Attitudes and Perceptions About Smoking Cessation in the Context of Lung Cancer Screening

Abstract

Broad adoption of lung cancer screening may inadvertently lead to negative population health outcomes if it is perceived as a substitute for smoking cessation.OBJECTIVE To understand views on smoking cessation from current smokers in the context of being offered lung cancer screening as a routine service in primary care. DESIGN, SETTING, AND PARTICIPANTSAs an ancillary study to the launch of a lung cancer screening program at 7 sites in the Veterans Health Administration, 45 in-depth semi-structured qualitative interviews about health beliefs related to smoking and lung cancer screening were administered from May 29 to September 22, 2014, by telephone to 37 current smokers offered lung cancer screening by their primary care physician. Analysis was conducted from June 15, 2014, to March 29, 2015. MAIN OUTCOMES AND MEASURESAttitudes and perceptions about the importance of smoking cessation in the context of lung cancer screening.RESULTS Lung cancer screening prompted most current smokers to reflect for the first time on what smoking means for their current and future health. However, 17 of 35 (49%) participants described mechanisms whereby screening lowered their motivation for cessation, including the perception that undergoing an imaging test yields the same health benefits as smoking cessation. Other misperceptions include the belief that everyone who participates in screening will benefit; the belief that screening and being able to return for additional screening offers protection from lung cancer; the perception by some individuals that findings from screenings have saved their lives by catching their cancer early when indeterminate findings are identified that can be monitored rather than immediately treated; and a reinforced belief in some individuals that a cancer-free screening test result indicates that they are among the lucky ones who will avoid the harms of smoking. CONCLUSIONS AND RELEVANCEIn this qualitative, lung cancer screening prompted many current smokers to reflect on their health and may serve as a potential opportunity to engage patients in discussions about smoking cessation. However, several concerning pathways were identified in which screening, when offered as part of routine care and described as having proven efficacy, may negatively influence smoking cessation. Health care professionals should be aware that the opportunity for early detection of lung cancer may be interpreted as a way of avoiding the harms of smoking. To promote cessation, discussions should focus on the emotional response to screening rather than clinical details (eg, nodule size) and address misperceptions about the value of early detection so that screening does not lower motivation to quit smoking.

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

“…On one hand, however, there is some evidence that positive LDCT screening results (e.g., detection of nodules) are associated with increases in quit rates and in reducing relapse among recent quitters (23, 24, 27, 29). On the other hand, screening may have paradoxical effects because others with a screen-detected nodule may be too scared or anxious to tackle quitting smoking (30), and patients with a normal LDCT screening result may feel little urgency to quit (31). Of note, among all persons screened, 80 to 86% have a normal or low-risk result (American College of Radiology Lung CT Screening Reporting and Data System [“Lung-RADS”] category 1 or 2) (32, 33).…”

Health checks in general practice: evidence first, not last

“…25 Another key aspect that needs to be balanced is the potential for unanticipated indirect effects. For example, a study by Zeliadt et al 26 revealed that smokers would be less likely to quit the habit if an effective lung cancer screening program was offered.…”

The Psychological Effects of Lung Cancer Screening on Heavy Smokers

“…This analysis involved 2 critical assumptions about the psychological effects of screening on heavy smokers: that the cascade of screening leads to few psychological harms and that screening has no effect on smoking behavior. The qualitative study by Zeliadt et al 5 in this issue of JAMA Internal Medicine should prompt us to revisit these 2 assumptions. Although many acknowledge the potential psychological effects of lung cancer screening, 6 we have little useful evidence to help determine the frequency and burden of the potential psychological harms of lung cancer screening.…”

“…Studies that do not use sensitive condition-specific measurement instruments are unlikely to detect the types of psychological effects that may result from screening. This issue is where the qualitative analysis by Zeliadt et al 5 is helpful. The investigators use a more sensitive qualitative approach to gain a richer understanding of the association between screening and heavy smokers' sense of their health.…”

“…The second assumption in the cost-effectiveness analysisthat screening has no effect on smoking behavior-is called into question by the finding that "nearly every participant described misperceptions about smoking that were exacerbated by screening." 5 These misperceptions ranged from the belief that screening offers protection for everyone who undergoes it to verification of the belief that smoking does not harm everyone and is not going to harm the individual smoker personally. These misperceptions, reinforced by offering screening, lead us to ask whether screening could reduce the motivation of heavy smokers to quit smoking.…”