Change in smoking status after spiral chest computed tomography scan screening

The impact of low-dose CT on smoking behavior among non-smokers, former-smokers, and smokers: A population-based screening cohort in rural China

BACKGROUND

Lung cancer screening may provide a "teachable moment" for the smoking cessation and relapse prevention. However, the impact of lung cancer screening on smoking initiation in non-smokers has not been reported.

METHODS

A baseline smoking behavior survey was conducted in 2000 participants who were screened by low-dose computed tomography (LDCT) from 2014 to 2018. All participants were re-surveyed on their smoking behavior in 2019. Of these, 312 participants were excluded, leaving 1688 participants in the final analysis. The smoking initiation rate in baseline non-smokers, the relapse rate in baseline former smokers, and the abstinence rate in baseline current smokers were calculated, respectively. The associations between screening results, demographic characteristics, and smoking behavior change were analyzed using multivariable logistic regression.

RESULTS

From 2014 to 2019, smoking prevalence significantly decreased from 52.6% to 49.1%. The prevalence of smoking initiation, relapse, and abstinence in baseline non-smokers, former, and current smokers was 16.8%, 22.9%, and 23.7%, respectively. The risk of smoking initiation in baseline non-smokers was significantly higher in those with negative screening result (adjusted OR = 2.97, 95% CI: 1.27-6.94). Compared to smokers who only received baseline screening, the chance of smoking abstinence in baseline current smokers was reduced by over 80% in those who attended 5 rounds of screening (adjusted OR = 0.15, 95% CI:0.08-0.27). No significant associations were found between smoking relapse and prior screening frequency, with at least one positive screening result. Age, gender, occupational exposure, income, and smoking pack years were also associated with smoking behavior changes.

CONCLUSIONS

The overall decreased smoking prevalence indicated an overwhelming effect of "teachable moment" on "license to smoke." A tailored smoking cessation strategy should be integrated into lung cancer screening.

Examining Tobacco Treatment Perceptions and Barriers among Black versus Non-Black Adults Attending Lung Cancer Screening

The US Preventive Services Task Force recommends annual lung cancer screening for patients at high risk based on age and smoking history. Understanding the characteristics of patients attending lung cancer screening, including potential barriers to quitting smoking, may inform ways to engage these high-risk patients in tobacco treatment and address health disparities. Patients attending lung cancer screening who currently smoke cigarettes completed a survey at Smilow Cancer Hospital at Yale-New Haven (N = 74) and the Medical University of South Carolina (N = 73) at the time of their appointment. The survey assessed demographics, smoking history, and perceptions and concerns about quitting smoking.

Patients were 55 to 76 years old (mean = 63.3, SD = 5.3), N = 64 (43.5%) female, and N = 31 (21.1%) non-Hispanic Black. Patients smoked 16.3 cigarettes per day on average (SD = 9.2) and rated interest in quitting smoking in the next month as moderate (mean = 5.6, SD = 3.1, measured from 0 = "very definitely no" to 10 = "very definitely yes"). The most frequently endorsed concerns about quitting smoking were missing smoking (70.7%), worry about having strong urges to smoke (63.9%), and concerns about withdrawal symptoms (59.9%). In comparison with other races/ethnicities, Black patients were less likely to report concerns about withdrawal symptoms and more likely to report smoking less now and perceiving no need to quit. Findings identified specific barriers for tobacco treatment and differences by race/ethnicity among patients attending lung cancer screening, including concerns about withdrawal symptoms and perceived need to quit. Identifying ways to promote tobacco treatment is important for reducing morbidity and mortality among this high-risk population.

PREVENTION RELEVANCE

The current study examines patient characteristics and tobacco treatment perceptions and barriers among patients attending lung cancer screening who continue to smoke cigarettes that may help inform ways to increase treatment engagement and address tobacco-related health disparities to reduce morbidity and mortality from smoking.

Lung cancer screening and smoking cessation efforts

Randomized-controlled trials have confirmed substantial reductions in lung cancer mortality with low-dose computed tomography (LDCT) screening. Evidence on how to integrate smoking cessation support in lung cancer screening is however scarce. This represents a significant gap in the literature, as a combined strategy of lung cancer screening and smoking cessation greatly reduces the mortality risk due to lung cancer and other related comorbidities. In this review, a literature search in MEDLINE, Embase, Web of Science, the Cochrane Central Register of Controlled Trials and Google Scholar was performed to identify randomized-controlled and observational studies investigating the effect of lung cancer screening trials and integrated cessation interventions on smoking cessation. Of the 236 identified records, we included 32 original publications. Smoking cessation rates in lung cancer screening trials are promising. Especially findings suspicious for lung cancer and referral to a physician might function as a teachable moment to motivate smoking abstinence in current smokers or recent quitters. More intensive, personalized and multi-modality smoking cessation interventions delivered by a clinician appear to be the most successful in influencing smoking behavior. While it is evident that smoking cessation should be incorporated in lung cancer screening, further research is required to ascertain the optimal treatment type, modality, timing, and content of communication including the incorporation of CT results to motivate health behavior change.

Comparing cotinine and NNAL verification of self-reported smoking status among lung cancer screening eligible population from the 2007-2014 National Health and Nutrition Examination Survey (NHANES)

Background: Biochemical verification of self-reported smoking status is not common among the population eligible for lung cancer screening (LCS). Methods: We used urinary NNAL (4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol and its glucuronides) and serum cotinine as the gold standard to determine the validity and reliability of self-reported smoking status from the 2007-2014 National Health and Nutrition Examination Survey (NHANES). Results: We found 2.3% (n = 652, equivalent to 5.3 million weighted population) of adults eligible for LCS according to the current United States Preventive Services Task Force guideline. Self-reported current smoking status performed similarly against NNAL and cotinine: sensitivity [89.7% (95%CI: 84.9%-94.5%) vs. 89.5% (95%CI: 84.8%-94.3%)]; specificity [99.7% (95%CI: 99.2%-100.0%) vs. 100% (95%CI:100%-100%)]; positive predictive value (PPV) and negative predictive value (NPV) were 99.8% (95%CI:99.4%-100.0%) versus 100% (95%CI:100%-100%) and 85.3% (95%CI: 79.1%-91.5%) versus 85.1% (95%CI: 79.1%-1.0%), respectively; and Kappa [86.5% (95%CI:80.5%-92.5%) vs. 86.5% (95%CI:80.6%-92.3%)]. Performance measures were better among females than males; worst among the non-Hispanic white and best among other race/ethnicity group. The validity and reliability of self-reported smoking status increased with increasing cutpoint levels of both NNAL and cotinine. Conclusions: Self-reported smoking status among people who are at high risk of lung cancer is reasonably reliable. The difference between using NNAL and cotinine appears to be minimal.

Understanding the Associations between Smoking-Related Risk Perception, Interest in Quitting Smoking, and Interest in Lung Cancer Screening among Homeless Adult Smokers

Individuals experiencing homelessness smoke cigarettes at high rates, suffer a disproportionate incidence of lung cancer, but are unlikely to be screened to enhance early detection. Understanding correlates of lung cancer screening (LCS) interest within this vulnerable group may lend insight into prevention and treatment efforts and reduce their smoking-related morbidity and mortality. This study sought to understand how risk perception and interest in quitting smoking relate to LCS interest among homeless adults. Participants comprised a convenience sample of CO-verified current smokers (N = 310; 72.6% men, M_age = 43 + 11.7) from a homeless shelter in Dallas, TX. Participants self-reported risk perception, interest in quitting smoking, and interest in LCS. The average risk perception was 6.7 + 3.2 (range 0-10), 74.8% (n = 232) agreed or strongly agreed with interest in LCS, and 65.8% (n = 204) were interested in quitting smoking. Greater interest in quitting smoking, but not greater risk perception, was associated with greater interest in LCS (adjusted OR: 1.968, (95% CI: 1.213, 3.191), p = 0.006). Risk perception and interest in quitting smoking did not interact in their association with interest in LCS. Results suggest that homeless smokers with an interest in quitting may be receptive to LCS: a diagnostic tool by which cancers can be caught at earlier stages and prior to metastasis. However, few in the current sample would be eligible for LCS based on current guidelines; results have implications for altered screening practices among chronic smokers experiencing homelessness.

[Smoking cessation and lung cancer screening]

Several studies have shown that lung cancer screening, using annual low-dose computed tomography (CT) scan in a targeted population of smokers and ex-smokers reduces overall and lung cancer specific mortality rates. This form of screening strategy is not currently established for use in France by the French High Authority for Health. Quitting smoking is the most important measure in reducing mortality from lung cancer. The maximum benefit in reducing mortality from lung cancer should be seen through an effective combination of smoking cessation intervention and chest CT screening to identify early, curable disease. However, current data to guide clinicians in the choice of smoking cessation interventions in this specific context are limited due to the small number of randomized studies that have been carried out. The optimal approach to smoking cessation during lung cancer screening needs to be clarified by new studies comparing different motivation strategies, establishing the ideal moment to propose stopping smoking and the most effective therapies to use.

Recommendations for Implementing Lung Cancer Screening with Low-Dose Computed Tomography in Europe

Lung cancer screening (LCS) with low-dose computed tomography (LDCT) was demonstrated in the National Lung Screening Trial (NLST) to reduce mortality from the disease. European mortality data has recently become available from the Nelson randomised controlled trial, which confirmed lung cancer mortality reductions by 26% in men and 39-61% in women. Recent studies in Europe and the USA also showed positive results in screening workers exposed to asbestos. All European experts attending the "Initiative for European Lung Screening (IELS)"-a large international group of physicians and other experts concerned with lung cancer-agreed that LDCT-LCS should be implemented in Europe. However, the economic impact of LDCT-LCS and guidelines for its effective and safe implementation still need to be formulated. To this purpose, the IELS was asked to prepare recommendations to implement LCS and examine outstanding issues. A subgroup carried out a comprehensive literature review on LDCT-LCS and presented findings at a meeting held in Milan in November 2018. The present recommendations reflect that consensus was reached.

Recommendations for Implementing Lung Cancer Screening with Low-Dose Computed Tomography in Europe

Lung cancer screening (LCS) with low-dose computed tomography (LDCT) was demonstrated in the National Lung Screening Trial (NLST) to reduce mortality from the disease. European mortality data has recently become available from the Nelson randomised controlled trial, which confirmed lung cancer mortality reductions by 26% in men and 39-61% in women. Recent studies in Europe and the USA also showed positive results in screening workers exposed to asbestos. All European experts attending the "Initiative for European Lung Screening (IELS)"-a large international group of physicians and other experts concerned with lung cancer-agreed that LDCT-LCS should be implemented in Europe. However, the economic impact of LDCT-LCS and guidelines for its effective and safe implementation still need to be formulated. To this purpose, the IELS was asked to prepare recommendations to implement LCS and examine outstanding issues. A subgroup carried out a comprehensive literature review on LDCT-LCS and presented findings at a meeting held in Milan in November 2018. The present recommendations reflect that consensus was reached.

A stepped-wedge randomized trial protocol of a community intervention for increasing lung screening through engaging primary care providers (I-STEP)

Lung cancer screening with low-dose computed tomography (LDCT) reduces lung cancer mortality, yet few eligible high-risk patients receive it annually. This protocol describes a community-partnered intervention (Toolkit) designed to support primary care practices in making referrals for lung screening and guiding patients into appropriate screening pathways. This study uses a stepped-wedge implementation design. Screening centers are randomized by readiness level to enter the intervention phase in three-month "steps" with pre-intervention data serving as the control. The primary outcome is whether delivery of the Toolkit to primary care practices results in a monthly increase in number of initial LDCT screenings. Six participating centers will identify 10 practices and reach 2-3 providers per practice to train them to use the Toolkit. The Toolkit will address known barriers to screening and referral at the patient and provider levels and provide support for required elements of screening. Toolkit components include adaptable evidence-based interventions to maximize compatibility with workflows. We hypothesize that after nine months of intervention delivery, the number of initial screening per center will double. Involving 60 practices achieves 80% power at 5% level of significance. Implementation outcomes such as adoption, acceptability, feasibility, adaptation, and sustainability will be assessed through field-notes and activity logs. LDCT for lung cancer screening currently reaches a small fraction of eligible adults. To reach the full potential to reduce mortality, primary care practices are an important venue for increasing appropriate referrals. This multidisciplinary trial will encourage acceptability and sustainability by using local knowledge and promoting partnership between providers and patients. Trial registration: ClinicalTrials.gov, NCT03958253.

Smoking Cessation in the ITALUNG Lung Cancer Screening: What Does “Teachable Moment” Mean?

Background

Changes in smoking habits and predictors of smoking cessation were examined in the randomized ITALUNG lung cancer screening trial.

Methods

In three centers, eligible smokers or ex-smokers (55–69 years, ≥20 pack-years in the last 10 years) were randomized to receive annual invitation for low-dose computed tomography for 4 years or usual care. At invitation, subjects received written information for a free smoking cessation program. Quitting outcome was assessed at year 4.

Results

Among participants who completed baseline assessments and year 4 screening, higher quitting (20.8% vs. 16.7%, p = .029) and lower relapse (6.41% vs. 7.56%, p = .50) rates were observed in the active screening group as compared to the usual-care control group. Corresponding figures in the intention-to-treat analysis were as follows: 16.04% versus 14.64% (p = .059) and 4.88% versus 6.43% (p = .26). Quitting smoking was significantly associated to male gender, lower pack-years, and having pulmonary nodules at baseline. Center-specific analyses showed a threefold statistically significant higher probability to quit associated with participating in the smoking cessation program. A subsample of smokers of the scan group from one center showed higher quitting rates over 12-month follow-up as compared to matched controls from the general population who underwent the same smoking cessation program.

Conclusions

Consistently with previous reports, in the ITALUNG trial, screened subjects showed significantly higher quit rates than controls, and higher quit rates were associated with both the presence of pulmonary nodules and participating in a smoking cessation program. Maximal effect on quitting outcome was observed with the participation in the smoking cessation program.

Implications

Participating in lung cancer screening promotes smoking cessation. An effective “teachable moment” may be achieved when the smoking cessation intervention is structured as integral part of the screening clinical visits and conducted by a dedicated team of health care professionals. Standardized guidelines for smoking cessation interventions in lung cancer screening are needed.

Five-year survival rate among older adults participating in the national geriatric screening program: A South Korean population-based cohort study

INTRODUCTION

This study aimed to assess the health benefits of a geriatric screening program comprising of physical function tests, screening questionnaires for depression and cognitive impairment, and bone mineral density measurements for women as a part of the National Screening Program for Transitional Ages (NSPTA). We compared the all-cause mortality between subjects who did and did not participate in the screening program.

METHODS

This was a nationwide longitudinal study with a 5-year follow-up based on a 10% sample of the National Health Insurance beneficiaries aged 60 years and older. Mortality records were obtained from the qualification dataset in the elderly cohort database of 2005-2013 provided by the National Health Insurance Service. A Cox proportional hazards model was used to analyze the mortality risk. We sampled 11,986 subjects each in the screened (intervention) and non-screened (control) groups after exact matching using propensity score.

RESULTS

After adjusting for demographic and socioeconomic characteristics (age, sex, household income, smoking, alcohol drinking, physical activity, body mass index, and the Charlson Comorbidity Index), all-cause mortality rates were found to be significantly lower (a) in the intervention group compared to the control group (hazard ratio = 0.73; 95% confidence interval: 0.65, 0.82) and (b) among women compared to men (hazard ratio = 0.50; 95% confidence interval: 0.44, 0.56). Lower hazard ratios were also observed among those with a higher body mass index, fewer comorbidities, and higher income.

CONCLUSION

A nationwide geriatric screening program might be helpful in reducing the incidence of premature deaths among older people.

Low-dose computed tomography for lung cancer screening in high-risk populations: a systematic review and economic evaluation

BACKGROUND

Diagnosis of lung cancer frequently occurs in its later stages. Low-dose computed tomography (LDCT) could detect lung cancer early.

OBJECTIVES

To estimate the clinical effectiveness and cost-effectiveness of LDCT lung cancer screening in high-risk populations.

DATA SOURCES

Bibliographic sources included MEDLINE, EMBASE, Web of Science and The Cochrane Library.

METHODS

Clinical effectiveness - a systematic review of randomised controlled trials (RCTs) comparing LDCT screening programmes with usual care (no screening) or other imaging screening programmes [such as chest X-ray (CXR)] was conducted. Bibliographic sources included MEDLINE, EMBASE, Web of Science and The Cochrane Library. Meta-analyses, including network meta-analyses, were performed. Cost-effectiveness - an independent economic model employing discrete event simulation and using a natural history model calibrated to results from a large RCT was developed. There were 12 different population eligibility criteria and four intervention frequencies [(1) single screen, (2) triple screen, (3) annual screening and (4) biennial screening] and a no-screening control arm.

RESULTS

Clinical effectiveness - 12 RCTs were included, four of which currently contribute evidence on mortality. Meta-analysis of these demonstrated that LDCT, with ≤ 9.80 years of follow-up, was associated with a non-statistically significant decrease in lung cancer mortality (pooled relative risk 0.94, 95% confidence interval 0.74 to 1.19). The findings also showed that LDCT screening demonstrated a non-statistically significant increase in all-cause mortality. Given the considerable heterogeneity detected between studies for both outcomes, the results should be treated with caution. Network meta-analysis, including six RCTs, was performed to assess the relative clinical effectiveness of LDCT, CXR and usual care. The results showed that LDCT was ranked as the best screening strategy in terms of lung cancer mortality reduction. CXR had a 99.7% probability of being the worst intervention and usual care was ranked second. Cost-effectiveness - screening programmes are predicted to be more effective than no screening, reduce lung cancer mortality and result in more lung cancer diagnoses. Screening programmes also increase costs. Screening for lung cancer is unlikely to be cost-effective at a threshold of £20,000/quality-adjusted life-year (QALY), but may be cost-effective at a threshold of £30,000/QALY. The incremental cost-effectiveness ratio for a single screen in smokers aged 60-75 years with at least a 3% risk of lung cancer is £28,169 per QALY. Sensitivity and scenario analyses were conducted. Screening was only cost-effective at a threshold of £20,000/QALY in only a minority of analyses.

LIMITATIONS

Clinical effectiveness - the largest of the included RCTs compared LDCT with CXR screening rather than no screening. Cost-effectiveness - a representative cost to the NHS of lung cancer has not been recently estimated according to key variables such as stage at diagnosis. Certain costs associated with running a screening programme have not been included.

CONCLUSIONS

LDCT screening may be clinically effective in reducing lung cancer mortality, but there is considerable uncertainty. There is evidence that a single round of screening could be considered cost-effective at conventional thresholds, but there is significant uncertainty about the effect on costs and the magnitude of benefits.

FUTURE WORK

Clinical effectiveness and cost-effectiveness estimates should be updated with the anticipated results from several ongoing RCTs [particularly the NEderlands Leuvens Longkanker Screenings ONderzoek (NELSON) screening trial].

STUDY REGISTRATION

This study is registered as PROSPERO CRD42016048530.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Lung Cancer Screening and Smoking Cessation Clinical Trials. SCALE (Smoking Cessation within the Context of Lung Cancer Screening) Collaboration

National recommendations for lung cancer screening for former and current smokers aged 55-80 years with a 30-pack-year smoking history create demand to implement efficient and effective systems to offer smoking cessation on a large scale. These older, high-risk smokers differ from participants in past clinical trials of behavioral and pharmacologic interventions for tobacco dependence. There is a gap in knowledge about how best to design systems to extend reach and treatments to maximize smoking cessation in the context of lung cancer screening. Eight clinical trials, seven funded by the National Cancer Institute and one by the Veterans Health Administration, address this gap and form the SCALE (Smoking Cessation within the Context of Lung Cancer Screening) collaboration. This paper describes methodological issues related to the design of these clinical trials: clinical workflow, participant eligibility criteria, screening indication (baseline or annual repeat screen), assessment content, interest in stopping smoking, and treatment delivery method and dose, all of which will affect tobacco treatment outcomes. Tobacco interventions consider the "teachable moment" offered by lung cancer screening, how to incorporate positive and negative screening results, and coordination of smoking cessation treatment with clinical events associated with lung cancer screening. Unique data elements, such as perceived risk of lung cancer and costs of tobacco treatment, are of interest. Lung cancer screening presents a new and promising opportunity to reduce morbidity and mortality resulting from lung cancer that can be amplified by effective smoking cessation treatment. SCALE teamwork and collaboration promise to maximize knowledge gained from the clinical trials.

Biomedical risk assessment as an aid for smoking cessation

BACKGROUND

A possible strategy for increasing smoking cessation rates could be to provide smokers with feedback on the current or potential future biomedical effects of smoking using, for example, measurement of exhaled carbon monoxide (CO), lung function, or genetic susceptibility to lung cancer or other diseases.

OBJECTIVES

The main objective was to determine the efficacy of providing smokers with feedback on their exhaled CO measurement, spirometry results, atherosclerotic plaque imaging, and genetic susceptibility to smoking-related diseases in helping them to quit smoking.

SEARCH METHODS

For the most recent update, we searched the Cochrane Tobacco Addiction Group Specialized Register in March 2018 and ClinicalTrials.gov and the WHO ICTRP in September 2018 for studies added since the last update in 2012.

SELECTION CRITERIA

Inclusion criteria for the review were: a randomised controlled trial design; participants being current smokers; interventions based on a biomedical test to increase smoking cessation rates; control groups receiving all other components of intervention; and an outcome of smoking cessation rate at least six months after the start of the intervention.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. We expressed results as a risk ratio (RR) for smoking cessation with 95% confidence intervals (CI). Where appropriate, we pooled studies using a Mantel-Haenszel random-effects method.

MAIN RESULTS

We included 20 trials using a variety of biomedical tests interventions; one trial included two interventions, for a total of 21 interventions. We included a total of 9262 participants, all of whom were adult smokers. All studies included both men and women adult smokers at different stages of change and motivation for smoking cessation. We judged all but three studies to be at high or unclear risk of bias in at least one domain. We pooled trials in three categories according to the type of biofeedback provided: feedback on risk exposure (five studies); feedback on smoking-related disease risk (five studies); and feedback on smoking-related harm (11 studies). There was no evidence of increased cessation rates from feedback on risk exposure, consisting mainly of feedback on CO measurement, in five pooled trials (RR 1.00, 95% CI 0.83 to 1.21; I² = 0%; n = 2368). Feedback on smoking-related disease risk, including four studies testing feedback on genetic markers for cancer risk and one study with feedback on genetic markers for risk of Crohn's disease, did not show a benefit in smoking cessation (RR 0.80, 95% CI 0.63 to 1.01; I² = 0%; n = 2064). Feedback on smoking-related harm, including nine studies testing spirometry with or without feedback on lung age and two studies on feedback on carotid ultrasound, also did not show a benefit (RR 1.26, 95% CI 0.99 to 1.61; I² = 34%; n = 3314). Only one study directly compared multiple forms of measurement with a single form of measurement, and did not detect a significant difference in effect between measurement of CO plus genetic susceptibility to lung cancer and measurement of CO only (RR 0.82, 95% CI 0.43 to 1.56; n = 189).

AUTHORS' CONCLUSIONS

There is little evidence about the effects of biomedical risk assessment as an aid for smoking cessation. The most promising results relate to spirometry and carotid ultrasound, where moderate-certainty evidence, limited by imprecision and risk of bias, did not detect a statistically significant benefit, but confidence intervals very narrowly missed one, and the point estimate favoured the intervention. A sensitivity analysis removing those studies at high risk of bias did detect a benefit. Moderate-certainty evidence limited by risk of bias did not detect an effect of feedback on smoking exposure by CO monitoring. Low-certainty evidence, limited by risk of bias and imprecision, did not detect a benefit from feedback on smoking-related risk by genetic marker testing. There is insufficient evidence with which to evaluate the hypothesis that multiple types of assessment are more effective than single forms of assessment.

Capitalizing on a teachable moment: Development of a targeted self-help smoking cessation intervention for patients receiving lung cancer screening

OBJECTIVE

The goal of the current study was to develop and examine the feasibility and acceptability of a self-help smoking cessation intervention targeted to the teachable moment of smokers undergoing low-dose computed tomography (LDCT) lung cancer screening.

MATERIALS AND METHODS

We used a multi-phase qualitative approach, including focus groups (N = 15) and learner verification interviews (N = 16) to develop a targeted intervention for patients receiving a LDCT screening, by extending and modifying a previously validated, self-help intervention. The new intervention was then tested in a feasibility study for acceptability and receptivity by smokers (N = 18) receiving a LDCT screening.

RESULTS

The main themes that emerged from the focus group findings included a need to address the counterproductive thoughts regarding a negative lung screen result, the desire to enjoy a healthy and smoke-free retirement, the need to increase self-efficacy regarding smoking cessation, and the desire to see statistics regarding survival after quitting smoking. Learner verification findings showed that participants responded favorably to most booklet and pamphlet changes. Minor changes were made to improve comprehension and enhance self-efficacy. Formative findings led to the development of a new initial booklet titled, "Lung Cancer Screening & Quitting Smoking: Taking Control of Your Health," as well as modifications of the existing self-help cessation intervention. The intervention was designed to be initiated at the LDCT appointment, prior to receipt of scan results, and with minimal disruption of clinic work-flow. Results from the feasibility study indicated that acceptability and satisfaction with the new intervention were high.

CONCLUSION

A validated self-help smoking-cessation intervention was modified for smokers receiving LDCT screening for lung cancer based on formative research guided by the teachable moment concept. The new intervention is ready for testing in a randomized controlled trial.

Smoking-related health beliefs and smoking behavior in the National Lung Screening Trial

Understanding the association between smoking-related health beliefs and smoking cessation in the context of lung screening is important for effective cessation treatment. The purpose of the current study is to explore how current smokers' self-reported smoking-related health cognitions (e.g., self-efficacy) and emotions (e.g., worry) are related to cessation. This study utilized longitudinal data from current smokers (age 55-74) in a sub-study of the National Lung Screening Trial (NLST; 2002-2006; N = 2738). Logistic regression analyses examined associations of cessation at last assessment with smoking-related health cognitions and emotions, demographics, and two-way interactions among smoking-related health cognition and emotion variables, gender, and age. Over 37% (n = 1028) of smokers had quit at their last assessment of smoking status. Simple logistic regressions showed the likelihood of quitting was greater among participants reporting higher perceived severity of smoking-related diseases (OR = 1.17, p = .04), greater self-efficacy for quitting (OR = 1.32, p < .001), and fewer perceived barriers to quitting (OR = 0.82, p = .01). Likelihood of quitting was lower among non-Hispanic Black participants (versus non-Hispanic White participants) (OR = 0.68, p = .04) and higher among older participants (OR = 1.03, p = .002). Multiple logistic regression showed that participants reporting greater self-efficacy for quitting (B = 0.09, p = .05), fewer perceived barriers to quitting (B = -0.22, p = .01), and who were older (B = 0.03, p < .01) were more likely to quit smoking. These results suggest that, among heavy smokers undergoing lung screening, smoking-related health cognitions and emotions are associated with smoking cessation. These health beliefs must be considered an integral component of cessation in screening settings.

Tobacco Dependence Predicts Higher Lung Cancer and Mortality Rates and Lower Rates of Smoking Cessation in the National Lung Screening Trial

BACKGROUND

Incorporating tobacco treatment within lung cancer screening programs has the potential to influence cessation in high-risk smokers. We aimed to better understand the characteristics of smokers within a screening cohort, correlate those variables with downstream outcomes, and identify predictors of continued smoking.

METHODS

This study is a secondary analysis of the National Lung Screening Trial randomized clinical study. Tobacco dependence was evaluated by using the Fagerstrӧm Test for Nicotine Dependence, the Heaviness of Smoking Index, and time to first cigarette (TTFC); descriptive statistics were performed. Clinical outcomes (smoking cessation, lung cancer, and mortality) were assessed with descriptive statistics and χ² tests stratified according to nicotine dependence. Logistic and Cox regression models were used to study the influence of dependence on smoking cessation and mortality, respectively.

RESULTS

Patients with high dependence scores were less likely to quit smoking compared with low dependence smokers (TTFC OR, 0.50 [95% CI, 0.42-0.60]). Indicators of high dependence, as measured according to all three metrics, were associated with worsening clinical outcomes. TTFC showed that patients who smoked within 5 min of waking (indicating higher dependence) had higher rates of lung cancer (2.07% for > 60 min after waking vs 5.92% ≤ 5 min after waking; hazard ratio [HR], 2.56 [95% CI, 1.49-4.41]), all-cause mortality (5.38% for > 60 min vs 11.21% ≤ 5 min; HR, 2.19 [95% CI, 1.55-3.09]), and lung cancer-specific mortality (0.55% for > 60 min vs 2.92% for ≤ 5 min; HR, 4.46 [95% CI, 1.63-12.21]).

CONCLUSIONS

Using TTFC, a one-question assessment of tobacco dependence, at the time of lung cancer screening has implications for personalizing tobacco treatment and improving risk assessment.

An integrated digital/clinical approach to smoking cessation in lung cancer screening: study protocol for a randomized controlled trial

Background

Delivering effective tobacco dependence treatment that is feasible within lung cancer screening (LCS) programs is crucial for realizing the health benefits and cost savings of screening. Large-scale trials and systematic reviews have demonstrated that digital cessation interventions (i.e. web-based and text message) are effective, sustainable over the long-term, scalable, and cost-efficient. Use of digital technologies is commonplace among older adults, making this a feasible approach within LCS programs. Use of cessation treatment has been improved with models that proactively connect smokers to treatment rather than passive referrals. Proactive referral to cessation treatment has been advanced through healthcare systems changes such as modifying the electronic health record to automatically link smokers to treatment.

Methods

This study evaluates the impact of a proactive enrollment strategy that links LCS-eligible smokers with an evidence-based intervention comprised of a web-based (WEB) program and integrated text messaging (TXT) in a three-arm randomized trial with repeated measures at one, three, six, and 12 months post randomization. The primary outcome is biochemically confirmed abstinence at 12 months post randomization. We will randomize 1650 smokers who present for a clinical LCS to: (1) a usual care control condition (UC) which consists of Ask–Advise–Refer; (2) a digital (WEB + TXT) cessation intervention; or (3) a digital cessation intervention combined with tobacco treatment specialist (TTS) counseling (WEB + TXT + TTS).

Discussion

The scalability and sustainability of a digital intervention may represent the most cost-effective and feasible approach for LCS programs to proactively engage large numbers of smokers in effective cessation treatment. We will also evaluate the impact and cost-effectiveness of adding proven clinical intervention provided by a TTS. We expect that a combined digital/clinical intervention will yield higher quit rates than digital alone, but that it may not be as cost-effective or feasible for LCS programs to implement. This study is innovative in its use of interoperable, digital technologies to deliver a sustainable, scalable, high-impact cessation intervention and to facilitate its integration within clinical practice. It will add to the growing knowledge base about the overall effectiveness of digital interventions and their role in the healthcare delivery system.

Trial registration

ClinicalTrials.gov, NCT03084835. Registered on 9 March 2017.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-017-2312-x) contains supplementary material, which is available to authorized users.

Smoking cessation results in a clinical lung cancer screening program

BACKGROUND

Lung cancer screening may provide a "teachable moment" for promoting smoking cessation. This study assessed smoking cessation and relapse rates among individuals undergoing follow-up low-dose chest computed tomography (CT) in a clinical CT lung screening program and assessed the influence of initial screening results on smoking behavior.

METHODS

Self-reported smoking status for individuals enrolled in a clinical CT lung screening program undergoing a follow-up CT lung screening exam between 1st February, 2014 and 31st March, 2015 was retrospectively reviewed and compared to self-reported smoking status using a standardized questionnaire at program entry. Point prevalence smoking cessation and relapse rates were calculated across the entire population and compared with exam results. All individuals undergoing screening fulfilled the National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology: Lung Cancer Screening v1.2012(®) high-risk criteria and had an order for CT lung screening.

RESULTS

A total of 1,483 individuals underwent a follow-up CT lung screening exam during the study interval. Smoking status at time of follow-up exam was available for 1,461/1,483 (98.5%). A total of 46% (678/1,461) were active smokers at program entry. The overall point prevalence smoking cessation and relapse rates were 20.8% and 9.3%, respectively. Prior positive screening exam results were not predictive of smoking cessation (OR 1.092; 95% CI, 0.715-1.693) but were predictive of reduced relapse among former smokers who had stopped smoking for 2 years or less (OR 0.330; 95% CI, 0.143-0.710). Duration of program enrollment was predictive of smoking cessation (OR 0.647; 95% CI, 0.477-0.877).

CONCLUSIONS

Smoking cessation and relapse rates in a clinical CT lung screening program rates are more favorable than those observed in the general population. Duration of participation in the screening program correlated with increased smoking cessation rates. A positive exam result correlated with reduced relapse rates among smokers recently quit smoking.

Smoking cessation interventions within the context of Low-Dose Computed Tomography lung cancer screening: A systematic review

The integration of smoking cessation interventions (SCIs) within the context of lung cancer screening programs is strongly recommended by screening guidelines, and is a requirement for Medicare coverage of screening in the US. In Europe, there are no lung cancer screening guidelines, however, research trials are ongoing, and prominent professional societies have begun to recommend lung cancer screening. Little is known about the types and efficacy of SCIs among patients receiving low-dose computed tomography (LDCT) screening. This review addresses this gap. Based on a systematic search, we identified six empirical studies published prior to July 1, 2015, that met inclusion criteria for our review: English language, SCI for LDCT patients, and reported smoking-related outcomes. Three randomized studies and three single-arm studies were identified. Two randomized controlled trials (RCTs) evaluated self-help SCIs, whereas one pilot RCT evaluated the timing (before or after the LDCT scan) of a combined (counseling and pharmacotherapy) SCI. Among the single-arm trials, two observational studies evaluated the efficacy of combined SCI, and one retrospectively assessed the efficacy of clinician-delivered smoking assessment, advice, and assistance. Given the limited research to date, and particularly the lack of studies reporting results from RCTs, assumptions that SCIs would be effective among this population should be made with caution. Findings from this review suggest that participation in a lung screening trial promotes smoking cessation and may represent a teachable moment to quit smoking. Findings also suggest that providers can take advantage of this potentially teachable moment, and that SCIs have been successfully implemented in screening settings. Continued systematic and methodologically sound research in this area will help improve the knowledge base and implementation of interventions for this population of smokers at risk for chronic disease.

Effectiveness of advice from physician and nurse on smoking cessation stage in Taiwanese male smokers attending a community-based integrated screening program

BACKGROUND

A screening program provides a teachable moment for primary prevention such as encouraging smoking cessation. However, little is known about the efficacy of smoking cessation intervention delivered to the general population through a community-based screening program.

METHODS

A quasi-experimental untreated control design with pre-test and post-test was conducted with 42 subjects receiving advice from physician and nurses (the PNA group), 39 receiving an informational leaflet (the leaflet group), and 308 control subjects.

RESULTS

The overall rate of reaching the action stage was 25 %, 5.7 %, and 7.8 in the PNA group, the leaflet group, and the control group, respectively. In approximately 45-60 % of all participants, the stage remained unchanged. Such an association between the intervention groups and stage changes was statistically significant (p = 0.02). The PNA group was more likely to have the improvement of stage (forward transition toward action stage) than the control group [adjusted odds ratio (aOR) = 2.27 (1.07-4.84)]. Deterioration (backward transition toward precontemplation) in the PNA intervention group was 37 % lower than that in the control group [aOR = 0.63 (0.20-2.01)].

CONCLUSIONS

This study demonstrated that smoking cessation advice from physician and nurse is conducive to smoking cessation, as shown by greater movement toward and less movement away from smoking cessation through a community-based integrated screening platform.

Pairing smoking-cessation services with lung cancer screening: A clinical guideline from the Association for the Treatment of Tobacco Use and Dependence and the Society for Research on Nicotine and Tobacco

Smoking cessation is crucial for reducing cancer risk and premature mortality. The US Preventive Services Task Force (USPSTF) has recommended annual lung cancer screening with low-dose computed tomography (LDCT), and the Center for Medicare and Medicaid Services recently approved lung screening as a benefit for patients ages 55 to 77 years who have a 30 pack-year history. The Society for Research on Nicotine and Tobacco (SRNT) and the Association for the Treatment of Tobacco Use and Dependence (ATTUD) developed the guideline described in this commentary based on an illustrative literature review to present the evidence for smoking-cessation health benefits in this high-risk group and to provide clinical recommendations for integrating evidence-based smoking-cessation treatment with lung cancer screening. Unfortunately, extant data on lung cancer screening participants were scarce at the time this guideline was written. However, in this review, the authors summarize the sufficient evidence on the benefits of smoking cessation and the efficacy of smoking-cessation interventions for smokers ages 55 to 77 years to provide smoking-cessation interventions for smokers who seek lung cancer screening. It is concluded that smokers who present for lung cancer screening should be encouraged to quit smoking at each visit. Access to evidence-based smoking-cessation interventions should be provided to all smokers regardless of scan results, and motivation to quit should not be a necessary precondition for treatment. Follow-up contacts to support smoking-cessation efforts should be arranged for smokers. Evidence-based behavioral strategies should be used at each visit to motivate smokers who are unwilling to try quitting/reducing smoking or to try evidence-based treatments that may lead to eventual cessation.

Dual-energy computed tomography for evaluation of pulmonary nodules with emphasis on metastatic lesions

BACKGROUND

The contrast enhancement of pulmonary nodules is a differential diagnostic criterion which can be helpful in staging investigations.

PURPOSE

To investigate the impact of dual-energy computed tomography (DECT) with regards to the evaluation of pulmonary nodules with emphasis on metastatic lesions.

MATERIAL AND METHODS

DECT scans of the thorax were performed in 70 consecutive patients. Data of the lung were acquired in the arterial and in delayed venous phase. The virtual native and overlay image data based on arterial and delayed venous phase of these lesions were compared using CT density values (HU) within the nodule tested for statistical significance.

RESULTS

A total of 156 pulmonary lesions ≥5 mm were identified on 70 DECT scans. There were no significant differences between the CT-value measurements in the virtual native images based on the arterial and delayed venous phase (27.9+/-3.9 HU vs.28.1+/-4.2 HU, P = 0.89) and between the CT-value measurements in the overlay images based on the arterial und delayed venous phase (35.5+/-6.8 HU vs. 36.6+/-5.0 HU, P = 0.75). Metastases of colorectal carcinoma (51.4+/-9.4 HU vs. 32.5+/-8.9 HU, P = 0.0001), malignant melanoma (56.1+/-6.4 HU vs. 34.2+/-1.6 HU, P = 0.0045), and thyroid cancer (53.5+/-15.5 HU vs. 15.7+/-4.2 HU, P = 0.001) showed a distinct wash-out, whereas metastases of lung cancer (23.1+/-6.3 HU vs. 58.6+/-4.8 HU, P = 0.001), salivary gland cancer (41.4+/-20.3 HU vs. 65.7+/-15.7 HU, P = 0.023), and sarcoma (56.2+/-7.4 HU vs. 90.2+/-3.4 HU, P = 0.001) had an increased enhancement in the delayed venous phase.

CONCLUSION

The contrast enhancement behavior of pulmonary metastases can be evaluated with DECT and depends on the type of the primary malignant tumor.

Pulmonary nodules and CT screening: the past, present and future

Lung cancer screening has come a long way since the early studies with chest X-ray. Advancing technology and progress in the processing of images have enabled low dose CT to be tried and tested, and evidence suggests its use can result in a significant mortality benefit. There are several issues that need refining in order to successfully implement screening in the UK and elsewhere. Some countries have started patchy implementation of screening and there is increased recognition that the appropriate management of pulmonary nodules is crucial to optimise benefits of early detection, while reducing harm caused by inappropriate medical intervention. This review summarises and differentiates the many recent guidelines on pulmonary nodule management, discusses screening activity in other countries and exposes the present barriers to implementation in the UK.

Brief Tailored Smoking Cessation Counseling in a Lung Cancer Screening Population is Feasible: A Pilot Randomized Controlled Trial

INTRODUCTION

Maximizing smoking abstinence in lung cancer screening participants is important to reduce individual risk of disease and improve screening cost-effectiveness; however, the optimal strategy remains undefined. We hypothesized that a single session of tailored face-to-face counseling on the day of screening CT scan, coupled with audio and printed cessation information would be feasible to deliver in a CT screening trial.

METHODS

We randomized volunteer smokers in the Queensland Lung Cancer Screening Study to intervention (counseling session, audio quit materials, printed quit materials, Quitline contact details) or control group (printed quit materials, Quitline contact details). Participants self-reported point prevalence quit rates at 1 year.

RESULTS

Fifty-five smokers were enrolled; 28 randomized to intervention and 27 controls. Median cigarette consumption was 25/day; 54/55 smoked at least 15 cigarettes per day. Median smoking duration was 46 years. Median Fagerström dependence score was 6. In total 58% did not report any quit attempt in the prior 12 months. Mean duration of counseling was 26.5 minutes. After 1 year, four participants (14.3%) in the intervention group and five participants (18.5%) in the control group had quit (P = .74). Combined annual point prevalence quit rate was 16.4%.

CONCLUSIONS

Although feasible to deliver a single session of tailored counseling on the day of screening this intervention had no discernible impact on cessation over and above printed materials and Quitline access. As participants exhibited hardcore smoking characteristics, more intensive strategies, in larger cohorts, should be explored.

IMPLICATIONS

The optimal smoking cessation strategy within a lung cancer screening program is not known. This study demonstrates that a single session of counseling can be feasibly delivered on the day of screening but may not have been intensive enough for long-term, hard-core smokers.

Readiness of Lung Cancer Screening Sites to Deliver Smoking Cessation Treatment: Current Practices, Organizational Priority, and Perceived Barriers

INTRODUCTION

Lung cancer screening represents an opportunity to deliver smoking cessation advice and assistance to current smokers. However, the current tobacco treatment practices of lung cancer screening sites are unknown. The purpose of this study was to describe organizational priority, current practice patterns, and barriers for delivery of evidence-based tobacco use treatment across lung cancer screening sites within the United States.

METHODS

Guided by prior work examining readiness of health care providers to deliver tobacco use treatment, we administered a brief online survey to a purposive national sample of site coordinators from 93 lung cancer screening sites.

RESULTS

Organizational priority for promoting smoking cessation among lung cancer screening enrollees was high. Most sites reported that, at the initial visit, patients are routinely asked about their current smoking status (98.9%) and current smokers are advised to quit (91.4%). Fewer (57%) sites provide cessation counseling or refer smokers to a quitline (60.2%) and even fewer (36.6%) routinely recommend cessation medications. During follow-up screening visits, respondents reported less attention to smoking cessation advice and treatment. Lack of patient motivation and resistance to cessation advice and treatment, lack of staff training, and lack of reimbursement were the most frequently cited barriers for delivering smoking cessation treatment.

CONCLUSIONS

Although encouraging that lung cancer screening sites endorsed the importance of smoking cessation interventions, greater attention to identifying and addressing barriers for tobacco treatment delivery is needed in order to maximize the potential benefit of integrating smoking cessation into lung cancer screening protocols.

IMPLICATIONS

This study is the first to describe practice patterns, organizational priority, and barriers for delivery of smoking cessation treatment in a national sample of lung cancer screening sites.

The Solitary Pulmonary Nodule

Due to the high etiological diversity and the potential for malignancy, pulmonary nodules represent a clinical challenge, becoming increasingly frequent as the number of CT examinations rises. The topic gains even more importance as clear evidence for the effectiveness of CT screening was provided by the National Lung Screening Trial (NLST). Yet, the results were tempered by the high false-positive rate and the requirement of performing further diagnostic procedures. The management of those detected solitary pulmonary nodules is currently based on the individuals' risk of developing lung cancer, the pulmonary nodule characteristics and the capability of diagnostic and therapeutic approaches.

The Relations Between False Positive and Negative Screens and Smoking Cessation and Relapse in the National Lung Screening Trial: Implications for Public Health

INTRODUCTION

Lung screening is an opportunity for smoking cessation and relapse prevention, but smoking behaviors may differ across screening results. Changes in smoking were evaluated among 18 840 current and former smokers aged 55-74 scheduled to receive three annual lung screenings.

METHODS

Participants were randomized to low-dose computed tomography or single-view chest radiography in the American College of Radiology/National Lung Screening Trial. Outcome measures included point and sustained (6-month) abstinence and motivation to quit among smokers; and relapse among smokers who quit during follow-up, recent quitters (quit < 6 months), and long-term former smokers (quit ≥ 6 months).

RESULTS

During five years of follow-up, annual point prevalence quit rates ranged from 11.6%-13.4%; 48% of current smokers reported a quit attempt and 7% of long-term former smokers relapsed. Any false positive screening result was associated with subsequent increased point (multivariable hazard ratio HR = 1.23, 95% CI = 1.13, 1.35) and sustained (HR = 1.28, 95% CI = 1.15, 1.43) abstinence among smokers. Recent quitters with ≥1 false positive screen were less likely to relapse (HR = 0.72, 95% CI = 0.54, 0.96). Screening result was not associated with relapse among long-term former smokers or among baseline smokers who quit during follow-up.

CONCLUSIONS

A false positive screen was associated with increased smoking cessation and less relapse among recent quitters. Consistently negative screens were not associated with greater relapse among long-term former smokers. Given the Affordable Care Act requires most health plans to cover smoking cessation and lung screening, the impact and cost-effectiveness of lung screening could be further enhanced with the addition of smoking cessation interventions.

A Combined Smoking Cessation Intervention within a Lung Cancer Screening Trial: A Pilot Observational Study

Aims and Background

The time of lung cancer screening may provide the ideal setting to discuss and initiate a smoking cessation plan that includes pharmacologic aids. No studies to date have fully investigated the potential effectiveness of such combined approach.

Methods

We prospectively evaluated the biochemically verified 1-year continuous abstinence rate from smoking of 187 persistent smokers enrolled within the Multicentric Italian Lung Detection Trial (MILD), who received a pharmacologic aid to quit smoking with varenicline along with behavioral counseling. The propensity of study subjects to succeed in smoking cessation was also monitored.

Results

At 12 months, the continuous abstinence rate from smoking was achieved in 37 out of 187 patients (19.8%), with a propensity to succeed in smoking cessation for the assisted attempt equal to 1.43, as compared to an unassisted MILD patient. At the end of the third month of therapy, 48.7% of subjects showed a continuous abstinence rate, while only 33.7% of patients were abstinent from smoking at 6 months. At baseline, the subgroup of MILD participants who were originally allocated to lung tomography showed higher smoking intensity than those allocated to no screening.

Conclusions

A combined smoking cessation intervention can be implemented with satisfactory results within a lung cancer screening program; this preliminary observation needs to be replicated in a prospective investigation. Clinicians should consider that lung cancer screening may be falsely reassuring for persistent smokers; therefore it should always be coupled with a smoking cessation program.

Incorporating a Smoking Cessation Intervention into Lung Cancer Screening Programs: Preliminary Studies

Two preliminary studies assessed whether telephone counseling (TC) is a feasible smoking cessation intervention following lung cancer screening. Seven older smokers undergoing lung cancer screening (pack years = 61.5) completed three TC sessions, which incorporated the screening result as motivation to quit. Participation (87.5%) and retention (85.7%) rates were good, and four smokers quit smoking (three of whom received abnormal results). We conducted four focus groups with 16 current and former older smokers (pack years = 55). Most believed that an abnormal scan would motivate them to quit and expressed interest in TC. TC may be feasible and potentially efficacious within lung screening programs.

Lung Cancer Screening With Low-Dose CT: Its Effect on Smoking Behavior

Lung cancer screening provides an opportunity for smoking cessation interventions. A review of the literature found that smokers who participated in lung cancer screening had a higher smoking cessation rate compared with smokers in the general population. However, the randomized controlled trials included in the review did not identify any difference in smoking cessation rates between the individuals who had a CT scan to screen for lung cancer and unscreened control groups. Multiple studies observed participants for lengths of time ranging from 1 to 36 months and concluded that individuals who received abnormal CT results had a higher smoking cessation rate compared with participants with normal CT results. A single study that observed participants for 6 years initially found similar increased cessation rates among those with abnormal CT results, but at the conclusion of the study the difference in cessation rates had dissipated. Lung cancer screening produces a teachable moment when individuals may be more receptive to smoking cessation interventions. Advanced practitioners should take an active role in promoting smoking cessation interventions and fostering this teachable moment created by lung cancer screening.

Screening for lung cancer with low-dose computed tomography: a review of current status

Screening using low-dose computed tomography (CT) represents an exciting new development in the struggle to improve outcomes for people with lung cancer. Randomised controlled evidence demonstrating a 20% relative lung cancer mortality benefit has led to endorsement of screening by several expert bodies in the US and funding by healthcare providers. Despite this pivotal result, many questions remain regarding technical and logistical aspects of screening, cost-effectiveness and generalizability to other settings. This review discusses the rationale behind screening, the results of on-going trials, potential harms of screening and current knowledge gaps.

Impact of lung cancer screening results on smoking cessation

BACKGROUND

Lung cancer screening programs may provide opportunities to reduce smoking rates among participants. This study evaluates the impact of lung cancer screening results on smoking cessation.

METHODS

Data from Lung Screening Study participants in the National Lung Screening Trial (NLST; 2002-2009) were used to prepare multivariable longitudinal regression models predicting annual smoking cessation in those who were current smokers at study entry (n = 15489, excluding those developing lung cancer in follow-up). The associations of lung cancer screening results on smoking cessation over the trial period were analyzed. All hypothesis testing used two sided P values.

RESULTS

In adjusted analyses, smoking cessation was strongly associated with the amount of abnormality observed in the previous year's screening (P < .0001). Compared with those with a normal screen, individuals were less likely to be smokers if their previous year's screen had a major abnormality that was not suspicious for lung cancer (odds ratio [OR] = 0.811; 95% confidence interval [CI] = 0.722 to 0.912; P < .001), was suspicious for lung cancer but stable from previous screens (OR = 0.785; 95% CI = 0.706 to 0.872; P < .001), or was suspicious for lung cancer and was new or changed from the previous screen (OR = 0.663; 95% CI = 0.607 to 0.724; P < .001). Differences in smoking prevalence were present up to 5 years after the last screen.

CONCLUSIONS

Smoking cessation is statistically significantly associated with screen-detected abnormality. Integration of effective smoking cessation programs within screening programs should lead to further reduction in smoking-related morbidity and mortality.

Quality of life and healthcare use in a randomized controlled lung cancer screening study

RATIONALE

Understanding the quality of life of lung cancer screening program participants, and the impact of program participation on quality of life and healthcare use, will help in the assessment of the value of screening.

OBJECTIVES

Determine the quality of life of participants in a lung cancer screening study and assess the effect of an abnormal screening finding on quality of life and healthcare use.

METHODS

Quality-of-life measures and data on the use of healthcare services were collected prospectively during a randomized controlled lung cancer screening trial using chest radiography with computer-aided detection. Comparisons of baseline measures were made with U.S. population norms for the EuroQol 5-Dimension index. The impact of receiving a message of the presence of a lung nodule was assessed for all measures.

MEASUREMENTS AND MAIN RESULTS

A total of 1,424 subjects participated. Twenty-five actionable nodules were reported. Baseline EuroQol 5-Dimension index scores were higher than U.S. population norms (P < 0.0001). The EuroQol 5-Dimension index score and St. George's Respiratory Questionnaire symptom score showed a significant change toward poorer quality of life after notification of the presence of a lung nodule (0.940 vs. 0.877, P = 0.022, and 25.7 vs. 34.0, P = 0.005, respectively). Chest imaging within 6 months of the screening examination occurred more frequently in those notified of a lung nodule (25.5 vs. 9.3%, P = 0.002).

CONCLUSIONS

Those who choose to enter a lung cancer screening program have a high baseline quality of life. The report of an abnormal screening finding can lower the quality of life and lead to increased chest imaging. Clinical trial registered with www.clinicaltrials.gov (NCT01663155).

Importance of Smoking Cessation in a Lung Cancer Screening Program

Early detection of lung cancer and smoking cessation interventions can decrease lung cancer mortality, but information on the effectiveness and interaction between smoking cessation and lung cancer screening is sparse and inconsistent. This review aims to synthesize recent studies in two major areas of interest. First, we explore the interactions and potential for synergies between lung cancer screening programs and smoking cessation by summarizing reported changes in smoking behavior observed in major screening trials in the United States and Europe, as well as attempts to use smoking cessation interventions to augment the benefits from lung cancer screening programs. Second, we review the interaction between smoking habits and pre/post-operative pulmonary resection outcomes, including changes in smoking behavior post-diagnosis and post-treatment. Information from these areas should allow us to maximize benefits from smoking cessation interventions through the entire lung cancer screening process, from the screen itself through potential curative resection after diagnosis.

[Advance of lung cancer screening with low-dose spiral CT]

Lung cancer has become the leading cause of cancer mortality globally, and 5-year survival rate is very poor. Screening and early detection are vital to improve survival and decrease mortality of lung cancer. In recent 20 years, low-dose spiral CT (LDCT) screening has become a research focus in this area. Randomized controlled trials have confirmed that LDCT can decrease lung cancer mortality. However, there are still some problems of LDCT. In this paper, we summarized the controversy that whether low-dose helical CT screening can reduce lung cancer mortality or not before its effectiveness was been confirmed, the results and problems in the randomized controlled trials and gave a prospect of low-dose helical CT screening's future application.

A cost-utility analysis of lung cancer screening and the additional benefits of incorporating smoking cessation interventions

BACKGROUND

A 2011 report from the National Lung Screening Trial indicates that three annual low-dose computed tomography (LDCT) screenings for lung cancer reduced lung cancer mortality by 20% compared to chest X-ray among older individuals at high risk for lung cancer. Discussion has shifted from clinical proof to financial feasibility. The goal of this study was to determine whether LDCT screening for lung cancer in a commercially-insured population (aged 50-64) at high risk for lung cancer is cost-effective and to quantify the additional benefits of incorporating smoking cessation interventions in a lung cancer screening program.

METHODS AND FINDINGS

The current study builds upon a previous simulation model to estimate the cost-utility of annual, repeated LDCT screenings over 15 years in a high risk hypothetical cohort of 18 million adults between age 50 and 64 with 30+ pack-years of smoking history. In the base case, the lung cancer screening intervention cost $27.8 billion over 15 years and yielded 985,284 quality-adjusted life years (QALYs) gained for a cost-utility ratio of $28,240 per QALY gained. Adding smoking cessation to these annual screenings resulted in increases in both the costs and QALYs saved, reflected in cost-utility ratios ranging from $16,198 per QALY gained to $23,185 per QALY gained. Annual LDCT lung cancer screening in this high risk population remained cost-effective across all sensitivity analyses.

CONCLUSIONS

The findings of this study indicate that repeat annual lung cancer screening in a high risk cohort of adults aged 50-64 is highly cost-effective. Offering smoking cessation interventions with the annual screening program improved the cost-effectiveness of lung cancer screening between 20% and 45%. The cost-utility ratios estimated in this study were in line with other accepted cancer screening interventions and support inclusion of annual LDCT screening for lung cancer in a high risk population in clinical recommendations.

Treatment of tobacco use in lung cancer: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines

BACKGROUND

Continued tobacco use in the setting of lung cancer management is frequently confounding and always of critical importance. We summarized the published literature concerning the management of tobacco dependence in patients with lung cancer and offer recommendations for integrating dependence treatment into ongoing oncologic care.

METHODOLOGY

MEDLINE, Embase, CINAHL, PsychINFO, and the Cochrane Collaborative databases were searched for English language randomized clinical trials, cohort studies, case-control studies, secular trend analyses, and case series relevant to the a priori identified clinical questions. Evidence grading, integration, and genesis of recommendations followed the methods described in "Methodology for Development of Guidelines for Lung Cancer" in the American College of Chest Physicians Lung Cancer Guidelines, 3rd ed.

RESULTS

We describe the approach to tobacco dependence in patients with lung cancer at various phases in the evolution of cancer care. For example, among patients undergoing lung cancer screening procedures, we recommend against relying on the screening itself, including procedures accompanied solely by self-help materials, as an effective strategy for achieving abstinence. Among patients with lung cancer undergoing surgery, intensive perioperative cessation pharmacotherapy is recommended as a method for improving abstinence rates. Cessation pharmacotherapy is also recommended for patients undergoing chemotherapy, with specific recommendations to use bupropion when treating patients with lung cancer with depressive symptoms, as a means of improving abstinence rates, depressive symptoms, and quality of life.

CONCLUSIONS

Optimal treatment of lung cancer includes attention to continued tobacco use, with abstinence contributing to improved patient-related outcomes at various phases of lung cancer management. Effective therapeutic interventions are available and are feasibly integrated into oncologic care. A number of important clinical questions remain poorly addressed by the existing evidence.

Is a cancer diagnosis a teachable moment for the patient's relative who smokes?

PURPOSE

This study examined a cancer diagnosis, versus orthopedic surgery, as a teachable moment for recruiting smokers and treating nicotine dependence among patients' relatives.

METHODS

Cancer patients and, for comparison, orthopedic patients at the University of Pennsylvania Health System were approached for referrals of relatives for a smoking cessation program, which involved behavioral counseling and nicotine patches. Primary outcomes were rate of program enrollment and rate of smoking abstinence. Potential mediators of smoking cessation were explored (e.g., treatment adherence, depression, anxiety). Two hundred and thirty-four relatives (113 cancer, 121 orthopedic) were considered eligible for the cessation program and comprised the study sample.

RESULTS

Relatives of oncology patients were significantly more likely to enroll in the smoking cessation program, vs. orthopedic relatives (75 % vs. 60%; OR = 1.96, 95% CI 1.07-3.61, p = .03), but they were not significantly more likely to remain in the program (61% vs. 52%) or quit smoking (19% vs. 26%; p's > .05). Compared to orthopedic relatives, oncology relatives showed significantly lower nicotine patch adherence and significantly greater levels of negative affect and depression and anxiety symptoms during treatment (p's < .05). Further, orthopedic relatives, compared to oncology relatives, showed a greater reduction in the perceived benefits of smoking (p = .06), which was significantly associated with abstinence (p = .02).

CONCLUSIONS

While a family member's cancer diagnosis may serve as a teachable moment for a smoker to enroll in a smoking cessation treatment program, high levels of psychological distress and perceptions of the benefits of smoking and low levels of treatment adherence may undermine successful abstinence among this population.

Examining whether lung screening changes risk perceptions: National Lung Screening Trial participants at 1-year follow-up

BACKGROUND

The National Lung Screening Trial (NLST) research team reported reduced lung cancer mortality among current and former smokers with a minimum 30 pack-year history who were screened with spiral computed tomography scans compared with chest x-rays. The objectives of the current study were to examine, at 1-year follow-up: 1) risk perceptions of lung cancer and smoking-related diseases and behavior change determinants, 2) whether changes in risk perceptions differed by baseline screening result; and 3) whether changes in risk perceptions affected smoking behavior.

METHODS

A 25-item risk perception questionnaire was administered to a subset of participants at 8 American College of Radiology Imaging Network/NLST sites before initial and 1-year follow-up screens. Items assessed risk perceptions of lung cancer and smoking-related diseases, cognitive and emotional determinants of behavior change, and knowledge of smoking risks.

RESULTS

Among 430 NLST participants (mean age, 61.0 years; 55.6% men; 91.9% white), half were current smokers at baseline. Overall, risk perceptions and associated cognitive and emotional determinants of behavior change did not change significantly from prescreen trial enrollment to 1-year follow-up and did not differ significantly by screening test result. Changes in risk perceptions were not associated with changes in smoking status (9.7% of participants quit, and 6.6% relapsed) at 1-year follow-up.

CONCLUSIONS

Lung screening did not change participants' risk perceptions of lung cancer or smoking-related disease. A negative screening test, which was the most common screening result, did not appear to decrease risk perceptions nor provide false reassurance to smokers.

American Cancer Society lung cancer screening guidelines

Findings from the National Cancer Institute's National Lung Screening Trial established that lung cancer mortality in specific high-risk groups can be reduced by annual screening with low-dose computed tomography. These findings indicate that the adoption of lung cancer screening could save many lives. Based on the results of the National Lung Screening Trial, the American Cancer Society is issuing an initial guideline for lung cancer screening. This guideline recommends that clinicians with access to high-volume, high-quality lung cancer screening and treatment centers should initiate a discussion about screening with apparently healthy patients aged 55 years to 74 years who have at least a 30-pack-year smoking history and who currently smoke or have quit within the past 15 years. A process of informed and shared decision-making with a clinician related to the potential benefits, limitations, and harms associated with screening for lung cancer with low-dose computed tomography should occur before any decision is made to initiate lung cancer screening. Smoking cessation counseling remains a high priority for clinical attention in discussions with current smokers, who should be informed of their continuing risk of lung cancer. Screening should not be viewed as an alternative to smoking cessation.

Biomedical risk assessment as an aid for smoking cessation

BACKGROUND

A possible strategy for increasing smoking cessation rates could be to provide smokers who have contact with healthcare systems with feedback on the biomedical or potential future effects of smoking, e.g. measurement of exhaled carbon monoxide (CO), lung function, or genetic susceptibility to lung cancer.

OBJECTIVES

To determine the efficacy of biomedical risk assessment provided in addition to various levels of counselling, as a contributing aid to smoking cessation.

SEARCH METHODS

For the most recent update, we searched the Cochrane Collaboration Tobacco Addiction Group Specialized Register in July 2012 for studies added since the last update in 2009.

SELECTION CRITERIA

Inclusion criteria were: a randomized controlled trial design; subjects participating in smoking cessation interventions; interventions based on a biomedical test to increase motivation to quit; control groups receiving all other components of intervention; an outcome of smoking cessation rate at least six months after the start of the intervention.

DATA COLLECTION AND ANALYSIS

Two assessors independently conducted data extraction on each paper, with disagreements resolved by consensus. Results were expressed as a relative risk (RR) for smoking cessation with 95% confidence intervals (CI). Where appropriate, a pooled effect was estimated using a Mantel-Haenszel fixed-effect method.

MAIN RESULTS

We included 15 trials using a variety of biomedical tests. Two pairs of trials had sufficiently similar recruitment, setting and interventions to calculate a pooled effect; there was no evidence that carbon monoxide (CO) measurement in primary care (RR 1.06, 95% CI 0.85 to 1.32) or spirometry in primary care (RR 1.18, 95% CI 0.77 to 1.81) increased cessation rates. We did not pool the other 11 trials due to the presence of substantial clinical heterogeneity. Of the remaining 11 trials, two trials detected statistically significant benefits: one trial in primary care detected a significant benefit of lung age feedback after spirometry (RR 2.12, 95% CI 1.24 to 3.62) and one trial that used ultrasonography of carotid and femoral arteries and photographs of plaques detected a benefit (RR 2.77, 95% CI 1.04 to 7.41) but enrolled a population of light smokers and was judged to be at unclear risk of bias in two domains. Nine further trials did not detect significant effects. One of these tested CO feedback alone and CO combined with genetic susceptibility as two different interventions; none of the three possible comparisons detected significant effects. One trial used CO measurement, one used ultrasonography of carotid arteries and two tested for genetic markers. The four remaining trials used a combination of CO and spirometry feedback in different settings.

AUTHORS' CONCLUSIONS

There is little evidence about the effects of most types of biomedical tests for risk assessment on smoking cessation. Of the fifteen included studies, only two detected a significant effect of the intervention. Spirometry combined with an interpretation of the results in terms of 'lung age' had a significant effect in a single good quality trial but the evidence is not optimal. A trial of carotid plaque screening using ultrasound also detected a significant effect, but a second larger study of a similar feedback mechanism did not detect evidence of an effect. Only two pairs of studies were similar enough in terms of recruitment, setting, and intervention to allow meta-analyses; neither of these found evidence of an effect. Mixed quality evidence does not support the hypothesis that other types of biomedical risk assessment increase smoking cessation in comparison to standard treatment. There is insufficient evidence with which to evaluate the hypothesis that multiple types of assessment are more effective than single forms of assessment.

Predictors of adverse smoking outcomes in the Prostate, Lung, Colorectal and Ovarian Cancer Screening Trial

BACKGROUND

The impact of lung cancer screening on smoking behavior is unclear. The aims of this ancillary study of the Prostate Lung Colorectal and Ovarian Cancer Screening Trial were to produce risk prediction models to identify individuals at risk of relapse or continued smoking and to evaluate whether cancer-screening variables affect long-term smoking outcomes.

METHODS

Participants completed a baseline questionnaire at trial enrollment and a supplemental questionnaire 4-14 years after enrollment, which assessed several cancer-related variables, including family history of cancer, comorbidities, and tobacco use. Multivariable logistic regression models were used to predict smoking status at completion of the supplemental questionnaire. The models' predictive performances were evaluated by assessing discrimination via the receiver operator characteristic area under the curve (ROC AUC) and calibration. Models were internally validated using bootstrap methods.

RESULTS

Of the 31&emsp14;694 former smokers on the baseline questionnaire, 1042 (3.3%) had relapsed (ie, reported being a current smoker on the supplemental questionnaire). Of the 6807 current smokers on the baseline questionnaire, 4439 (65.2%) reported continued smoking on the supplemental questionnaire. Relapse was associated with multiple demographic, medical, and tobacco-related characteristics. This model had a bootstrap median ROC AUC of 0.862 (95% confidence interval [CI] = 0.858 to 0.866) and a calibration slope of 1.004 (95% CI = 0.978 to 1.029), indicating excellent discrimination and calibration. Predictors of continued smoking also included multiple demographic, medical, and tobacco-related characteristics. This model had an ROC AUC of 0.611 (95% CI = 0.605 to 0.614) and a slope of 1.006 (95% CI = 0.962 to 1.041), indicating modest discrimination. Neither the trial arm nor the lung-screening result was statistically significantly associated with smoking outcomes.

CONCLUSION

These models, if validated externally, may have public health utility in identifying individuals at risk for adverse smoking outcomes, who may benefit from relapse prevention and smoking cessation interventions.

Genetic and biochemical alterations in non-small cell lung cancer

Despite significant advances in the detection and treatment of lung cancer, it causes the highest number of cancer-related mortality. Recent advances in the detection of genetic alterations in patient samples along with physiologically relevant animal models has yielded a new understanding of the molecular etiology of lung cancer. This has facilitated the development of potent and specific targeted therapies, based on the genetic and biochemical alterations present in the tumor, especially non-small-cell lung cancer (NSCLC). It is now clear that heterogeneous cell signaling pathways are disrupted to promote NSCLC, including mutations in critical growth regulatory proteins (K-Ras, EGFR, B-RAF, MEK-1, HER2, MET, EML-4-ALK, KIF5B-RET, and NKX2.1) and inactivation of growth inhibitory pathways (TP53, PTEN, p16, and LKB-1). How these pathways differ between smokers and non-smokers is also important for clinical treatment strategies and development of targeted therapies. This paper describes these molecular targets in NSCLC, and describes the biological significance of each mutation and their potential to act as a therapeutic target.