Lung Cancer Screening Programs May Have Unintended Consequences on Beliefs about Smoking Cessation

BACKGROUND:
Implementation of lung cancer screening programs has been growing as a result of recommendations that heavy smokers be offered annual lung cancer screening with low-dose CT chest imaging. However, guidelines emphasize that patients should not perceive screening as a substitute for smoking cessation. Thus, this study aimed to learn from patients who were offered screening how the availability of screening influenced their motivations regarding smoking cessation. The VHA Lung Cancer Screening Clinical Demonstration Project is a pilot study implementing a primary care-based lung cancer screening clinical reminder at 7 VAMCs. Veterans (n=37) were approached within a few days of being offered screening to participate in 2 telephone interviews, one shortly after being offered screening, and the second after receiving their results, and were offered $50 for participating in each interview (due to how quickly screening was conducted, most Veterans were only interviewed once, after they had received their results).

FINDINGS:

• Current smokers attached exaggerated personal benefits to lung cancer screening. Misperceptions about susceptibility to harms from tobacco can be reinforced and potentially exacerbated by screening due to existing cognitive biases about smoking and exaggerated beliefs in the value of early detection provided by lung cancer screening.
• Five themes emerged around types of misperceptions related to cessation associated with screening: 1) screening was valuable because everyone screened would be protected, 2) screening would show how much damage had been caused by an individual's smoking, 3) identification and monitoring of a lung nodule was evidence that cancer can be caught early (e.g., detection of a nodule meant that "screening was working"), 4) screening reduces the likelihood of needing cancer treatment (e.g., screening could cure cancer if the cancer was found early enough), and 5) screening verified the belief that smoking doesn't harm everyone and "won't harm me personally."
• Three out of 37 participants reported that they had quit smoking for at least 30 days since being offered screening.

LIMITATIONS:

• The qualitative nature of the study did not allow investigators to quantify how screening will affect quit rates or generalize to broad populations.
• Those who participated may have been more positive toward screening.

IMPLICATIONS:
Offering Veterans lung cancer screening as a proven clinical service distracts and often subverts smoking cessation messages. If this leads to lower quit rates among smokers, this would dilute or even eliminate the population-level value of lung cancer screening. Investigators recommend that healthcare professionals de-emphasize the clinical aspects of screening results (e.g., nodule size) and focus on the emotional reactions smokers have to undergoing screening by developing messages to address the different types of misperceptions associated with screening.

Zeliadt S, Heffner J, Sayre G, Klein D, Simons C, Williams J, Reinke L, Au D. Attitudes and Perceptions about Smoking Cessation in the Context of Lung Cancer Screening. JAMA Internal Medicine September 1, 2015;175(9):1530-37.