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

Cytisine as a smoking cessation aid: Preliminary observations with a modified therapeutic scheme in real life

INTRODUCTION

Cigarette smoke accounts for over 90,000 deaths each year in Italy. Tobacco dependence treatment guidelines suggest adopting an integrated pharmacological-behavioral model of intervention. Cytisine is a partial agonist of nicotinic receptors. Trials conducted to date have demonstrated its good efficacy in promoting smoking cessation. The cytisine scheme of treatment consists of 25 days of treatment. A 40-day regimen, with an escalating dose and an extended duration of the treatment, has been in use in many anti-smoking centers in Italy for several years, but to date there are no reports on the use of cytisine with this scheme.

METHODS

A retrospective, real-life, observational study was conducted between January 2016 and September 2022. The 300 patients who had received at least one dose of study medication were selected. Continuous variables were compared by the Wilcoxon-Mann-Whitney test. Univariate and multivariate logistic regression models were implemented for self-reported seven-day point prevalence for abstinence at three, six and 12 months.

RESULTS

The median age of the patients was 59 years, 57% were women. The median smoking exposure was 33.8 pack-years. Self-reported smoking abstinence at three, six and 12 months was 68.7%, 56.3% and 47.3% respectively. 84% completed the cytisine treatment, 31.3% reported adverse events and in 8.3% these led to dropping out of the treatment.

CONCLUSION

Cytisine, administered with a novel therapeutic scheme in the real-life setting of a specialized anti-smoking center, significantly promotes smoking abstinence. However, more studies are needed to assess the tolerability and efficacy of this new regimen.

Identifying determinants of varenicline adherence using the Theoretical Domains framework: a rapid review

BACKGROUND

Adhering to varenicline has been shown to significantly improve the chances of successfully quitting smoking, with studies indicating a twofold increase in 6-month quit rates. However, despite its potential benefits, many individuals struggle with maintaining good adherence to varenicline; thus there is a need to develop scalable strategies to help people adhere. As a first step to inform the development of an intervention to improve adherence to varenicline, we conducted a rapid literature review to identify: 1) modifiable barriers and facilitators to varenicline adherence, and 2) behaviour change techniques associated with increased adherence to varenicline.

METHODS

We searched MEDLINE, Embase, APA PsycINFO, CINAHL, and the Cochrane Central Register of Controlled Trials for relevant studies published between 2006 and 2022. Search terms included "varenicline," "smoking cessation," and "adherence," and their respective subject headings and synonyms. We screened and included studies reporting modifiable determinants of adherence to varenicline and then assessed quality, extracted modifiable determinants and mapped them to the Theoretical Domains Framework version 2 and the Behaviour Change Technique Taxonomy version 1.

RESULTS

A total of 1,221 titles were identified through the database searches; 61 met the eligibility criteria. Most of the studies were randomized controlled trials and predominantly focused on barriers to varenicline. Only nine studies explicitly mentioned behaviour change techniques used to help varenicline adherence. Eight domains were identified as barriers to varenicline adherence (behavioural regulation, memory, goals, intentions, beliefs about capabilities, beliefs about consequences, optimism/pessimism, and environmental context) and five as facilitators (knowledge, behavioural regulation, beliefs about capabilities, social influences, and environmental context).

CONCLUSIONS

This study identifies barriers and facilitators that should be addressed when developing a complex adherence intervention tailored to patients' needs based on modifiable determinants of medication adherence, some of which are under- used by existing adherence interventions. The findings from this review will inform the design of a theory-based healthbot planned to improve varenicline adherence in people undergoing smoking cessation treatment.

SYSTEMATIC REVIEW REGISTRATION

This study was registered with PROSPERO (# CRD42022321838).

How Does Environmental and Occupational Exposure Contribute to Carcinogenesis in Genitourinary and Lung Cancers?

Environmental and occupational exposures have been associated with an increased risk of different types of cancers, although the exact mechanisms of higher carcinogenesis risk are not always well understood. Lung cancer is the leading cause of global cancer mortality, and, also, genitourinary neoplasms are among the main causes of cancer-related deaths in Western countries. The purpose of this review is to describe the main environmental and occupational factors that increase the risk of developing lung and genitourinary cancers and to investigate carcinogenesis mechanisms that link these agents to cancer onset. Further objectives are to identify methods for the prevention or the early detection of carcinogenic agents and, therefore, to reduce the risk of developing these cancers or to detect them at earlier stages.

Smoking Cessation by Phone Counselling in a Lung Cancer Screening Program: A Retrospective Comparative Cohort Study

Introduction

Smoking cessation integration within lung cancer screening programs is challenging. Currently, phone counselling is available across Canada for individuals referred by healthcare workers and by self-referral. We compared quit rates after phone counselling interventions between participants who self-refer, those referred by healthcare workers, and those referred by a lung cancer screening program.

Methods

This is a retrospective cohort study of participants referred to provincial smoking cessation quit line in contemporaneous cohorts: self-referred participants, healthcare worker referred, and those referred by a lung cancer screening program if they were still actively smoking at the time of first contact. Baseline, covariates (sociodemographic information, smoking history, and history of mental health disorder) and quit intentions (stage of change, readiness for change, previous use of quit programs, and previous quit attempts) were compared among the three cohorts. Our primary outcome was defined as self-reported 30-day abstinence rates at 6 months. Multivariable logistic regression was used to identify whether group assignment was associated with higher quit rates.

Results

Participants referred by a lung cancer screening program had low quit rates (12%, 95% CI: 5–19) at six months despite the use of phone counselling. Compared to patients who were self-referred to the smoking cessation phone helpline, individuals referred by a lung cancer screening program were much less likely to quit (adjusted OR 0.37; 95% CI: 0.17–0.8), whereas those referred by healthcare workers were twice as likely to quit (adjusted OR 2.16 (1.3–3.58)) even after adjustment for differences in smoking intensity and quit intentions.

Conclusions

Phone counselling alone has very limited benefit in a lung cancer screening program. Participants differ significantly from those who are otherwise referred by healthcare workers. This study underlines the importance of a dedicated and personalized tobacco treatment program within every lung cancer screening program. The program should incorporate best practices and encourage treatment regardless of readiness to quit.

Lung Cancer Screening with Low-Dose CT in Smokers: A Systematic Review and Meta-Analysis

Lung cancer continues to be one of the main causes of cancer death in Europe. Low-dose computed tomography (LDCT) has shown high potential for screening of lung cancer in smokers, most recently in two European trials. The aim of this review was to assess lung cancer screening of smokers by LDCT with respect to clinical effectiveness, radiological procedures, quality of life, and changes in smoking behavior. We searched electronic databases in April 2020 for publications of randomized controlled trials (RCT) reporting on lung cancer and overall mortality, lung cancer morbidity, and harms of LDCT screening. A meta-analysis was performed to estimate effects on mortality. Forty-three publications on 10 RCTs were included. The meta-analysis of eight studies showed a statistically significant relative reduction of lung cancer mortality of 12% in the screening group (risk ratio = 0.88; 95% CI: 0.79-0.97). Between 4% and 24% of screening-LDCT scans were classified as positive, and 84-96% of them turned out to be false positive. The risk of overdiagnosis was estimated between 19% and 69% of diagnosed lung cancers. Lung cancer screening can reduce disease-specific mortality in (former) smokers when stringent requirements and quality standards for performance are met.

Cessation classification likelihood increases with higher expired-air carbon monoxide cutoffs: a meta-analysis

BACKGROUND

Expired-air carbon monoxide (CO) is commonly used to biochemically verify smoking status. The CO cutoff and CO monitor brand may affect the probability of classifying smokers as abstinent, thus influencing conclusions about the efficacy of cessation trials. No systematic reviews have tested this hypothesis. Therefore, we performed a meta-analysis examining whether the likelihood of smoking cessation classification varied due to CO cutoff and monitor brand.

METHODS

Eligible studies (k = 122) longitudinally assessed CO-verified cessation in adult smokers in randomized trials. Primary meta-regressions separately assessed differences in quit classification likelihood due to continuous and categorical CO cutoffs (Low, 3-4 parts per million [ppm]; [SRNT] Recommended, 5-6 ppm; Moderate, 7-8 ppm; and High, 9-10 ppm); exploratory analyses compared likelihood outcomes between monitor brands: Bedfont and Vitalograph.

RESULTS

The likelihood of quit classification increased 18% with each 1 ppm increase above the lowest cutoff (3 ppm). Odds of classification as quit significantly increased between each cutoff category and High: 261% increase from Low; 162% increase from Recommended; and 150% increase from Moderate. There were no differences in cessation classification between monitor brands.

CONCLUSIONS

As expected, higher CO cutoffs were associated with greater likelihood of cessation classification. The lack of CO monitor brand differences may have been due to model-level variance not able to be followed up in the present dataset. Researchers are advised to report outcomes using a range of cutoffs-including the recommended range (5-6 ppm)-and the CO monitor brand/model used. Using higher CO cutoffs significantly increases likelihood of quit classification, possibly artificially elevating treatment strategies.

Implementation of lung cancer screening: what are the main issues?

Two large-scale RCTs have shown computed tomography (CT) lung cancer screening to be efficacious in reducing lung cancer mortality (8–24% in men, 26–59% in women). However, lung cancer screening implicitly means personalised and risk-based approaches. Health care systems’ implementation of personalised screening and prevention is still sparse, and likely to be of variable quality, because of important remaining uncertainties, which have been incompletely addressed or not at all so far. Further optimisation of lung cancer screening programs is expected to reduce harms and maintain or enhance benefit for eligible European citizens, whilst significantly reducing health care costs. Some main uncertainties (e.g., Risk-based eligibility, Risk-based screening intervals, Volume CT screening, Smoking Cessation, Gender and Sex differences, Cost-Effectiveness) are discussed in this review. 4-IN-THE-LUNG-RUN (acronym for: Towards INdividually tailored INvitations, screening INtervals and INtegrated co-morbidity reducing strategies in lung cancer screening) is the first multi-centred implementation trial on volume CT lung cancer screening amongst 24,000 males and females, at high risk for developing lung cancer, across five European countries, started in January 2020. Through providing answers to the remaining questions with this trial, many EU citizens will swiftly benefit from this high-quality screening technology, others will face less harms than previously anticipated, and health care costs will be substantially reduced. Implementing a new cancer screening programme is a major task, with many stakeholders and many possible facilitators but also barriers and obstacle.

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.

[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.

Milestones towards lung cancer screening implementation

The European Society of Radiology (ESR) and European Respiratory Society (ERS) published their joint statement paper on lung cancer screening (LCS), on 12 February 2020. This document joins and completes previous recommendations on LCS with specific emphasis on the analysis of issues encountered in the practical implementation of LCS in the community. Major milestones to enable the most efficient and equal dissemination of LCS are recognised as engagement of all stakeholders (e.g. candidate/participant, general practitioners, up to the specialised LCS facility), quality assurance, and primary prevention in the form of provision of counselling for 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.

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.

Combining smoking cessation interventions with LDCT lung cancer screening: A systematic review

Providing smoking cessation treatment with annual low dose CT (LDCT) screening offers an opportunity to reduce smoking-related morbidity and mortality. However, the optimal approach for delivering cessation interventions in the LDCT screening context is unknown. We searched for randomized controlled trials and observational studies with a control group testing a smoking cessation intervention among adults undergoing LDCT screening through May 1, 2018 using MEDLINE, the Cochrane Library, Web of Science, EMBASE, PsycINFO, and ClinicalTrials.gov. Two reviewers independently reviewed each study to assess eligibility and extracted information using pre-specified protocols for included studies. Given significant differences in the interventions in each study, meta-analyses for the included studies could not be performed. Of 2513 identified studies, 9 met inclusion criteria. Five of the included studies were randomized controlled trials while 4 were observational studies with a control group. Studies were of varying quality, but overall were of poor to fair quality with significant potential for bias and limited generalizability. Based on the available studies, there was insufficient data to suggest a particular approach to smoking cessation counseling in the LDCT screening setting. While no studies compared combined pharmacotherapy and counseling to counseling alone or compared the various pharmacologic agents, we identified several studies underway investigating new approaches during LDCT screening. The optimal strategy for smoking cessation in patients undergoing LDCT screening remains unclear. Future studies should focus on evaluating effectiveness and implementation of combined counseling and pharmacotherapy to optimize smoking cessation during LDCT screening.

Inflammatory status and lung function predict mortality in lung cancer screening participants

Supplemental Digital Content is available in the text.

Low-dose computed tomography (LDCT) screening trials have based their risk selection algorithm on age and tobacco exposure, but never on pulmonary risk-related biomarkers. In the present study, the baseline inflammatory status, measured by C-reactive protein (CRP) level, and lung function, measured by forced expiratory volume in 1 s (FEV₁), were tested as independent predictors of all-cause mortality in LDCT-screening participants. Between 2000 and 2010, 4413 volunteers were enrolled in two LDCT-screening trials, with evaluable baseline CRP and FEV₁ values: 2037 were included in the discovery set and 2376 were included in the validation set. The effect of low FEV₁ or high CRP alone or combined was evaluated by Kaplan–Meier mortality curves and hazard ratio (HR) with 95% confidence interval (CI) by fitting Cox proportional hazards models. The overall mortality risk was significantly higher in participants with FEV₁ of up to 90% (HR: 2.13, CI: 1.43–3.17) or CRP more than 2 mg/l (HR: 3.38, CI: 1.60–3.54) and was still significant in the fully adjusted model. The cumulative 10-year probability of death was 0.03 for participants with FEV₁ of more than 90% and CRP up to 2 mg/l, 0.05 with only FEV₁ of up to 90% or CRP above 2 mg/l, and 0.12 with FEV₁ of up to 90% and CRP above 2 mg/l. This predictive performance was confirmed in the two external validation cohorts with 10-year mortality rates of 0.06, 0.12, and 0.14, and 0.03, 0.07, and 0.14, respectively. Baseline inflammatory status and lung function reduction are independent predictors of all-cause long-term mortality in LDCT-screening participants. CRP and FEV₁ could be used to select higher-risk individuals for future LDCT screening and preventive programs.

Current Smokers' Preferences for Receiving Cessation Information in a Lung Cancer Screening Setting

The purpose of this study was to identify current smokers' communication format preferences for receiving smoking cessation information in a lung cancer screening setting. A cross-sectional correlational design using survey methodology with 159 screening-eligible current smokers was the method used. Data was dichotomized (digital versus traditional preference) and analyzed using Pearson's chi-squared test, Mann-Whitney U test, and logistic regression. Race was a statistically significant predictor with White participants having four times greater odds of reporting preference for a digital format for receiving smoking cessation information such as social media and/or supportive text messages (OR: 4.06; p = 0.004). Lung cancer screening is a new venue where current long-term smokers can be offered information about smoking cessation while they are engaging in a health-promoting behavior and potentially more likely to contemplate quitting. It is important to consider the communication format preference of current smokers to support cessation uptake. This study is the first to examine communication format preference of current smokers in the context of the lung cancer screening venue. Key differences noted by race support the need for further research examining multiple formats of communication with efforts to maximize options in the cancer screening setting.

Lung cancer screening with low-dose spiral computed tomography: evidence from a pooled analysis of two Italian randomized trials

The benefits and harms of lung cancer (LC) screening with low-dose computed tomography (LDCT) are debatable. Positive results from the US National Lung Screening Trial were not evident in the European trials, possibly due to their smaller sample sizes. To address this issue, we conducted a patient-level pooled analysis of two Italian randomized controlled trials. Data from DANTE and MILD trials were combined for a total of 3640 individuals in the LDCT arm and 2909 in the control arm. LC and overall mortality were analyzed using multivariate hazard ratios (HRs) and log-rank tests stratified by study. The median follow-up was 8.2 years, with a total of 30 480 person-years in the LDCT arm and 22 157 in the control arm. A total of 192 patients developed LC in the LDCT arm and 105 in the control arm. Half of the LC cases in the LDCT arm had stage IA or IB cancer, as compared with 21% in the control arm. Overall mortality rates/100 000 person-years were 925 in the LDCT arm and 1074 in the control arm, and LC mortality rates were 299 and 357, respectively. The multivariate pooled overall mortality HR was 0.89 (95% confidence interval: 0.74-1.06) and the LC mortality HR was 0.83 (95% confidence interval: 0.61-1.12) for the LDCT arm as compared with the control arm. The present pooled analysis shows a nonsignificant 11% reduction in overall mortality in individuals undergoing LDCT screening as compared with the control arm. A pooled analysis of all European trials would be a useful contribution to assess the real benefit of LDCT screening.

Project reach: Piloting a risk-tailored smoking cessation intervention for lung screening

The purpose of this study was to explore the feasibility, acceptability, and efficacy of a telephone-based smoking cessation intervention for lung screening patients. Participants (N = 39) were enrolled in a single-arm pilot study of a four-session telephone-based intervention. Self-report measures were completed at baseline, post-intervention, and 3-month follow-up. Participants were long-term smokers; 62 percent were not motivated to quit. Twenty-three percent attempted quitting, 29 percent decreased their smoking, and 11 percent reported abstinence. Confidence increased (p < .001) and there were trends toward increased importance (p = .09) and comparative disease risk (p = .02). This intervention was acceptable and associated with improvements in smoking-related beliefs and behaviors.

Lung cancer screening: latest developments and unanswered questions

The US National Lung Screening Trial showed that individuals randomly assigned to screening with low-dose CT scans had 20% lower lung cancer mortality than did those screened with conventional chest radiography. On the basis of a review of the literature and a modelling study, the US Preventive Services Task Force recommends annual screening for lung cancer for individuals aged 55-80 years who have a 30 pack-year smoking history and either currently smoke or quit smoking within the past 15 years. However, the balance between benefits and harms of lung cancer screening is still greatly debated. The large number of false-positive results and the potential for overdiagnosis are causes for concern. Some investigators suggest the ratio between benefits and harms could be improved through various means. Nevertheless, many questions remain with regard to the implementation of lung cancer screening. This paper highlights the latest developments in CT lung cancer screening and provides an overview of the main unanswered questions.

Pharmacogenetic study of seven polymorphisms in three nicotinic acetylcholine receptor subunits in smoking-cessation therapies

Smoking-cessation therapy reduces the risk of smoking-related diseases, but is successful only in a fraction of smokers. There is growing evidence that genetic variations in nicotinic acetylcholine receptor (nAChR) subunits influence the risk of nicotine dependence and the ability to quit smoking. To investigate the role of polymorphisms in nAChR genes on smoking quantity and the outcome of smoking-cessation therapies, we carried out an association study on 337 smokers who underwent pharmacotherapy with varenicline, bupropion, nicotine replacement therapy (NRT) alone, or NRT plus bupropion. Smoking habit and abstention were assessed from the number of cigarettes smoked per day (CPD) and the exhaled CO (eCO), at baseline and up to 12 months. We genotyped seven polymorphisms in genes encoding the nAChR subunits CHRNA4, CHRNA5, and CHRNB2. At baseline, both CPD and eCO were associated with polymorphisms in the CHRNA5 locus (rs503464, rs55853698, rs55781567 and rs16969968; P < 0.01). rs503464, a variant in the 5′-UTR of CHRNA5, was also associated with short-, mid- and long-term responses to therapy (P = 0.011, P = 0.0043, P = 0.020, respectively), although after correction for multiple testing only the association at the mid-term assessment remained significant (FDR = 0.03). These data support the role of individual genetic makeup in the ability to 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.

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.

Screening with Low-Dose Computed Tomography Does Not Improve Survival of Small Cell Lung Cancer

INTRODUCTION

Small cell lung cancer (SCLC) constitutes a distinct component of symptomatic or advanced-stage lung cancers in clinical practice and in lung cancer screening trials. The purpose of this study was to describe the outcome of SCLC in lung cancer screening trials and compare the frequency of SCLC in our cohort with that in the major lung cancer screening trials.

METHODS

Subjects with a diagnosis of SCLC were selected from two lung cancer screening trials by low-dose computed tomography (LDCT), and their demographic characteristics, clinical parameters, tumor stage at diagnosis, therapy, and survival times were recorded. Survival curves were estimated using the Kaplan-Meier method.

RESULTS

Ten cases of SCLC were reported in 45,141 person-years (22 in 100,000 person-years), representing the 6% of all lung cancer cases. Cumulative tobacco consumption was 82 pack-years compared with 39 and 46 pack-years for the overall study population and subjects with non-SCLC, respectively. Most of the neoplasms were in an advanced stage (seven in stage IV and one each in stages IIIb, IIIa, and Ia). Two subjects were treated with lobectomy for curative purposes and died of diffuse metastasis within 2 years of diagnosis. The median overall survival time in the LDCT arms was 20.6 months, with no survivors remaining at 3 years.

CONCLUSIONS

Subjects in whom SCLC develops are a subgroup of smokers with extremely high cumulative tobacco consumption. Consequently, the frequency of SCLC in our population was lower than in other screening populations, with higher cumulative tobacco consumption. Screening for lung cancer by LDCT does not improve survival of SCLC, with no survivors remaining at 3 years after diagnosis.