Data abstraction focused on extracting data to support the phenomenon of this integrative literature review. Each of the articles that met the criteria for inclusion in this review was evaluated on purpose of the study, measurement of the outcome variable, study design, sample characteristics, procedures, and interventions received by participants and results. Data from the articles were extracted and coded by one reviewer and checked by another reviewer. Data were placed into a grid that was developed for the study. Content analysis of the data that were placed into the grid was done by 2 reviewers to address the research questions and to identify and synthesize the results of the integrative review. Additional tables of the phenomenon of interest were made in order to enhance analysis and interpretation of the data (Table 2).
Motivation and Readiness to Quit
Three23,27,31 studies (33.3%) provided information about motivation to quit smoking, and 1 study (11%) about readiness to stop smoking.29 Ashraf and colleagues31 measured motivation to quit smoking using a single-item question that asked about motivation to quit smoking, with scores ranging from 1 (no motivation) to 5 (high motivation). They found that the motivation score at 1-year follow-up in the CT group for continued smokers was 3.2, and it was 3.7 for recent quitters. In the control group, the motivation score for continued smokers was 3.3, and it was 3.5 for recent quitters.31 Ostroff and colleagues23 found that of those who reported quit or reduced smoking following enrollment, about 87% stated that the enrollment in Early Lung Cancer Action Program had been a major influence in increasing their motivation to quit smoking. Altogether, about 74% of the participants agreed that participation in the Early Lung Cancer Action Program increased their motivation for quitting smoking.23
In the other study, investigators assessed quit motivation using methods obtained by Prokhorov et al.33 In this study, individuals were classified as either at precontemplation (not considering quitting in the next 6 months), contemplation (considering quitting in the next 6 months), or preparation (considering quitting in the next 30 days and have tried to quit). Investigators found that about 14.5% of participants reported not considering quitting in the next 6 months, 51% reported they were considering quitting in the next 6 months, and 34.5% reported that they were considering quitting in the next 30 days and have tried to quit.27 The other study assessed the percentage of readiness to stop smoking among study participants from 2 trials. Taylor and colleagues29 found that about 20% of the participants from this Lung Screening Study reported that they were ready to stop smoking in the next 30 days, 44.6% were ready to stop in the next 6 months, and 35% were not thinking to stop smoking. The percentage of readiness to stop smoking among participants from the National Lung Screening Trial was as follows: 24.1% were ready to stop smoking in the next 30 days, 43% were ready to stop in the next 6 months, and 33% were not thinking about quitting smoking.29 In the few studies that have been conducted to date, it appears that the majority of patients who undergo CT screening experience increased motivation to quit smoking. Moreover, across the various studies, 20% to 35% of participants were preparing to stop smoking in the next 30 days and 43% to 51% of participants were thinking about quitting smoking within the next 6 months.
Smoking Abstinence Measures Associated With CT Screening
The measurement of smoking abstinence outcomes varied across the studies from 1 month to 6 years after CT screening. Details of the outcome measurement are presented in Table 2. Taken together, smoking abstinence rates ranged from 6.6%29 to 42%28 after CT screening among the various studies. The majority of studies (n = 6 [66.6%]) followed patients for at least 1 year after screening.24,26,28,30–32 In the 2 studies (22%) that were conducted less than 1 year after screening, the smoking abstinence rates ranged from 6.6%29 to 16%,27 whereas in the 3 studies (33.3%) that measured smoking abstinence rates at 1 year after the CT screening, the quit rates ranged from 11.9%31 to 15.5%.26 In the 1 study that followed participants for 6 years, the investigators found that about 35% of baseline smokers reported smoking abstinence on at least 1 follow-up smoking assessment, and 29% reported prolonged abstinence.30
In the 2 studies (22%) that used an RCT design to measure smoking abstinence rates, the quit rate in 1 study was found to be 15.1% in the screening arm and 19.8% in the control arm at 2 years after CT screening.32 The other RCT found the quit rate similar between the intervention group where participants underwent CT screening and the group where participants did not undergo CT screening; however, all participants in this study received minimal smoking cessation counseling (<5 minutes) by nurses.31 The quit rate at the 1-year follow-up in the CT arm was 11.9%, and in the control arm, it was 11.8%.31 One study reported quit rates of participants who received annual screenings for 3 years. At the first annual visit, 14% of participants who smoked at baseline reported abstinence from smoking, 22% at the second annual visit, and 24% at the third annual visit.28
Six23,24,26,28–31 of the studies (66.6%) provided information about the association between screening results and smoking quit rates (Table 2). Five of these 6 studies suggest that abnormal lung screening results among current smokers may promote smoking cessation. Townsend and colleagues28 followed study subjects for 3 years and found that, among participants who received abnormal CT screens each of the previous 3 years, 42% reported abstinence from smoking compared with 28% with 2 abnormal screens, 24% with 1 abnormal screen, and 20% with no abnormal screens.28 One study conducted by Cox and colleagues,24 however, did not find statistically significant association between CT screening result and smoking behavior change in either group. Subjects in this study received recommendations based on their CT scan result: no follow-up, follow-up in 6 months, follow-up in 3 months, follow-up as soon as possible/biopsy, and other. Follow-up recommendations were based on the size of the largest noncalcified nodule detected on the CT scan. Rates of smoking cessation did not vary according to the CT screening follow-up recommendations.24
Predictors of Smoking Abstinence
Most of the studies (88.8%) provided information about predictors of smoking cessation.23,24,26–29,31,32 Four of the 8 studies (50%) reported that among current smokers, smoking abstinence was associated with older age.24,27,28,31 However, Ostroff and colleagues23 found that smoking abstinence was associated with younger age. Other covariates associated with smoking abstinence among current smokers were worse pulmonary function, high cancer anxiety, perceived benefit of quitting, lower nicotine addiction, having multiple abnormal CT findings, higher level of quitting self-efficacy, and acknowledgement of the advantages of quitting. One study (11%) found that higher education level was also associated with prolonged smoking abstinence.32 Among former smokers, abstinence from smoking was associated with a longer duration of abstinence before the baseline visit.24,28 Cox and colleagues24 found that study participants abstinent at baseline for 1 year or less experienced 30% relapse rate, and participants abstinent for 2 or more years experienced 2% relapse rate.24
Interest in Smoking Cessation Treatment
Three studies (33.3%) reported participants’ interest in receiving smoking cessation intervention along with lung cancer screening.23,27,29 Interest in receiving smoking cessation interventions as part of CT screening was high among subjects and ranged from.58%29 to 86%.23 Taylor and colleagues29 found that nicotine replacement therapy and free counseling were the cessation methods that participants were most interest in receiving.29
Smoking Cessation Interventions
In most of the studies, subjects did not receive smoking cessation intervention, but participants in 5 studies (55%)27,28,30–32 received some kind of information about quitting smoking. Subjects in a study conducted by Schnoll and colleagues27 were advised to quit smoking and received information about local smoking cessation programs and smoking cessation treatments (eg, nicotine replacement therapies). Smoking cessation messages were reinforced by the research coordinator during any telephone contacts.27 Current smokers in a study conducted by Anderson and colleagues30 were advised to quit smoking and were provided contact information for telephone quitline.30 In addition to CT screening, all subjects received minimal smoking cessation counseling (<5 minutes) by nurses in an RCT conducted by Ashraf and colleagues.31 In another RCT, current smokers in both screening and control study arms received a standard smoking cessation brochure or questionnaire by which people could ask for tailored smoking cessation information from STIVORO (The Dutch Expertise Centre on Tobacco Control).32
Most of the participants in a study conducted by Townsend and colleagues28 did not receive any advice or information on smoking cessation. However, 171 subjects of 926 current smokers at the first follow-up assessment participated in a randomized trial of standard written, self-help materials compared with a written list of Internet resources for smoking cessation. Researchers found, at 1-year follow-up, that there were no statistically significant differences in 7-day point prevalence quit rates between the groups.28
Recent evidence suggests that CT screening is an effective method in detecting lung cancer in early stages and leads to reduced death rates. An important consideration associated with increased use of this technology is how lung cancer screening with CT will affect decisions surrounding smoking cessation. Some authors have suggested that screening may present as a “teachable moment,” where one may be open to positive behavioral changes, whereas others have expressed concerns that receiving negative results from a screening test may promote continued smoking. Taken together, the evidence from the studies in this literature review strongly suggests that CT screening motivates participants in lung cancer screening program to quit smoking. Overall, the quit rate among most of the studies (88.8%) was higher than 11%; only 1 study conducted by Taylor and colleagues29 reported a quit rate of 6.6%, but they measured smoking status only within 1 month after the CT screening. Besides this study, the quit rate across all other studies was high, ranging from 11.9% to 42% after CT screening. This smoking abstinence rate is markedly higher among those receiving CT screening as compared with the expected annual abstinence rate of 4% to 7% among self-quitters in the general population.34 Therefore, it appears that CT screening for lung cancer is a “teachable moment” to address smoking cessation.
Ashraf and colleagues,31 however, argue that CT screening has no effect on smoking behavior because they found similar quit rates in the screening arm (11.9%) and in the control arm (11.8%) of an RCT designed to examine the effect of CT screening on mortality and smoking behaviors. All participants in this trial received minimal smoking cessation counseling (<5 minutes) by certified smoking cessation nurses with at least 3 years’ counseling experience.31 The results of the study found that the quit rate among participants in both arms of the study was higher as compared with the general population of self-quitters. Contrary to the assumption that screening had no effect, it may be that participants who agreed to participate in Ashraf and colleagues’ study had heightened perceptions of lung cancer risk and may have been more receptive to changing their smoking behavior. Studies have shown that even brief smoking cessation counseling of 3 minutes or less can help smokers to quit smoking and increases the overall tobacco abstinence rates.34,35 In the case of heightened risk perception, this effect may be amplified.36 Given the controversy in the literature about the impact of screening on smoking abstinence rates, further research is needed to understand who is interested in undergoing CT screening and the underlying mechanisms that are associated with smoking abstinence during lung cancer screening.
Despite the fact that there is controversy about maintaining abstinence after CT screening, the results of these studies also suggest that CT screening for lung cancer provides significant motivation for smoking cessation. The majority of the findings were consistent across the studies, showing that smokers with higher motivation to quit were able to quit smoking. Some of the studies reported that approximately 51% of smokers were considering quitting in the next 6 months, and 35% were considering quitting in the next 30 days27; these percentages are much higher compared with those in other studies. For example, Hughes and colleagues37 examined the prevalence of use of tobacco treatment and intentions about future use. They studied 884 tobacco smokers of Vermont and found that only 29% of participants planned to quit in the next month.37 Thus, the percentage of individuals who planned to quit in the next month appears to be higher among smokers who underwent CT screening for lung cancer as compared with those in the general population.
Several predictors for smoking cessation among current smokers were identified in the studies examined in this review. Factors associated with smoking abstinence were older age, worse pulmonary function, higher cancer anxiety, higher perceived benefit of quitting, lower nicotine addiction, having multiple abnormal CT findings, higher quitting self-efficacy, and acknowledgement of the advantages of quitting. The presence of an abnormal CT scan finding appears to be the strongest factor associated with smoking abstinence rate, providing evidence that the diagnosis of a smoking-related illness, in particular, provides a “teachable moment” that can be used to enhance cessation rates. The highest abstinent rate (42%) from smoking was found among those participants who received 3 abnormal results.28 This finding provides further support that lung cancer screening is a unique opportunity to change smoking behavior of participants and may act as a trigger for cessation.
It is important to recognize that only 5 of the studies (56%) provided some kind of intervention along with CT screening to promote smoking cessation among study participants. The most common smoking cessation intervention was brief advice alone. According to the US Department of Health and Human Services, the criterion standard for smoking cessation intervention is combined treatment with pharmacotherapy and behavioral counseling.34 Receiving more intensive smoking cessation interventions is important, given that the use of pharmacotherapy with behavioral counseling is associated with 2- or 3-fold increase in smoking abstinence rates.34 It is encouraging to note that most of the participants who underwent CT screening reported that they would like to receive smoking cessation assistance in order to quit smoking. This provides an opportunity to offer smoking cessation interventions at a time when participants may be more receptive to making a quit attempt. Several barriers exist to provide smoking cessation interventions to cigarette smokers, such as lack of provider time, lack of knowledge, and lack of reimbursement for smoking cessation interventions.34,38 As CT screening becomes more common, these barriers must be addressed in order to increase the uptake of evidence-based smoking cessation treatments and enhance smoking abstinence rates at a time when smokers are receptive to receipt of interventions.
One notable gap in the studies conducted to date is that the vast majority of participants were white. As CT screening gains acceptability and becomes available for widespread use, one major concern is that lung cancer disparities will widen, especially among blacks and those of lower socioeconomic status.39 Understanding barriers to receipt of CT screening among high-risk populations will be essential to ensure that those most in need of this technology are able to access it and reap the potential benefits associated with earlier diagnosis of a potentially lethal disease and integrating health promotion activities such as smoking cessation at a time when patients appear to be receptive to change.
This integrative review suggests that smoking cessation rates were higher among individuals being screened for lung cancer as compared with the general population, and having a positive screening result was associated with even higher smoking cessation rates. In addition, participants undergoing lung cancer screening had increased motivation to quit smoking. It is interesting to note that smoking abstinence rates after CT screening were high even without the delivery of smoking cessation interventions. However, participants’ undergoing CT screening indicated a high level of interest in receiving smoking cessation interventions as part of screening. Taken together, these results suggest that lung cancer screening represents a “teachable moment” for the delivery of the smoking cessation interventions. Further research is needed to better understand the impact of technology on decisions surrounding smoking cessation. Given that smoking abstinence rates are high, understanding the underlying mechanisms for behavioral change through the use of theory-based studies would be an important avenue for future research.
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Keywords:© 2012 Lippincott Williams & Wilkins, Inc.
Current smokers; Helical computed tomography; Lung cancer; Screening; Smoking abstinence