The U.S. Preventive Services Task Force (USPSTF) recently issued a B recommendation that individuals age 55-80 with a significant history of smoking should be offered annual lung cancer screening with low-dose chest CT imaging. VHA conducted a Lung Cancer Screening Demonstration Project in 8 sites (10/1/2013-9/30/2015) to identify best practices for rollout of screening nationally across VHA. A critical challenge identified by the Demonstration Project is how best to integrate smoking cessation counseling. Interviews with participants in the Demonstration Project found that patients offered screening feel protected from the harms of smoking and may perceive screening to be an alternative to cessation. These qualitative findings provided the foundation for developing and pilot testing a telephone-based counseling intervention to effectively integrate smoking cessation counseling into the lung cancer screening process.
The objectives of this pilot study were: 1) Test the feasibility of a prototype tele-nurse intervention among Veterans receiving lung cancer screening in order to discuss screening results and connect them to smoking cessation services; 2) Compare utilization of smoking cessation resources among participants in the prototype MI intervention with a convenience sample of Veterans receiving usual care in the Demonstration Project; and 3) Conduct a qualitative assessment of the tele-nurse sessions to assess barriers in use of cessation resources, assess patient acceptability of the intervention, and identify effective messaging about the integration of cessation services with lung cancer screening.
The content of the prototype tele-nurse intervention based on the Extended Parallel Processing Modeling was organized into to two telephone sessions. We designed a protocol for proactively reaching out to patients after they were referred for screening, but prior to undergoing screening. The first session focused on reviewing any additional questions patients may have about the screening process. The second session was designed to be delivered to patients after they had received their screening results from their provider. The intervention sessions incorporated principles of motivational interviewing guided by the trans-theoretical behavioral change model with a focus on overcoming barriers to using available smoking cessation tools, including counseling and medications.
We recruited current smokers who were offered screening at 4 VA medical centers (NY Harbor, NY, Portland, OR, Charleston, SC, and Durham, NC). Potential participants were identified by the study site (Seattle, WA) using weekly data extractions from the VHA's National Corporate Data Warehouse. Central IRB approval was obtained to facilitate recruitment and data collection from multiple sites. We used a pragmatic approach to assign potential participants to the intervention or control groups. Current smokers identified as having an upcoming screening visit and could be contacted prior to receiving their screening results were assigned to the intervention group; and individuals who had recently been screened and had already received their screening results when identified during the weekly data extractions were assigned to the control group. A 2:1 ratio of control to intervention participants was utilized because of the availability of potential control subjects using the centralized Corporate Data Warehouse identification approach. Both groups were sent study invitation packets, which for intervention participants described the two-call intervention and a subsequent telephone evaluation survey, and for control participants described only a telephone evaluation survey about lung cancer screening. Participants in both groups received lung cancer screening care as it was provided by their medical center, which included screening results letters providing the national VA Quitline number (1-855-QUIT-VET) and access to tobacco treatment services at their facility.
Motivational Interviewing strategies were used to provide smokers with education about lung cancer screening, evidence based cessation treatments, and their individual health risks associated with smoking, deliver feedback about their screening results, promote more accurate understanding of the benefits of smoking cessation relative to lung cancer screening, enhance motivation and self-efficacy for attempting cessation, and facilitate decision making about smoking cessation. Because lung cancer screening in VHA focuses on connecting participants with VHA tobacco control services, our primary outcome was whether the participant reported use of any behavioral support service including: a) connecting with the VA Quitline, b) an appointment with a tobacco treatment counselor, or c) participation in a group counseling session. Secondary outcomes included 7-day self-reported cigarette abstinence and 7-day abstinence from any tobacco product, motivation to quit as measured by 1-item Contemplation Ladder, the 3-item Stages of Change algorithm, and single item cessation self-efficacy measure. Intervention participants were asked 4 additional items about their satisfaction with participating in the intervention. The sample size for the pilot trial was based on the available pilot budget of $100,000 and guidelines for Stage I treatment development projects. Frequencies and descriptive statistics are reported, along with estimates of the intervention effect using risk ratios with 95% confidence intervals rather than null hypothesis significance testing due to the size of the pilot trial.
Overall, 28 of 98 (29%) individuals approached participated in the two-call intervention and 27 (28%) participated in the telephone evaluation. Of the 141 participants approached for the control evaluation, 56 (40%) participated in the telephone evaluation . One critical challenge with recruitment was the use of a telephone line based at the research study site which was required to indicate "Unknown Caller" on caller ID. The convenience sampling approach for selection of the control group subjects resulted in similar in demographic and clinical characteristics as the participants in the intervention group.
The pilot intervention was considered successful with respect to feasibility and utilization of cessation services. More intervention participants utilized behavioral cessation support services - the primary study goal - compared to control participants (44% vs 11%). Participants receiving the intervention were four times more likely to use behavioral cessation support than the control group (Relative Risk (RR) 4.1; 95% confidence interval (CI): 1.7 - 9.9). More participants receiving the intervention reported 7-day abstinence from cigarettes two weeks after receiving their screening results compared to intervention participants (19% vs 7%, RR: 2.6; 95% CI: 0.8 - 8.9). Process outcomes included the key intervention targets of motivational readiness and self-efficacy to quit. These process outcomes were better among intervention participants: fewer intervention participants indicated they had no confidence they could quit compared to control participants (11% vs 36%). Most participants had heard of the VA Quitline, although more intervention participants reported using it than control participants (15% vs 5%). The use of NRT medications for smoking cessation was an unexpected finding. Use of NRT was not significantly different across study arms; however, fewer intervention participants reported using NRT since being offered screening compared to control participants (37% vs 50%).
Enthusiasm for the intervention was high, with 89% of participants reporting they were satisfied with the proactive telephone calls and 81% indicating that they would definitely or probably recommend participating in the calls to a friend.
Our findings suggest that integrating risk messages with brief motivational interventions when counseling current smokers participating in lung cancer screening, both before screening and after they have their screening results, can be a valuable component of lung cancer screening delivery. This study demonstrates that this counseling can potentially be delivered by a telephone counselor with whom the patient has not previously interacted during an in-person clinic visit. The findings provide a strong signal for acceptability and efficacy of the intervention and support further evaluation in a larger randomized implementation trial.
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