The Impact of Computed Tomography Screening for Lung Cancer on Smoking Behaviors: A Teachable Moment?
Poghosyan, Hermine PhD(c), MPH, BSN; Kennedy Sheldon, Lisa PhD, APRN-BC; Cooley, Mary E. PhD, RN
Author Affiliations: College of Nursing and Health Sciences, University of Massachusetts, Boston (Ms Poghosyan and Dr Kennedy Sheldon), and Phyllis F. Cantor Center for Research in Nursing and Patient Care Services, Dana Farber Cancer Institute, Boston, Massachusetts (Dr Cooley).
This article was written as part of a course that was developed through a U56 grant collaboration. The U56 grant mechanism is a Cancer Disparities Research Partnership Program between a comprehensive cancer center (DFCI) and a minority serving institution (UMB). One of the 4 projects for this grant was the development of a joint Cancer Nursing, Health Disparities and Health Policy Program between DFCI and UMB. Dr Cooley taught the course that was supported by this mechanism, and Ms Poghosyan wrote this article as part of the course work. Drs Cooley and Kennedy Sheldon provided assistance to Ms Poghosyan inorder for the article to be rewritten for publication consideration.Dr Karen M. Emmons is the site principal investigator at DFCI, and DrAdam Colon-Carmona is the site principal investigator for UMB for the entire U56 project.
The authors have no funding or conflicts of interest to disclose.
Correspondence: Hermine Poghosyan, PhD(c), MPH, BSN, College of Nursing and Health Sciences, University of Massachusetts, 100 Morrissey Blvd, Boston, MA 02125 (firstname.lastname@example.org).
Accepted for publication November 2, 2011.
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.
Lung cancer is the leading cause of cancer-related death in the United States. In 2010, an estimated 222,520 new lung cancer cases and 157,300 deaths are expected in the United Sates.1 Risk factors associated with development of lung cancer include cigarette smoking; various occupational exposures, such as asbestos, environmental tobacco smoke, radon, and arsenic2; and chronic obstructive pulmonary disease.3 However, the main risk factor associated with development of lung cancer is smoking cigarettes. In fact, approximately, 90% of all lung cancer cases are related to tobacco exposure.2 In the United States, the smoking prevalence rate among adults 18 years or older was 20.6% in 2009, which represents approximately 46.6 million current adult smokers.4 Prevalence of current smokers, however, varies significantly by gender, race/ethnicity, education, and poverty level.4
The high rate of mortality from lung cancer is due to the fact that the majority of patients have advanced disease at the time of diagnosis when curative treatment is no longer possible.5,6 When lung cancer is diagnosed at an early stage, surgical resection is the preferred treatment option that improves the overall survival6; the 5-year survival for these patients ranges from 55% to 72%.7 Early stages of lung cancer appropriate for surgical resection are considered stages I and II.8 Only 16% of new lung cancer cases, however, are diagnosed at stage I or II.9 The 5-year survival of patients with more advanced disease is approximately 4% to 14%.10 Therefore, early detection of lung cancer is an important step toward improving the overall survival in lung cancer patients.
Identification of an effective screening test for those at high risk of developing lung cancer would enable earlier diagnosis and the potential for curative treatment. For early detection of lung cancer, screening chest x-rays and sputum cytology have been proposed. However, all of the previous randomized controlled trials (RCTs) failed to show a reduction in mortality resulting from screening with chest x-ray and sputum cytology.11–14 More recently, helical computed tomography (CT) has emerged as a potential screening test for lung cancer, with the potential for low-dose spiral chest CT scans to detect early-stage lung carcinomas and reduce the mortality rate.15–17
Early RCTs of lung cancer screening have investigated the effectiveness of CT screening for early detection of lung cancer but failed to show a reduction in lung cancer mortality.17,18 However, recently, very promising results have been reported regarding the effectiveness of CT screening for lung cancer. The RCT National Lung Screening Trial revealed that low-dose CT screening reduces lung cancer mortality by 20% compared with chest radiography, which is comparable to the results of screening with mammography.16,19 Therefore, CT screening is emerging as an effective method for the early detection of lung cancer.
Given that this technology has the potential to be used widely to detect earlier-stage lung cancer, an important consideration is that it is very important to correctly identify the target population to enhance the efficacy of CT screening in identifying those at high risk of developing lung cancer. Although cigarette smoking is the major risk factor for lung cancer, the risk of developing lung cancer depends on duration and intensity of smoking as measured by the number of cigarettes smoked per day. The risk of developing lung cancer increases more with increasing duration of smoking than the number of cigarettes smoked per day.20,21 Thus, a high-risk population are considered current smokers with a history of at least 30 years of smoking and an average consumption of at least 20 cigarettes (1 package) per day regardless of the age at which this risk level is reached and former smokers who quit no more than 5 years ago.22
Smoking history is a significant risk factor for development of lung cancer; thus, an important component of care surrounding the use of this technology is the impact of screening on decisions surrounding smoking cessation. It is important to recognize that smoking cessation is one of the most effective interventions to prevent cancer and is also essential after the diagnosis of cancer to improve clinical outcomes. Controversy exists about how the use of this technology may affect smoking behaviors. On the one hand, there is a concern that individuals who have normal CT results may have less motivation for smoking cessation and would be less likely to stop smoking.23 On the other hand, lung cancer screening with CT may present as a “teachable moment” for smoking cessation,24 and because many smokers would like to quit smoking, the use of lung cancer screening may increase the motivation for quitting smoking17
The purposes of this article were to conduct an integrative literature review to synthesize the evidence regarding the impact of lung cancer screening with CT on smoking behaviors of current smokers, examine the relationship between CT screening and smoking abstinence rates among current smokers, and identify future avenues for research in this population. The specific aims that were identified for this review were to (1) examine the relationship between low-dose chest CT screening and motivation to quit smoking, (2) examine the relationship between CT screening and smoking abstinence rate among current smokers, (3) identify factors associated with smoking abstinence after CT screening, and (4) describe the type of smoking cessation interventions that have been delivered along with CT screening.
Ganong’s25 guidelines were used to conduct this narrative integrative review. This approach suggests that researchers (1) identify specific aims for the research review, (2) identify inclusion criteria for appropriate selection of articles, (3) examine the articles for prespecified characteristics, and (4) then synthesize and interpret the results of the selected literature using content analysis.25
To conduct a comprehensive literature search, MEDLINE, PubMed, and CINAHL computerized databases were used to identify relevant articles. The key words used for the literature search were lung cancer, computed tomography, screening, smoking cessation, and smoking behavior. Additional key words were added as well, such as motivation and quit smoking. The inclusion criteria for studies in this review were that the studies had to be empirical studies and of English language and look at smoking behavior change after screening for lung cancer with CT. All studies published before September 2010 that met the inclusion criteria were included.
The search of the electronic databases yielded 560 articles. The study flow for the review is shown in the Figure. The titles of all articles were read, and only 78 titles met the inclusion criteria. After reviewing the abstracts of the 78 articles, 25 articles were selected to assess for inclusion in the integrative review. After further review of the 25 studies, 16 studies were excluded because they did not explicitly look at smoking behavior change after screening for lung cancer with CT. Thus, only 9 articles met the inclusion criteria and were included in this review. Seven studies were conducted in the United States,23,24,26–30 1 study was conducted in the Denmark,31 and 1 study was conducted in Belgium.32 Details of the included studies are presented in Table 1.
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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Current smokers; Helical computed tomography; Lung cancer; Screening; Smoking abstinence
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