Attitudes towards the integration of smoking cessation into lung cancer screening in the United Kingdom: A qualitative study of individuals eligible to attend

"Because That is the Right Thing to do": A Focus Group Study of Australian Expert Perspectives on Offering Smoking Cessation Support in Lung Cancer Screening

INTRODUCTION

Lung cancer screening (LCS) trials, targeting people with a smoking history, have demonstrated reduced mortality. How to optimally embed evidence-based smoking cessation support in LCS, including in Australia, needs to be better understood. We sought experts' perspectives to identify potential barriers and effective implementation strategies.

AIMS AND METHODS

Perceptions of providing smoking cessation support in LCS were elicited in 24 focus groups and three individual interviews with clinicians, cancer screening program managers/policymakers, and researchers during 2021. We conducted framework analysis and mapped key topics to the updated Consolidated Framework for Implementation Research (CFIR).

RESULTS

Experts (N = 84 participants) strongly supported capitalizing on an "opportune time" for smoking cessation and new LCS participant contact opportunities throughout the screening and assessment pathway. Many advocated for adapting existing cessation resources to the LCS setting and providing support without participant costs. Experts generally considered referral alone to established programs (eg, telephone Quitline) as insufficient, but likely helpful in follow-up, and dedicated cessation specialist roles as essential. Broader cessation messaging (via mass media/community channels) was also suggested to reinforce individualized support. Experts described inherent alignment, and an ethical responsibility, to deliver smoking cessation as a core LCS component. It was suggested that LCS-eligible participants' varied experiences of stigma, health literacy, and motivation, be considered in cessation support. Primary care support and individualized interventions were suggested to facilitate implementation.

CONCLUSIONS

Experts considered smoking cessation support essential in LCS. The expert-identified and multi-level implementation strategies described here can directly inform smoking cessation-specific planning for Australia's forthcoming National LCS Program.

IMPLICATIONS

The international literature includes few examples considering how best to provide smoking cessation support within a LCS program in advance of program commencement. Our analysis, using the updated CFIR, is one of the first to explore experts' perspectives within this context. Experts identified multiple implementation barriers to providing smoking cessation support within and outside of an Australian LCS program, including key work infrastructure barriers, and advocated for providing tailored interventions within this program. Our foundational work in a new targeted screening program's preimplementation phase will allow international comparisons to be made.

Patient Perspectives on a Patient-Facing Tool for Lung Cancer Screening

BACKGROUND

Individuals with high risk for lung cancer may benefit from lung cancer screening, but there are associated risks as well as benefits. Shared decision-making (SDM) tools with personalized information may provide key support for patients. Understanding patient perspectives on educational tools to facilitate SDM for lung cancer screening may support tool development.

AIM

This study aimed to explore patient perspectives related to a SDM tool for lung cancer screening using a qualitative approach.

METHODS

We elicited patient perspectives by showing a provider-facing SDM tool. Focus group interviews that ranged in duration from 1.5 to 2 h were conducted with 23 individuals with high risk for lung cancer. Data were interpreted inductively using thematic analysis to identify patients' thoughts on and desires for a patient-facing SDM tool.

RESULTS

The findings highlight that patients would like to have educational information related to lung cancer screening. We identified several key themes to be considered in the future development of patient-facing tools: barriers to acceptance, preference against screening and seeking empowerment. One further theme illustrated effects of patient-provider relationship as a limitation to meeting lung cancer screening information needs. Participants also noted several suggestions for the design of technology decision aids.

CONCLUSION

These findings suggest that patients desire additional information on lung cancer screening in advance of clinical visits. However, there are several issues that must be considered in the design and development of technology to meet the information needs of patients for lung cancer screening decisions.

PATIENT OR PUBLIC CONTRIBUTION

Patients, service users, caregivers or members of the public were not involved in the study design, conduct, analysis or interpretation of the data. However, clinical experts in health communication provided detailed feedback on the study protocol, including the focus group approach. The study findings contribute to a better understanding of patient expectations for lung cancer screening decisions and may inform future development of tools for SDM.

Early Diagnosis and Lung Cancer Screening

Lung cancer remains the most significant cause of cancer death, accounting for about 20% of all cancer-related mortality. A significant reason for this is delayed diagnosis, either due to lack of symptoms in early-stage disease or presentation with non-specific symptoms common with a broad range of alternative diagnoses. More is needed in terms of increasing public awareness, providing adequate healthcare professional education and implementing clinical pathways that improve the earlier diagnosis of symptomatic lung cancer. Low-dose computed tomography screening of high-risk, asymptomatic populations has been shown to reduce lung cancer mortality, with focus now shifting towards how best to implement lung cancer screening on a wider scale in a safe, efficient and cost-effective manner. For maximum benefit, efforts must be made to optimise uptake, especially among high-risk populations with significant socioeconomic deprivation, as well as successfully incorporate tobacco-dependency treatment. Quality assured programme management will be critical to minimising screening-related harms and adequately managing incidental findings. By undertaking the above, there can be optimism that lung cancer outcomes can be improved significantly in the near future.