vol. 
53
 (pg. 
533
-
541
doi:10.1007/s11427-010-0097-1
Yang
G
Fan
LM
Tan
J
Qi
G
Zhang
Y
Samet
JM
, et al.  . 
Smoking in China: Findings from the 1996 national prevalence survey
Journal of the American Medical Association
 , 
1999
, vol. 
282
 (pg. 
1247
-
1253
doi:10.1001/jama.282.13.1247
Yang
L
Sung
HY
Mao
Z
Hu
TW
Rao
K
Economic costs attributable to smoking in China: Update and an 8-year comparison, 2000–2008
Tobacco Control
 , 
2011
, vol. 
20
 (pg. 
266
-
272
doi:10.1136/tc.2010.042028
Yang
S
Li
Y
[The efficacy of acupuncture therapy in smoking cessation with 30 patients]
World Health Digest
 , 
2010
, vol. 
7
 (pg. 
381
-
382
)
Yao
T
Ong
M
Lee
A
Jiang
Y
Mao
Z
Smoking knowledge, attitudes, behavior, and associated factors among Chinese male surgeons
World Journal of Surgery
 , 
2009
, vol. 
33
 (pg. 
910
-
917
doi:10.1007/s00268-009-9938-0
Yeh
ML
Chang
CY
Chu
NF
Chen
HH
A six-week acupoint stimulation intervention for quitting smoking
American Journal of Chinese Medicine
 , 
2009
, vol. 
37
 (pg. 
829
-
836
doi:10.1142/S0192415X09007314
Yu
JM
Hu
DY
Jiang
QW
Zhang
LJ
Dong
Y
Li
SC
[Smoking status in Chinese cardiovascular physicians in 2008]
Chinese Medical Journal
 , 
2009
, vol. 
89
 (pg. 
2400
-
2403
)
Zhang
H
Cai
BQ
The impact of tobacco on lung health in China
Respirology
 , 
2003
, vol. 
8
 (pg. 
17
-
21
doi:10.1046/j.1440-1843.2003.00433.x
Zheng
P
Guo
F
Chen
Y
Fu
Y
Ye
T
Fu
H
A randomized controlled trial of group intervention based on social cognitive theory for smoking cessation in China
Journal of Epidemiology
 , 
2007
, vol. 
17
 (pg. 
147
-
155
doi:10.2188/jea.17.147
Ziedonis
DM
Guydish
J
Williams
J
Steinberg
M
Foulds
J
Barriers and solutions to addressing tobacco dependence in addiction treatment programs
Alcohol Research and Health
 , 
2006
, vol. 
29
 (pg. 
228
-
235
Ziedonis
DM
Zammarelli
L
Seward
G
Oliver
K
Guydish
J
Hobart
M
, et al.  . 
Addressing tobacco use through organizational change: A case study of an addiction treatment organization
Journal of Psychoactive Drugs
 , 
2007
, vol. 
39
 (pg. 
451
-
459