Elsevier

Lung Cancer

Volume 98, August 2016, Pages 91-98
Lung Cancer

Review
Smoking cessation interventions within the context of Low-Dose Computed Tomography lung cancer screening: A systematic review

https://doi.org/10.1016/j.lungcan.2016.05.028Get rights and content

Highlights

  • Participation in lung cancer screening may represent a teachable moment for quitting smoking.

  • Evidence has not yet supported tailored self-help cessation interventions for this population.

  • There have been few studies testing smoking cessation interventions for lung screening patients.

  • Research is needed to test and implement cessation interventions in the LDCT screening setting.

Abstract

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.

Introduction

Lung cancer is the leading cause of cancer-related mortality worldwide, and is the second most diagnosed cancer in both men and women in the US and in Europe [1], [2]. The most important risk factor for lung cancer is tobacco smoking, which is associated with approximately 85–90% of all lung cancer cases in the US and Europe [2], [3]. In Europe, lung cancer accounts for 12% of all new cancer diagnoses, as well as 20% of all cancer deaths [1]. In the US, lung cancer accounts for 13% of total new cancer diagnosis and 27% of total cancer deaths [4], and there are approximately 8.6 million adults between the ages of 55 and 75 who have extensive smoking histories (i.e., ≥30 pack-years) and are consequently at higher risk for developing lung cancer [5]. Smoking cessation is the most effective way to reduce the risk of developing lung cancer among smokers [2].

For decades, screening for breast, cervical, and colon cancer has been the standard of care, but screening for lung cancer was not recommended due to a lack of research demonstrating decreased mortality. This changed when results of the prospective randomized National Lung Screening Trial (NLST) were published in 2011 [6]. The NLST demonstrated that screening using low-dose computed tomography (LDCT) reduced mortality from lung cancer by 20% as compared to individuals who received a standard chest X-ray. In the US, LDCT is now considered an effective practice that both reduces mortality from lung cancer [6], [7] and demonstrates promise as a cost-effective screening method [8]. In Europe, there are not yet sufficient data to determine whether LDCT screening has a significant mortality impact. Results are expected in the near future from the recently-completed NELSON trial, the largest European randomized controlled trial (RCT) of lung cancer screening [9].

A review by the U.S. Preventive Services Task Force (USPSTF) [10] recommended that all individuals eligible for lung cancer screening (adults at high risk; individuals age 55–80 with a 30 pack-year smoking history, either current smokers or those who have quit within the previous 15 years) should receive smoking cessation interventions (SCIs) to prevent continued tobacco use and tobacco-related disease. In fact, this review emphasized the importance of advising smokers to stop smoking and offering cessation treatment as part of a lung cancer screening program. LDCT screening may prevent lung cancer deaths for both former and current smokers, and that the opportunity for smoking cessation provides an added benefit for screening participants who continue to smoke. In fact, lung cancer screening alone, without smoking cessation advice, could provide unjustified relief to smokers, reducing their likelihood of quitting smoking. Guidelines have emphasized, and the Center for Medicare and Medicaid Services (CMS) now requires, carefully counseling patients to ensure that screening is not perceived as a substitute for smoking cessation [11], [12]. Smoking cessation in addition to lung cancer screening could further reduce lung cancer-related mortality beyond the effects of LDCT screening alone [13], [14]. Thus, the integration of an SCI within the framework of a lung cancer screening program could and should be rigorously implemented, as suggested in published screening guidelines [15], [16], [17]. Although there are no established lung cancer guidelines or reimbursement for screening in Europe, the European Society of Radiology and the European Respiratory Society have recommended lung cancer screening in medical settings, and has encouraged the inclusion of smoking cessation programs and experienced staff providing effective cessation advice [18].

LDCT has been shown to serve as a “teachable moment” that encourages cessation in the high risk smoking population that receives the screening [19], [20], [21], [22], [23], [24], [25]. The concept of “teachable moment” is used to explain health events that motivate individuals to adopt risk-reducing health behaviors [26]. Some studies suggest that participation in a lung screening trial in itself induces smoking cessation, as compared to spontaneous quit rates [22], [27], [28]. For example, in a study conducted in the Netherlands, van der Aalst et al. [22] reported that 16.6% of all participants quit smoking within two years of a screening trial with a minimal intervention (written smoking cessation information only once at randomization), which is higher that the estimated 3%-7% spontaneous quit attempts observed in the general population. Offering specialized SCIs within lung cancer screening programs may provide an opportunity to capitalize upon this “teachable moment” to improve cessation rates further.

Despite the research cited above, a recent systematic review of studies assessing changes in smoking behavior within the LDCT process concluded that there is limited evidence that LDCT itself promotes cessation [29]. Specifically, the relationship between lung screening and smoking cessation behaviors may differ based on the screening result. Several studies have investigated the impact of abnormal (positive) versus normal (negative) results on smoking behavior among screened individuals [23], [27], [30], [31], [32]. It has been suggested that informing individuals at high-risk for lung cancer of a negative screening result may give them permission, license, or a “green light” to continue smoking [21]. That is, individuals whose screens are normal may continue their unhealthy behaviors because they think they have a clean bill of health. It is plausible that the negative screening may create some relief among smokers based on false confidence. Prior research, however, has not fully supported this notion [19], [23], [30]. Cox et al. [19] found no evidence that participants receiving negative screening results were less likely to change their smoking behavior compared to participants receiving positive results in a sample of 1475 high risk adults. Using the same sample, Townsend et al. [23] found that 20% of current smokers at baseline who received 3 normal screens reported abstinence from smoking at 3-years follow-up. This rate of 20% is within the expected levels (9–21%) based on estimated spontaneous quit rates in a general population (3–7% annual quit rate over 3 years, assuming no relapse, [33]). Anderson et al. [30] provided evidence indicating that a consistently negative result in a lung cancer screening program was not associated with a reduced likelihood of achieving long-term abstinence or increased relapse over a 6 year follow-up.

Although a negative screening result may not impede smoking cessation, there is some evidence a positive (abnormal) screening result is associated with greater motivation to quit smoking [24] and actual smoking cessation [20], [21], [23], [32], [34]. For example, Tammemagi et al. [32] showed that smoking cessation was strongly associated with the severity of the result (amount of abnormality) observed in the previous year’s screening. Styn et al. [34] found that abnormal CT screening results were associated with increased likelihood of smoking cessation at 1 year follow-up. Townsend et al. [23] evaluated the impact of three annual lung cancer screenings and found that the number of abnormal screening results (0, 1, 2, or 3) was linearly associated with smoking abstinence rates (20%, 24%, 28%, and 42%, respectively).

Although there is evidence that both early detection of lung cancer and SCIs can decrease lung cancer mortality, studies of SCIs conducted among smokers screened for lung cancer remain scarce. Nevertheless, SCIs are strongly recommended in lung cancer screening [10], [16], and smokers pursuing lung cancer screening appear interested in smoking cessation and are motivated to quit [21], [22], [23], [24]. However, there is a lack of systematic, controlled research on intervention modalities for screening patients. It is important to identify what (if any) types of SCIs are most efficacious in promoting abstinence among the population presenting for LDCT screenings. Therefore, we conducted a systematic literature review of studies reporting smoking-related outcomes from cessation interventions among patients receiving LDCT.

Section snippets

Search strategy

We conducted a systematic search of the following databases to identify relevant peer-reviewed published research articles: PubMed (titles or abstracts), ISI Web of Science (titles or topics), and The Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews. We also identified additional references from relevant articles included in the review and relevant systematic reviews. Search terms used included: smoking cessation AND intervention AND lung cancer AND

Results

Of the initial 108 titles identified by the search strategy, 88 met our criteria for abstract review, and 23 met our criteria for full text review. Sixty five articles were excluded during this screening process, and an additional 17 titles were excluded during full text review. In total, six articles met all inclusion criteria and were included in this review—three RCTs and three single-arm studies. A PRISMA diagram describing the study selection and exclusion process of this systematic review

Discussion

The aim of this review was to identify, describe, and synthesize findings from SCIs conducted with patients receiving LDCT for lung cancer screening. Overall, the studies included in this systematic review are heterogeneous in design, sample size, SCI modality, timing of intervention, and measurement of smoking abstinence outcomes. Six studies were included in the review, but only three were RCTs, and efficacy results across all studies were modest at best. Nevertheless, there were some

Conflicts of interest statement

Thomas H. Brandon receives research support from Pfizer, Inc. All other authors declare that they have no conflicts of interest. The authors alone are responsible for the content and writing of the article.

Funding

Preparation of this review was supported by James and Esther King grant 4KB17 from the Florida Biomedical Research Program and by Postdoctoral Training Grant, Galician Program for Research, Innovation and Growth 2011-2015 (I2C Plan), modality A, Xunta de Galicia, Spain.

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