Attitudes and Perceptions About Smoking Cessation in the Context of Lung Cancer Screening | Cancer Screening, Prevention, Control | JAMA Internal Medicine | JAMA Network
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Aberle  DR, Adams  AM, Berg  CD,  et al; National Lung Screening Trial Research Team.  Reduced lung-cancer mortality with low-dose computed tomographic screening.  N Engl J Med. 2011;365(5):395-409.PubMedGoogle ScholarCrossref
Aberle  DR, Abtin  F, Brown  K.  Computed tomography screening for lung cancer: has it finally arrived? implications of the national lung screening trial.  J Clin Oncol. 2013;31(8):1002-1008.PubMedGoogle ScholarCrossref
Moyer  VA; US Preventive Services Task Force.  Screening for lung cancer: US Preventive Services Task Force recommendation statement.  Ann Intern Med. 2014;160(5):330-338.PubMedGoogle ScholarCrossref
Centers for Medicare & Medicaid Services.  Decision memo for screening for lung cancer with low dose computed tomography (LDCT) (CAG-00439N). Accessed April 9, 2015.
Wender  R, Fontham  ETH, Barrera  E  Jr,  et al.  American Cancer Society lung cancer screening guidelines.  CA Cancer J Clin. 2013;63(2):107-117.PubMedGoogle ScholarCrossref
Slatore  CG, Baumann  C, Pappas  M, Humphrey  LL.  Smoking behaviors among patients receiving computed tomography for lung cancer screening: systematic review in support of the US Preventive Services Task Force.  Ann Am Thorac Soc. 2014;11(4):619-627.PubMedGoogle ScholarCrossref
Park  ER, Gareen  IF, Jain  A,  et al.  Examining whether lung screening changes risk perceptions: National Lung Screening Trial participants at 1-year follow-up.  Cancer. 2013;119(7):1306-1313.PubMedGoogle ScholarCrossref
Tammemägi  MC, Berg  CD, Riley  TL, Cunningham  CR, Taylor  KL.  Impact of lung cancer screening results on smoking cessation.  J Natl Cancer Inst. 2014;106(6):dju084.PubMedGoogle ScholarCrossref
Taylor  KL, Cox  LS, Zincke  N, Mehta  L, McGuire  C, Gelmann  E.  Lung cancer screening as a teachable moment for smoking cessation.  Lung Cancer. 2007;56(1):125-134.PubMedGoogle ScholarCrossref
Park  ER, Streck  JM, Gareen  IF,  et al.  A qualitative study of lung cancer risk perceptions and smoking beliefs among national lung screening trial participants.  Nicotine Tob Res. 2014;16(2):166-173.PubMedGoogle ScholarCrossref
Gareen  IF, Duan  F, Greco  EM,  et al.  Impact of lung cancer screening results on participant health-related quality of life and state anxiety in the National Lung Screening Trial.  Cancer. 2014;120(21):3401-3409.PubMedGoogle ScholarCrossref
van der Aalst  CM, van den Bergh  KA, Willemsen  MC, de Koning  HJ, van Klaveren  RJ.  Lung cancer screening and smoking abstinence: 2 year follow-up data from the Dutch-Belgian randomised controlled lung cancer screening trial.  Thorax. 2010;65(7):600-605.PubMedGoogle ScholarCrossref
Schwartz  LM, Woloshin  S, Fowler  FJ  Jr, Welch  HG.  Enthusiasm for cancer screening in the United States.  JAMA. 2004;291(1):71-78.PubMedGoogle ScholarCrossref
Fagerlin  A, Sepucha  KR, Couper  MP, Levin  CA, Singer  E, Zikmund-Fisher  BJ.  Patients’ knowledge about 9 common health conditions: the DECISIONS survey.  Med Decis Making. 2010;30(5)(suppl):35S-52S.PubMedGoogle ScholarCrossref
Hoffman  RM, Elmore  JG, Fairfield  KM, Gerstein  BS, Levin  CA, Pignone  MP.  Lack of shared decision making in cancer screening discussions: results from a national survey.  Am J Prev Med. 2014;47(3):251-259.PubMedGoogle ScholarCrossref
Heatherton  TF, Kozlowski  LT, Frecker  RC, Fagerström  KO.  The Fagerström Test for Nicotine Dependence: a revision of the Fagerström Tolerance Questionnaire.  Br J Addict. 1991;86(9):1119-1127.PubMedGoogle ScholarCrossref
McMaster  C, Lee  C.  Cognitive dissonance in tobacco smokers.  Addict Behav. 1991;16(5):349-353.PubMedGoogle ScholarCrossref
Fotuhi  O, Fong  GT, Zanna  MP, Borland  R, Yong  HH, Cummings  KM.  Patterns of cognitive dissonance–reducing beliefs among smokers: a longitudinal analysis from the International Tobacco Control (ITC) Four Country Survey.  Tob Control. 2013;22(1):52-58. PubMedGoogle ScholarCrossref
Kinsinger  LS, Atkins  D, Provenzale  D, Anderson  C, Petzel  R.  Implementation of a new screening recommendation in health care: the Veterans Health Administration’s approach to lung cancer screening.  Ann Intern Med. 2014;161(8):597-598.Google ScholarCrossref
National Center for Health Promotion and Disease Prevention.  Lung cancer screening. Accessed April 9, 2015.
Elo  S, Kyngäs  H.  The qualitative content analysis process.  J Adv Nurs. 2008;62(1):107-115.PubMedGoogle ScholarCrossref
Pope  C, Ziebland  S, Mays  N.  Qualitative research in health care: analysing qualitative data.  BMJ. 2000;320(7227):114-116.PubMedGoogle ScholarCrossref
Zhang  Y, Wildemuth  BM. Qualitative analysis of content. In: Wildemuth  BM, ed.  Applications of Social Research Methods to Questions in Information and Library Science. Westport, CT: Libraries Unlimited; 2009:308-319.
Fiore  M, Jaen  C, Baker  T,  et al; Clinical Practice Guideline Treating Tobacco Use and Dependence 2008 Update Panel, Liaisons, and Staff.  A clinical practice guideline for treating tobacco use and dependence: 2008 update: a US Public Health Service report.  Am J Prev Med. 2008;35(2):158-176.PubMedGoogle ScholarCrossref
Prochaska  JO, DiClemente  CC.  Stages and processes of self-change of smoking: toward an integrative model of change.  J Consult Clin Psychol. 1983;51(3):390-395.PubMedGoogle ScholarCrossref
Sandelowski  M.  Sample size in qualitative research.  Res Nurs Health. 1995;18(2):179-183.PubMedGoogle ScholarCrossref
US Census Bureau.  Education: educational attainment. 2010/cats/education/educational_attainment.html. Accessed April 27, 2015.
Wiener  RS, Gould  MK, Woloshin  S, Schwartz  LM, Clark  JA.  What do you mean, a spot? a qualitative analysis of patients’ reactions to discussions with their physicians about pulmonary nodules.  Chest. 2013;143(3):672-677. PubMedGoogle Scholar
Slatore  CG, Press  N, Au  DH, Curtis  JR, Wiener  RS, Ganzini  L.  What the heck is a “nodule”? a qualitative study of veterans with pulmonary nodules.  Ann Am Thorac Soc. 2013;10(4):330-335.PubMedGoogle ScholarCrossref
Zikmund-Fisher  BJ, Fagerlin  A, Ubel  PA.  Risky feelings: why a 6% risk of cancer does not always feel like 6%.  Patient Educ Couns. 2010;81(suppl):S87-S93.PubMedGoogle ScholarCrossref
Weinstein  ND, Klein  WM.  Resistance of personal risk perceptions to debiasing interventions.  Health Psychol. 1995;14(2):132-140.PubMedGoogle ScholarCrossref
Mustanski  B, Rendina  HJ, Greene  GJ, Sullivan  PS, Parsons  JT.  Testing negative means I’m lucky, making good choices, or immune: diverse reactions to HIV test results are associated with risk behaviors.  Ann Behav Med. 2014;48(3):371-383.PubMedGoogle ScholarCrossref
Wiener  RS, Gould  MK, Woloshin  S, Schwartz  LM, Clark  JA.  “The thing is not knowing:” patients’ perspectives on surveillance of an indeterminate pulmonary nodule.  Health Expect. 2015;18(3):355-365.PubMedGoogle ScholarCrossref
Slatore  CG, Golden  SE, Ganzini  L, Wiener  RS, Au  DH.  Distress and patient-centered communication among veterans with incidental (not screen-detected) pulmonary nodules: a cohort study.  Ann Am Thorac Soc. 2015;12(2):184-192.PubMedGoogle ScholarCrossref
Meyrick  J.  What is good qualitative research? a first step towards a comprehensive approach to judging rigour/quality.  J Health Psychol. 2006;11(5):799-808.PubMedGoogle ScholarCrossref
Swensen  SJ, Jett  JR, Hartman  TE,  et al.  Lung cancer screening with CT: Mayo Clinic experience.  Radiology. 2003;226(3):756-761.PubMedGoogle ScholarCrossref
McWilliams  AM, Mayo  JR, Ahn  MI, MacDonald  SL, Lam  SC.  Lung cancer screening using multi-slice thin-section computed tomography and autofluorescence bronchoscopy.  J Thorac Oncol. 2006;1(1):61-68.PubMedGoogle ScholarCrossref
McWilliams  A, Tammemagi  MC, Mayo  JR,  et al.  Probability of cancer in pulmonary nodules detected on first screening CT.  N Engl J Med. 2013;369(10):910-919.PubMedGoogle ScholarCrossref
Henschke  CI, Yip  R, Yankelevitz  DF, Smith  JP; International Early Lung Cancer Action Program Investigators.  Definition of a positive test result in computed tomography screening for lung cancer: a cohort study.  Ann Intern Med. 2013;158(4):246-252.PubMedGoogle ScholarCrossref
Original Investigation
September 2015

Attitudes and Perceptions About Smoking Cessation in the Context of Lung Cancer Screening

Author Affiliations
  • 1Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, Washington
  • 2Department of Health Services, University of Washington, Seattle
  • 3Tobacco & Health Behavior Science Research Group, Fred Hutchinson Cancer Research Center, Seattle, Washington
  • 4Swedish Medical Group, Swedish Medical Center, Seattle, Washington
  • 5Division of Pulmonary and Critical Care Medicine, University of Washington, Seattle
JAMA Intern Med. 2015;175(9):1530-1537. doi:10.1001/jamainternmed.2015.3558

Importance  Broad adoption of lung cancer screening may inadvertently lead to negative population health outcomes if it is perceived as a substitute for smoking cessation.

Objective  To understand views on smoking cessation from current smokers in the context of being offered lung cancer screening as a routine service in primary care.

Design, Setting, and Participants  As an ancillary study to the launch of a lung cancer screening program at 7 sites in the Veterans Health Administration, 45 in-depth semi-structured qualitative interviews about health beliefs related to smoking and lung cancer screening were administered from May 29 to September 22, 2014, by telephone to 37 current smokers offered lung cancer screening by their primary care physician. Analysis was conducted from June 15, 2014, to March 29, 2015.

Main Outcomes and Measures  Attitudes and perceptions about the importance of smoking cessation in the context of lung cancer screening.

Results  Lung cancer screening prompted most current smokers to reflect for the first time on what smoking means for their current and future health. However, 17 of 35 (49%) participants described mechanisms whereby screening lowered their motivation for cessation, including the perception that undergoing an imaging test yields the same health benefits as smoking cessation. Other misperceptions include the belief that everyone who participates in screening will benefit; the belief that screening and being able to return for additional screening offers protection from lung cancer; the perception by some individuals that findings from screenings have saved their lives by catching their cancer early when indeterminate findings are identified that can be monitored rather than immediately treated; and a reinforced belief in some individuals that a cancer-free screening test result indicates that they are among the lucky ones who will avoid the harms of smoking.

Conclusions and Relevance  In this qualitative, lung cancer screening prompted many current smokers to reflect on their health and may serve as a potential opportunity to engage patients in discussions about smoking cessation. However, several concerning pathways were identified in which screening, when offered as part of routine care and described as having proven efficacy, may negatively influence smoking cessation. Health care professionals should be aware that the opportunity for early detection of lung cancer may be interpreted as a way of avoiding the harms of smoking. To promote cessation, discussions should focus on the emotional response to screening rather than clinical details (eg, nodule size) and address misperceptions about the value of early detection so that screening does not lower motivation to quit smoking.