Smoking behavior 1 year after computed tomography screening for lung cancer: Effect of physician referral for abnormal CT findings

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.

Chronic Obstructive Pulmonary Disease and Lung Cancer: A Review for Clinicians

Chronic obstructive pulmonary disease (COPD) and lung cancer are common global causes of morbidity and mortality. Because both diseases share several predisposing risks, the 2 diseases may occur concurrently in susceptible individuals. The diagnosis of COPD has important implications for the diagnostic approach and treatment options if lesions concerning for lung cancer are identified during screening. Importantly, the presence of COPD has significant implications on prognosis and management of patients with lung cancer. In this monograph, we review the mechanistic linkage between lung cancer and COPD, the impact of lung cancer screening on patients at risk, and the implications of the presence of COPD on the approach to the diagnosis and treatment of lung cancer. This manuscript succinctly reviews the epidemiology and common pathogenetic factors for the concurrence of COPD and lung cancer. Importantly for the clinician, it summarizes the indications, benefits, and complications of lung cancer screening in patients with COPD, and the assessment of risk factors for patients with COPD undergoing consideration of various treatment options for lung cancer.

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.

Receipt of Tobacco Treatment and One-Year Smoking Cessation Rates Following Lung Cancer Screening in the Veterans Health Administration

BACKGROUND

Implementation of effective smoking cessation interventions in lung cancer screening has been identified as a high-priority research gap, but knowledge of current practices to guide process improvement is limited due to the slow uptake of screening and dearth of data to assess cessation-related practices and outcomes under real-world conditions.

OBJECTIVE

To evaluate cessation treatment receipt and 1-year post-screening cessation outcomes within the largest integrated healthcare system in the USA-the Veterans Health Administration (VHA). Design Observational study using administrative data from electronic medical records (EMR). Patients Currently smoking Veterans who received a first lung cancer screening test using low-dose CT (LDCT) between January 2014 and June 2018. Main Outcomes Tobacco treatment received within the window of 30 days before and 30 days after LDCT; 1-year quit rates based on EMR Smoking Health Factors data 6-18 months after LDCT. Key Results Of the 47,609 current smokers screened (95.3% male), 8702 (18.3%) received pharmacotherapy and/or behavioral treatment for smoking cessation; 531 (1.1%) received both. Of those receiving pharmacotherapy, only one in four received one of the most effective medications: varenicline (12.1%) or combination nicotine replacement therapy (14.3%). Overall, 5400 Veterans quit smoking-a rate of 11.3% (missing=smoking) or 13.5% (complete case analysis). Treatment receipt and cessation were associated with numerous sociodemographic, clinical, and screening-related factors.

CONCLUSIONS

One-year quit rates for Veterans receiving lung cancer screening in VHA are similar to those reported in LDCT clinical trials and cohort studies (i.e., 10-17%). Only 1% of Veterans received the recommended combination of pharmacotherapy and counseling, and the most effective pharmacotherapies were not the most commonly received ones. The value of screening within VHA could be improved by addressing these treatment gaps, as well as the observed disparities in treatment receipt or cessation by race, rurality, and psychiatric conditions.

Improved motivation and readiness to quit shortly after lung cancer screening: Evidence for a teachable moment

BACKGROUND

For patients at high risk for lung cancer, screening using low-dose computed tomography (lung cancer screening [LCS]) is recommended. The purpose of this study was to examine whether screening may serve as a teachable moment for smoking-related outcomes.

METHODS

In a smoking-cessation trial, participants (N = 843) completed 2 phone interviews before randomization: before LCS (T0) and after LCS (T1). By using logistic and linear regression, the authors examined teachable moment variables (perceived risk, lung cancer worry) and outcomes (readiness, motivation, and cigarettes per day [CPD]).

RESULTS

Participants were a mean ± SD age of 63.7 ± 5.9 years, had 47.8 ± 7.1 pack-years of smoking, 35.2% had a high school diploma or General Educational Development (high school equivalency) degree or less, and 42.3% were undergoing their first scan. Between T0 and T1, 25.7% of participants increased readiness to quit, 9.6% decreased readiness, and 64.7% reported no change (P < .001). Motivation to quit increased (P < .05) and CPD decreased between assessments (P < .001), but only 1.3% self-reported quitting. Compared with individuals who reported no lung cancer worry/little worry, extreme worry was associated with readiness to quit in the next 30 days (odds ratio, 1.8; 95% CI, 1.1-3.0) and with higher motivation (b = 0.83; P < .001) at T1. Individuals undergoing a baseline (vs annual) scan were more ready to quit in the next 30 days (odds ratio, 1.8; 95% CI, 1.3-2.5).

CONCLUSIONS

During the brief window between registering for LCS and receiving the results, the authors observed that very few participants quit smoking, but a significant proportion improved on readiness and motivation to quit, particularly among individuals who were undergoing their first scan and those who were extremely worried about lung cancer. These results indicate that providing evidence-based tobacco treatment can build upon this teachable moment.

Protocol to evaluate an enterprise-wide initiative to increase access to lung cancer screening in the Veterans Health Administration

INTRODUCTION

The Veterans Affairs Partnership to increase Access to Lung Screening (VA-PALS) is an enterprise-wide initiative to implement lung cancer screening programs at VA medical centers (VAMCs). VA-PALS will be using implementation strategies that include program navigators to coordinate screening activities, trainings for navigators and radiologists, an open-source software management system, tools to standardize low-dose computed tomography image quality, and access to a support network. VAMCs can utilize strategies according to their local needs. In this protocol, we describe the planned program evaluation for the initial 10 VAMCs participating in VA-PALS.

MATERIALS AND METHODS

The implementation of programs will be evaluated using the Consolidated Framework for Implementation Research to ensure broad contextual guidance. Program evaluation measures have been developed using the Reach, Effectiveness, Adoption, Implementation and Maintenance framework. Adaptations of screening processes will be assessed using the Framework for Reporting Adaptations and Modifications to Evidence Based Interventions. Measures collected will reflect the inner settings, estimate and describe the population reached, adoption by providers, implementation of the programs, report clinical outcomes and maintenance of programs. Analyses will include descriptive statistics and regression to evaluate predictors and assess implementation over time.

DISCUSSION

This theory-based protocol will evaluate the implementation of lung cancer screening programs across the Veterans Health Administration using scientific frameworks. The findings will inform plans to expand the VA-PALS initiative beyond the original sites and can guide implementation of lung cancer screening programs more broadly.

Screening for Lung Cancer With Low-Dose Computed Tomography: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force

IMPORTANCE

Lung cancer is the leading cause of cancer-related death in the US.

OBJECTIVE

To review the evidence on screening for lung cancer with low-dose computed tomography (LDCT) to inform the US Preventive Services Task Force (USPSTF).

DATA SOURCES

MEDLINE, Cochrane Library, and trial registries through May 2019; references; experts; and literature surveillance through November 20, 2020.

STUDY SELECTION

English-language studies of screening with LDCT, accuracy of LDCT, risk prediction models, or treatment for early-stage lung cancer.

DATA EXTRACTION AND SYNTHESIS

Dual review of abstracts, full-text articles, and study quality; qualitative synthesis of findings. Data were not pooled because of heterogeneity of populations and screening protocols.

MAIN OUTCOMES AND MEASURES

Lung cancer incidence, lung cancer mortality, all-cause mortality, test accuracy, and harms.

RESULTS

This review included 223 publications. Seven randomized clinical trials (RCTs) (N = 86 486) evaluated lung cancer screening with LDCT; the National Lung Screening Trial (NLST, N = 53 454) and Nederlands-Leuvens Longkanker Screenings Onderzoek (NELSON, N = 15 792) were the largest RCTs. Participants were more likely to benefit than the US screening-eligible population (eg, based on life expectancy). The NLST found a reduction in lung cancer mortality (incidence rate ratio [IRR], 0.85 [95% CI, 0.75-0.96]; number needed to screen [NNS] to prevent 1 lung cancer death, 323 over 6.5 years of follow-up) with 3 rounds of annual LDCT screening compared with chest radiograph for high-risk current and former smokers aged 55 to 74 years. NELSON found a reduction in lung cancer mortality (IRR, 0.75 [95% CI, 0.61-0.90]; NNS to prevent 1 lung cancer death of 130 over 10 years of follow-up) with 4 rounds of LDCT screening with increasing intervals compared with no screening for high-risk current and former smokers aged 50 to 74 years. Harms of screening included radiation-induced cancer, false-positive results leading to unnecessary tests and invasive procedures, overdiagnosis, incidental findings, and increases in distress. For every 1000 persons screened in the NLST, false-positive results led to 17 invasive procedures (number needed to harm, 59) and fewer than 1 person having a major complication. Overdiagnosis estimates varied greatly (0%-67% chance that a lung cancer was overdiagnosed). Incidental findings were common, and estimates varied widely (4.4%-40.7% of persons screened).

CONCLUSIONS AND RELEVANCE

Screening high-risk persons with LDCT can reduce lung cancer mortality but also causes false-positive results leading to unnecessary tests and invasive procedures, overdiagnosis, incidental findings, increases in distress, and, rarely, radiation-induced cancers. Most studies reviewed did not use current nodule evaluation protocols, which might reduce false-positive results and invasive procedures for false-positive results.

Real-World Lung Cancer CT Screening Performance, Smoking Behavior, and Adherence to Recommendations: Lung-RADS Category and Smoking Status Predict Adherence

BACKGROUND. Low-dose CT (LDCT) lung cancer screening (LCS) has been shown to decrease mortality in persons with a significant smoking history. However, adherence in real-world LCS programs is significantly lower than in randomized controlled trials. OBJECTIVE. The purpose of this article is to assess real-world LDCT LCS performance and factors predictive of adherence to LCS recommendations. METHODS. We retrospectively identified all persons who underwent at least two LCS examinations from 2014 to 2019. Patient demographics, smoking history and behavior changes, Lung-RADS category, PPV, NPV, and adherence to screening recommendations were recorded. Predictors of adherence were assessed via univariate comparisons and multivariate logistic regression. RESULTS. A total of 260 persons returned for follow-up LDCT (57.7% had two, 34.2% had three, 7.7% had four, and 0.4% had five LDCT examinations). A total of 43 of 260 (16.5%) had positive (Lung-RADS category 3 or above) scans, of which 27 of 260 persons (10.3%) were graded as Lung-RADS category 3, eight of 260 (3.1%) were category 4A, six of 260 (2.3%) were category 4B, and two of 260 (0.8%) were category 4X. Cancer was diagnosed in four of the 260 (three with lung cancer and one with metastatic melanoma). A total of 143 of 260 (55.0%) persons were current smokers at baseline and 121 of 260 (46.5%) were current smokers at the last round of LCS. LCS had sensitivity of 100.0%, specificity of 84.8%, PPV of 9.3%, and NPV of 100%. Overall adherence was 43.0% but increased progressively with higher Lung-RADS category (Lung-RADS 1: 33.2%; Lung-RADS 2: 46.3%; Lung-RADS 3: 53.8%; Lung-RADS 4A: 77.8%; Lung-RADS 4B: 83.3%; Lung-RADS 4X: 100%; p < .001). was also higher in former versus current smokers (50.0% vs 36.2%; p < .001). Being a former smoker and having a nodule that is Lung-RADS category 3 or greater were the only significant independent predictors of adherence. CONCLUSION. Our real-world LCS program showed very high sensitivity and NPV, but moderate specificity and very low PPV. Adherence to LCS recommendations increased with former versus current smokers and in those with positive (Lung-RADS categories 3, 4A, 4B, or 4X) LCS examinations. Adherence was less than 50.0% in current smokers and persons with negative (Lung-RADS categories 1 or 2) LCS examinations. CLINICAL IMPACT. Our results offer a road map for targeted performance improvement by focusing on LCS subjects less likely to remain in the program, such as persons with negative LCS examinations and persons who continue to smoke, potentially improving LCS cost effectiveness and maximizing its societal benefits.

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.

Cost-Effectiveness of Smoking Cessation Interventions in the Lung Cancer Screening Setting: A Simulation Study

BACKGROUND

Guidelines recommend offering cessation interventions to smokers eligible for lung cancer screening, but there is little data comparing specific cessation approaches in this setting. We compared the benefits and costs of different smoking cessation interventions to help screening programs select specific cessation approaches.

METHODS

We conducted a societal-perspective cost-effectiveness analysis using a Cancer Intervention and Surveillance Modeling Network model simulating individuals born in 1960 over their lifetimes. Model inputs were derived from Medicare, national cancer registries, published studies, and micro-costing of cessation interventions. We modeled annual lung cancer screening following 2014 US Preventive Services Task Force guidelines plus cessation interventions offered to current smokers at first screen, including pharmacotherapy only or pharmacotherapy with electronic and/or web-based, telephone, individual, or group counseling. Outcomes included lung cancer cases and deaths, life-years saved, quality-adjusted life-years (QALYs) saved, costs, and incremental cost-effectiveness ratios.

RESULTS

Compared with screening alone, all cessation interventions decreased cases of and deaths from lung cancer. Compared incrementally, efficient cessation strategies included pharmacotherapy with either web-based cessation ($555 per QALY), telephone counseling ($7562 per QALY), or individual counseling ($35 531 per QALY). Cessation interventions continued to have costs per QALY well below accepted willingness to pay thresholds even with the lowest intervention effects and was more cost-effective in cohorts with higher smoking prevalence.

CONCLUSION

All smoking cessation interventions delivered with lung cancer screening are likely to provide benefits at reasonable costs. Because the differences between approaches were small, the choice of intervention should be guided by practical concerns such as staff training and availability.

[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.

Lung cancer screening: does pulmonary nodule detection affect a range of smoking behaviours?

BACKGROUND

Lung cancer screening can reduce lung cancer mortality by 20%. Screen-detected abnormalities may provide teachable moments for smoking cessation. This study assesses impact of pulmonary nodule detection on smoking behaviours within the first UK trial of a novel auto-antibody test, followed by chest x-ray and serial CT scanning for early detection of lung cancer (Early Cancer Detection Test-Lung Cancer Scotland Study).

METHODS

Test-positive participants completed questionnaires on smoking behaviours at baseline, 1, 3 and 6 months. Logistic regression compared outcomes between nodule (n = 95) and normal CT groups (n = 174) at 3 and 6 months follow-up.

RESULTS

No significant differences were found between the nodule and normal CT groups for any smoking behaviours and odds ratios comparing the nodule and normal CT groups did not vary significantly between 3 and 6 months. There was some evidence the nodule group were more likely to report significant others wanted them to stop smoking than the normal CT group (OR across 3- and 6-month time points: 3.04, 95% CI: 0.95, 9.73; P = 0.06).

CONCLUSION

Pulmonary nodule detection during lung cancer screening has little impact on smoking behaviours. Further work should explore whether lung cancer screening can impact on perceived social pressure and promote smoking cessation.

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.

Patient-Physician Discussions on Lung Cancer Screening: A Missed Teachable Moment to Promote Smoking Cessation

INTRODUCTION

Little is known about whether patients and physicians perceive lung cancer screening (LCS) as a teachable moment to promote smoking cessation or the degree to which physicians in "real world" settings link LCS discussions with smoking cessation counseling. We sought to characterize patient and physician perspectives of discussions about smoking cessation during LCS.

METHODS

We conducted a qualitative study (interviews and focus groups) with 21 physicians and 28 smokers screened in four diverse hospitals. Transcripts were analyzed for characteristics of communication about smoking cessation and LCS, the perceived effect on motivation to quit smoking, the degree to which physicians leverage LCS as a teachable moment to promote smoking cessation, and suggestions to improve patient-physician communication about smoking cessation in the context of LCS.

RESULTS

Patients reported that LCS made them more cognizant of the health consequences of smoking, priming them for a teachable moment. While physicians and patients both acknowledged that smoking cessation counseling was frequent, they described little connection between their discussions regarding LCS and smoking cessation counseling. Physicians identified several barriers to integrating discussions on smoking cessation and LCS. They volunteered communication strategies by which LCS could be leveraged to promote smoking cessation.

CONCLUSIONS

LCS highlights the harms of smoking to patients who are chronic, heavy smokers and thus may serve as a teachable moment for promoting smoking cessation. However, this opportunity is typically missed in clinical practice.

IMPLICATIONS

LCS highlights the harms of smoking to heavily addicted smokers. Yet both physicians and patients reported little connection between LCS and tobacco treatment discussions due to multiple barriers. On-site tobacco treatment programs and post-screening messaging tailored to the LCS results are needed to maximize the health outcomes of LCS, including smoking quit rates and longer-term smoking-related morbidity and mortality.

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.

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.

Determinants of motivation to quit in smokers screened for the early detection of lung cancer: a qualitative study

Background

The promotion of smoking cessation within lung cancer screening could lead to benefits for smoking-related disease and improve cost-effectiveness of screening. Little is known about how smokers respond to lung cancer screening and how this impacts smoking behaviour. We aimed to understand how lung cancer screening influences individual motivations about smoking, including in those who have stopped smoking since screening.

Methods

Thirty one long-term smokers aged 51–74 took part in semi-structured interviews about smoking. They had been screened with the EarlyCDT-Lung Test (13 positive result; 18 negative) as part of the Early Cancer Detection Test Lung Cancer Scotland Study. They were purposively sampled for interview based on their self-reported post-screening smoking behaviour. Eleven participants had stopped smoking since screening. Verbatim interview transcripts were analysed using thematic analysis.

Results

Two key overarching themes were interpretations of screening test results and emotional responses to those interpretations. Participants’ understanding of the risk implied by their test result was often inaccurate, for example a negative result interpreted as an ‘all-clear’ from lung cancer and a positive result as meaning lung cancer would definitely develop. Those interpretations led to emotional responses (fear, shock, worry, relief, indifference) influencing motivations about smoking. Other themes included a wake-up call causing changes in perceived risk of smoking-related disease, a feeling that now is the time to stop smoking and family influences. There was no clear pattern in smoking motivations in those who received positive or negative test results. Of those who had stopped smoking, some cited screening experiences as the sole motivation, some cited screening along with other coinciding factors, and others cited non-screening reasons. Cues to change were experienced at different stages of the screening process. Some participants indicated they underwent screening to try and stop smoking, while others expressed little or no desire to stop.

Conclusions

We observed complex and individualised motivations about smoking following lung cancer screening. To be most effective, smoking cessation support in this context should explore understanding of screening test results and may need to be highly tailored to individual emotional responses to screening.

Electronic supplementary material

The online version of this article (10.1186/s12889-018-6211-1) contains supplementary material, which is available to authorized users.

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.

Screening for Lung Cancer: Communicating With Patients

OBJECTIVE

The purposes of this article are to detail the experience of a single-center academic institution in applying the patient-centered approach to a lung cancer screening program and to examine how this approach can expand to other aspects of follow-up imaging of lung nodules.

CONCLUSION

As the practice of patient-centered radiology gains attention, diagnostic radiologists are findings new ways to become more involved in patient care. A lung cancer screening program is one opportunity for radiologists to consult with and educate patients.

Stakeholder Research Priorities for Smoking Cessation Interventions within Lung Cancer Screening Programs. An Official American Thoracic Society Research Statement

RATIONALE

Smoking cessation counseling in conjunction with low-dose computed tomography (LDCT) lung cancer screening is recommended in multiple clinical practice guidelines. The best approach for integrating effective smoking cessation interventions within this setting is unknown.

OBJECTIVES

To summarize evidence, identify research gaps, prioritize topics for future research, and propose standardized tools for use in conducting research on smoking cessation interventions within the LDCT lung cancer screening setting.

METHODS

The American Thoracic Society convened a multistakeholder committee with expertise in tobacco dependence treatment and/or LDCT screening. During an in-person meeting, evidence was reviewed, research gaps were identified, and key questions were generated for each of three research domains: (1) target population to study; (2) adaptation, development, and testing of interventions; and (3) implementation of interventions with demonstrated efficacy. We also identified standardized measures for use in conducting this research. A larger stakeholder panel then ranked research questions by perceived importance in an online survey. Final prioritization was generated hierarchically on the basis of average rank assigned.

RESULTS

There was little consensus on which questions within the population domain were of highest priority. Within the intervention domain, research to evaluate the effectiveness in the lung cancer screening setting of evidence-based smoking cessation interventions shown to be effective in other contexts was ranked highest. In the implementation domain, stakeholders prioritized understanding strategies to identify and overcome barriers to integrating smoking cessation in lung cancer screening settings.

CONCLUSIONS

This statement offers an agenda to stimulate research surrounding the integration and implementation of smoking cessation interventions with LDCT lung cancer screening.

Smoking control: challenges and achievements

Smoking is the most preventable and controllable health risk. Therefore, all health care professionals should give their utmost attention to and be more focused on the problem of smoking. Tobacco is a highly profitable product, because of its large-scale production and great number of consumers. Smoking control policies and treatment resources for smoking cessation have advanced in recent years, showing highly satisfactory results, particularly in Brazil. However, there is yet a long way to go before smoking can be considered a controlled disease from a public health standpoint. We can already perceive that the behavior of our society regarding smoking is changing, albeit slowly. Therefore, pulmonologists have a very promising area in which to work with their patients and the general population. We must act with greater impetus in support of health care policies and social living standards that directly contribute to improving health and quality of life. In this respect, pulmonologists can play a greater role as they get more involved in treating smokers, strengthening anti-smoking laws, and demanding health care policies related to lung diseases.

Lung cancer and tobacco smoking in Crete, Greece: reflections from a population-based cancer registry from 1992 to 2013

Background

The Cancer Registry of Crete is a regional population database that collects cancer morbidity/mortality data along with several risk factors. The current study assessed the geographical variation of lung cancer among ever and never smokers in Crete during the last 20 years.

Method

Lung cancer patient records (1992–2013) including information on medical history and smoking habits were obtained from the Cancer Registry of Crete. Age-Adjusted Incidence Rates (AAIR), prevalence of smoking among lung cancer patients and the Population-Attributable Fraction (PAF%) of tobacco smoking were estimated. Kaplan-Meier curves, grouped per smoking status were constructed, and spatio-temporal analyses were carried out to assess the geographical variations of lung cancer and smoking (a = 0.05).

Results

New lung cancer cases in Crete accounted for 9% of all cancers (AAIR_{both genders} = 40.2/100,000/year, AAIR_males = 73.1/100,000/year, AAIR_females = 11.8/100,000/year). Ever smokers presented significantly higher incidence compared to ex-smokers (p = 0.02) and never smokers (p < 0.001). The highest increase was observed in ever smokers (AAIR₁₉₉₂ = 19.2/100,000/year, AAIR₂₀₁₃ = 25.4/100,000/year, p = 0.03), while never smokers presented the lowest increase from 1992 to 2013 (AAIR₁₉₉₂ = 5.3/100,000/year, AAIR₂₀₁₃ = 6.8/100,000/year, p = 0.2). The PAF% of lung cancer mortality is 86% for both genders (males: 89%, females: 78%). AAIRs ranged from 25 to 50/100,000/year, while significant geographical differences were observed among the municipalities of Crete (p = 0.02). Smokers living in the south-east urban regions presented higher risk of dying from lung cancer (RR = 2.2; 95%CI = 1.3–3.5).

Conclusions

The constant increase of lung cancer rates among both genders, especially in females, outlines the need for targeted, geographically-oriented, life-style preventive measures. Design of population-based screening programs, tobacco awareness campaigns and smoking cessation programs in lung cancer hot spots could be guide by these findings.

Lung Cancer Screening with Chest Computed Tomography in People Living with HIV: A Review by the Multidisciplinary CANCERVIH Working Group

A shift in mortality and morbidity has been observed in people living with human immunodeficiency virus (PLWHIV) from acquired immunodeficiency syndrome (AIDS) to non-AIDS diseases. Lung cancer has the highest incidence rates among all the non-AIDS-defining malignancies and is associated with mortality rates that exceed those of other cancers. Strategies to increase lung cancer survival in PLWHIV are needed. Lung cancer screening with chest LDCT has been shown to be efficient in the general population at risk. The objective of this review is to discuss lung cancer screening with chest computed tomography in PLWHIV. Lung cancer screening in PLWHIV is feasible. Whether PLWHIV could benefit from an age threshold for screening that is earlier than the minimum age of 55 years usually required in the general population still needs further investigation. Studies evaluating smoking cessation programs and how they could be articulated with lung cancer screening programs are also needed in PLWHIV.

A prospective and retrospective analysis of smoking behavior changes in ever smokers with high risk for lung cancer from New Mexico and Pennsylvania

Cigarette smoking is the leading preventable cause of death worldwide. The aim of this study is to conduct a prospective and retrospective analysis of smoking behavior changes in the Lovelace Smokers Cohort (LSC) and the Pittsburgh Lung Screening Study cohort (PLuSS). Area under the curve (AUC) for risk models predicting relapse based on demographic, smoking, and relevant clinical variables was 0.93 and 0.79 in LSC and PLuSS, respectively. The models for making a quit attempt had limited prediction ability in both cohorts (AUC≤0.62). We identified an ethnic disparity in adverse smoking behavior change that Hispanic smokers were less likely to make a quit attempt and were more likely to relapse after a quit attempt compared to non-Hispanic Whites. SNPs at 15q25 and 11p14 loci were associated with risk for smoking relapse in the LSC. Rs6495308 at 15q25 has a large difference in minor allele frequency between non-Hispanic Whites and Hispanics (0.46 versus 0.23, P<0.0001) and was associated with risk for ever relapse at same magnitude between the two ethnic groups (OR=1.36, 95% CI=1.10 to 1.67 versus 1.59, 95% CI=1.00 to 2.53, P=0.81). In summary, the risk prediction model established in LSC and PLuSS provided an excellent to outstanding distinguishing for abstainers who will or will not relapse. The ethnic disparity in adverse smoking behavior between Hispanics and non-Hispanic Whites may be at least partially explained by the sequence variants at 15q25 locus that contains multiple nicotine acetylcholine receptors.

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.

Feasibility and efficacy of early lung cancer diagnosis with chest computed tomography in HIV-infected smokers

OBJECTIVE

Lung cancer screening with chest computed tomography (CT) is beneficial in smokers aged 55 to 74 years. We studied the risks, benefits and feasibility of early lung cancer diagnosis with CT in HIV-infected smokers.

DESIGN AND SETTING

French, multicentre, single round chest CT study in France, realized between February 2011 and June 2012.

PARTICIPANTS

Patients were HIV-infected smokers at least 40 years, at least 20 pack-years, with a CD4 T-lymphocyte nadir count below 350 cells/μl.

INTERVENTION

Single chest CT with a proposed standardized workup algorithm of positive images.

MAIN OUTCOME MEASURE

The outcome was the number of histologically proven lung cancers diagnosed by CT with a 2-year follow-up.

RESULTS

Median age of the 442 included patients was 49.8 years, 81.6% were under 55 years, 84% were men, median smoking was 30 pack-years, median nadir and last CD4 cell counts were 168 and 574 cells/μl, respectively, and 90% of patients had a plasma HIV RNA below 50 copies/ml. A positive image at baseline was reported in 94 (21%) patients, and 15 (3.4%) patients had 18 invasive procedures with no serious adverse events. Lung cancer was diagnosed in 10 patients (six at early stages), of which nine (2.0%, 95% confidence interval: 0.9-3.8) were CT detected, and eight in patients below 55 years.

CONCLUSION

Early lung cancer diagnosis with CT in HIV-infected smokers was feasible, safe, and yielded a significant number of cancers. Lung cancer screening of HIV-infected smokers with an important history of immunodeficiency revealed a substantial number of cancers at younger ages than the targeted range in the general population.

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.

Stages of change, determinants, and mortality for smoking cessation in adult Taiwanese screenees

We aimed to investigate the associations between three smoking-related constructs (pros and cons of smoking, temptation to smoke, and self-efficacy of resisting smoking) and stage of change (precontemplation, contemplation, preparation, and action) based on the transtheoretical model among smokers attending a community-based screening program. We also assessed their effects on long-term all-cause mortality. A prospective cohort study, with an average of 7 years of follow-up, was conducted by enrolling 454 male smoking screenees. The comparisons of the mean score of each variable pertaining to three smoking-related constructs across four stages of smoking cessation were assessed by analysis of variance. The impacts of both smoking-related constructs and smoking cessation stage measured at baseline on 7-year mortality were assessed by using proportional hazards regression model. The differences in the mean scores of pros and cons of smoking, temptation to smoke, and self-efficacy of resisting smoking across four stages of smoking cessation were statistically significant (P < 0.01). The precontemplation group and the contemplation group as opposed to the action group increased the risk for all-cause mortality, but the size of effect was not statistically significant (P = 0.39) when age, duration of smoking, and three smoking- related constructs were controlled. Those with a lower social aspect of self-efficacy were approximately threefold [adjusted hazard ratio = 3.22 (95 % CI 1.26-8.21)] risk for all-cause death compared with those with a higher one. Three smoking-related constructs were highly associated with smoking cessation stage, and low self-efficacy was independently predictive of long-term mortality among male smokers attending a community-based screening 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.

Does Screening Participation Affect Cigarette Smokers' Decision to Quit? A Long-Horizon Panel Data Analysis

Background

Despite decades of intensive anti-tobacco initiatives, millions of people are still smoking. The health authorities are seeking new tools and extended knowledge. Screening programs may, in addition to the potential health benefits from early detection of smoking related diseases, also increase smoking cessation among participants. This study examines the effect of screening participation by comparing the smokers' cessation hazard in screening years to non-screening years.

Methods

All smokers (n=10,471) participated in a three-wave cardiovascular screening and were followed up over a maximum of 14 years. The panel was merged with administrative registers. We used a flexible discrete-time duration model to investigate the effect of the screening program while simultaneously accounting for the possible influence of personal characteristics, addiction indicators, economic factors, health status and health changes. Specifically, we examined and compared long-term smokers (LT; smoked ≥25 years) with short-term (ST; smoked ≤ 5 years) and medium-term (MT; smoked 10-20 years) smokers.

Results

We found that 29% of LT smokers quitted smoking during the follow-up whereas 32% of MT and 48% of ST smokers reported the same. The screening participation years stood out as especially important for all groups. The impact of the first screening was particularly high, and for the first two screenings, the effect was higher for long-term smokers than for the smokers with shorter smoking careers. Receiving an abnormal test result was not associated with a significant increase in cessation hazard for any group of smokers.

Conclusions

The substantial effect of being invited to and participating in a screening appears robust, and may prove useful when discussing future policies for smoking cessation. This paper suggests that further initiatives for consultations with health personnel, in this case through a screening program, could increase the quitting hazard.

Lung cancer screening with low-dose computed tomography for primary care providers

This review provides an update on lung cancer screening with low-dose computed tomography (LDCT) and its implications for primary care providers. One of the unique features of lung cancer screening is the potential complexity in patient management if an LDCT scan reveals a small pulmonary nodule. Additional tests, consultation with multiple specialists, and follow-up evaluations may be needed to evaluate whether lung cancer is present. Primary care providers should know the resources available in their communities for lung cancer screening with LDCT and smoking cessation, and the key points to be addressed in informed and shared decision-making discussions with patients.

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.

The impact of computed tomography screening for lung cancer on smoking behaviors: a teachable moment?

BACKGROUND

Helical computed tomography (CT) has emerged as a potential screening test for lung cancer. An important component of care surrounding the use of this technology is the impact of screening on decisions surrounding smoking cessation.

OBJECTIVE

The aim of this article was to conduct an integrative review of literature on the impact of lung cancer screening with CT on smoking behaviors of current smokers.

METHODS

Ganong's [Res Nurs Health. 1987;10(1):1-11] guidelines were used to conduct this integrative review. Computerized databases were used to identify relevant articles. Data were extracted from the studies, and then content analysis was used to synthesize the findings.

RESULTS

Nine studies were identified and reviewed. The quit rate among participants ranged from 6.6% to 42% after screening. Among current smokers, smoking abstinence was associated with older age, worse pulmonary function, and having multiple abnormal CT findings. Motivation to quit smoking, within the next 30 days, ranged from 14% to 35% among smokers. Factors associated with increased motivation were older age, lower nicotine addiction, fewer lung cancer symptoms, higher self-efficacy, and acknowledgment of the advantages of quitting smoking.

CONCLUSIONS

Participants undergoing lung cancer screening had increased motivation to quit smoking. Computed tomographic screening for lung cancer appears to be a teachable moment to address smoking cessation.

IMPLICATIONS FOR PRACTICE

Screening for lung cancer is only one step to fight lung cancer. Incorporating smoking cessation interventions along with the use of technology is necessary to fight this deadly disease.

[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.

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.

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.