Delivering tobacco dependence treatment in lung cancer screening programs serving socioeconomically disadvantaged populations

Background

Lung cancer continues to be the leading cause of cancer death in the United States with cigarette smoking accounting for 85–90% of all lung cancer cases in the United States (1,2). While the prevalence of smoking has declined since the 1960s, tobacco use is alarmingly high in low-income populations (3). Underserved patients with low socioeconomic status (SES) are at a higher risk for developing and dying from lung cancer due to limited access to health care services and higher smoking prevalence (3-5).

Although quitting smoking is the most effective intervention to reduce lung cancer mortality (6,7), quit rates are low. Certain groups, including smokers with lower incomes, individuals with co-morbid substance use and/or psychiatric disorders, and certain minority groups have higher rates of tobacco use and are less likely to be offered, to use, and to successfully complete evidence-based tobacco dependence treatment (8-11). Therefore, connecting underserved smokers with evidence-based cessation treatment is critical for reducing tobacco related cancer disparities.

Lung cancer screening is one such opportunity to connect low SES smokers to tobacco treatment. In 2011, the National Lung Screening Trial (NLST) found that in patients at high risk for developing lung cancer, lung cancer screening with low-dose helical computed tomography (LDCT) resulted in a 20% reduction in mortality from lung cancer compared to screening with single-view chest X-ray (12). The U.S. Preventive Services Task Force (USPSTF) recommends that for those at high risk for lung cancer (those aged 55–80 years with a 30-pack-year smoking history who were either current smokers or had quit within the last 15 years) undergo annual screening for lung cancer with LDCT (13).

Approximately 50% of individuals eligible for LDCT screening are estimated to be current smokers (14,15). Within the NLST, current smokers, blacks, and those with less than a high school education had a higher risk of lung cancer death (16). Current smokers who undergo annual LDCT screening and successfully quit smoking derive the greatest reduction in lung cancer mortality. Thus, providing both LDCT screening and tobacco dependence treatment to current smokers offers the opportunity to dramatically reduce smoking-related morbidity and mortality.

Recognizing the importance associated with helping adults quit smoking, the USPSTF recommends that smoking cessation interventions be delivered in conjunction with LDCT screening (17). Additionally, the Centers for Medicare and Medicaid Services (CMS) requires current smokers to receive counseling on the importance of smoking cessation and, if appropriate, information about smoking-cessation interventions in order to receive Medicare reimbursement of LDCT screening. Lung cancer screening programs thus offer a unique opportunity to incorporate tobacco treatment.

The Society for Research on Nicotine and Tobacco (SRNT) and the Association for the Treatment of Tobacco Use and Dependence (ATTUD) have recently provided a clinical guideline regarding delivery of smoking cessation interventions in the context of lung cancer screening (18). In this report, we summarize the SRNT/ATTUD guidelines on integrating smoking cessation interventions into lung cancer screening programs. We discuss barriers, potential solutions, and ongoing research efforts on how to implement tobacco treatment within lung cancer screening programs, particularly as it pertains to low SES populations.

Summary of SRNT/ATTUD Clinical Guideline on delivery of smoking cessation interventions within lung cancer screening programs

The SRNT/ATTUD has recently published a position statement on pairing smoking-cessation statements with lung cancer screening (18). The guideline recommends that smokers who present for lung cancer screening should be encouraged to quit smoking at each visit, regardless of lung cancer screening results. Smokers in this high risk group should be assisted with access to evidence-based behavioral and pharmacologic treatments as outlined in the US Public Health Service (PHS) Treating Tobacco Use and Dependence Clinical Practice Guideline and that follow-up contacts to support smoking-cessation efforts should be arranged for smokers (19).

The PHS outlines an effective, brief intervention model called the 5As. In this model, at each visit, health care providers should “Ask” patients about their smoking, “Advise” smokers to quit, “Assess” smokers’ willingness to quit, “Assist” smokers in quitting, (such as provide practical counseling and FDA approved medications), and “Arrange” for follow-up with smokers (by telephone or in person) after their scheduled quit date. In a retrospective case-control study analyzing self-reported physician interventions and quit rates by NLST participants, among the 5As approach, the “Assist” and “Arrange” steps increased odds of quitting by 40% and 46% respectively (20).

The SRNT/ATTUD position statement on pairing smoking cessation services with LDCT screening highlights that because motivation to quit fluctuates in this population, that an opt-out tobacco-treatment approach should be considered in which all smokers undergoing LDCT screening receive access to smoking-cessation treatment regardless of their motivation to quit (18). The SRNT/ATTUD position statement also recommends that for patients who are not motivated to quit, evidence-based strategies, such as the 5Rs should be used at each visit to motivate smokers to try quitting smoking. In the 5R model, at each visit health care providers should have discussions with the patient of the personal “Relevance” of smoking cessation, the “Risks” of smoking, the “Rewards” of smoking cessation, and the potential “Roadblocks” to quitting. The fifth step is to “Repeat” these steps as necessary at all visits.

Barriers and potential solutions to delivering guideline-recommended tobacco treatment in low SES smokers undergoing LDCT screening

Most U.S. adult smokers are poor, have less than a high school education, and/or are on Medicaid (21). In implementing tobacco treatment in lung cancer programs that serve predominately low SES smokers, it is important to understand both patient-level and provider-level factors that contribute to disparities in use of tobacco cessation treatment in this patient population. Low income smokers may be less likely to seek treatment because of significant life stressors, lower levels of knowledge about the benefits of pharmacotherapy, as well as significant barriers to health care access (22,23). Clinicians should therefore not miss opportunities to address smoking cessation at any screening visit. Unfortunately, while most health care providers believe smoking cessation is important, many studies have noted that only a small minority provide guideline recommended cessation support to their patients (22,23). Within the LDCT screening setting, barriers such as limited time, resources, and knowledge about tobacco treatment, as well as difficulty identifying screen-eligible smokers prevent optimal delivery of tobacco treatment. Overcoming these barriers in any given facility will vary depending on the resources available for tobacco dependence treatment.

Electronic health record (EHR) to identify and treat screen-eligible smokers

Using the EHR to proactively reach screen-eligible patients may be effective at overcoming provider bias in offering LCS and/or smoking interventions to a variety of patient populations, including racial and ethnic minorities, low income patients, or patients with mental health disorders. The EHR can also prompt clinicians to encourage quitting and connect patients to cessation resources and materials such as quitlines. Interactive Voice Response (IVR), a phone technology that allows a computer to detect voice responses during a call, may provide an efficient way to reach large populations, such as patients identified in the EHR as screen-eligible smokers.

Knowledge of FDA-approved medications and counseling skills

It is imperative that clinicians have the knowledge and skills to deliver smoking cessation services to their patients during the LDCT screening visit. There is high quality evidence that delivered smoking cessation counselling (either group or individual) can assist smokers to quitting and that intensive counseling improves quit rates over brief interventions (19). Interventions that combine pharmacotherapy and behavioral support increase smoking cessation success compared to a minimal intervention or usual care. Smokers should be offered counseling, such as the 5A’s model, at each screening visit.

There are seven FDA-approved medications for tobacco treatment: (I) five forms of nicotine replacement therapy (nicotine gum, lozenges, and patches can be bought without a prescription; nicotine nasal spray and inhalers are available by prescription only); (II) Bupropion (Wellbutrin; Zyban); and (III) Varenicline (Chantix). Physicians should feel comfortable in prescribing combination NRT (e.g., patch plus gum) and combination NRT plus bupropion to further improve quit rates. Clinicians should also know that based on the results of a large clinical trial (24), the Boxed Warning for serious mental health side effects from the Chantix and Bupropion drug label was removed in December 2016. Prescribing guidelines for the 7 FDA-approved medications are available at http://www.aafp.org/dam/AAFP/documents/patient_care/tobacco/pharmacologic-guide.pdf.

Available resources and information for receiving training in tobacco treatment

For some facilities, a dedicated service in the LDCT facility or a dedicated clinician with tobacco treatment experience could be integrated into the lung cancer screening treatment team to provide tobacco treatment services. Training in tobacco treatment can be received either online (http://tobaccodependence.chestnet.org/) or by attending specialized training in tobacco treatment (http://www.attud.org). Furthermore, materials tailored to Hispanic and African-American patients are available at http://smokefree.gov. Other approaches include referring to internal or external facilities specializing in tobacco treatment and/or toll-free quitlines (800-QUIT-NOW) available in all 50 states. Quit Lines (available in both English and Spanish) may be particularly helpful for low-income patients since access to these services is free.

Tailoring smoking cessation counseling based on smokers’ responses to LDCT screening and results

Some evidence exists that smokers receiving positive LDCT screening results may have increased smoking cessation (25-28), whereas those receiving normal screening results may feel little urgency to quit (29). Clinicians can co-create a teachable moment that builds on these responses to screening and LDCT results to motivate their patients to quit smoking. A tobacco treatment specialist integrated into the LDCT process can deliver tailored interventions based on the individual’s readiness to quit and/or lung cancer screening results to help overcome clinician barriers of time constraints, competing priorities, and knowledge gap of available treatments.

Research gaps and future directions

LDCT screening may represent a “teachable moment” in which to reach these heavily addicted smokers at a time when they may be more aware of the harms of tobacco use and thus more likely to be receptive to smoking cessation interventions. While there are little data on the effectiveness of smoking cessation interventions in the lung cancer screening setting (20,30-35), more intensive interventions appear to be associated with greater improvement in readiness to quit and 6-month smoking abstinence in patients undergoing LDCT screening (20).

In the SRNT/ATTUD guideline, the authors highlight the need for (I) research on the optimal intensity, timing relative to screening, and delivery mode of smoking-cessation interventions for this population and important moderators of these effects and (II) research on the potential adverse effects of screening on smoking-cessation motivation, the barriers to implementing smoking-cessation interventions within LDCT clinics, and the education and training needs of LCDT clinical staff to support smoking cessation (18). The American Thoracic Society (ATS) has recently convened a panel to develop a policy statement outlining a research agenda on the integration and implementation of smoking cessation interventions with LDCT lung cancer screening (36). This statement highlights research gaps and prioritizes key research questions in three domains: (I) target population to study; (II) adaptation, development, and testing of interventions; and (III) implementation of interventions with demonstrated efficacy and identified standardized measures to conduct this research.

To address research gaps in this area, eight clinical trials [seven funded by the National Cancer Institute (NCI) and one by the Veterans Health Administration (VHA)] will test smoking cessation interventions for smokers undergoing LDCT lung cancer screening (37,38). Investigators from these trials have formed the Smoking Cessation within the Context of Lung Cancer Screening (SCALE) collaboration and have outlined standardized measures and approaches to conduct high-quality studies in this setting. Little research has focused on challenges specific to low SES populations, such as how to reach and support low income and minority screen-eligible smokers in their cessation attempts and treatment adherence. Through the American Lung Association (ALA) Lung Cancer Discovery award mechanism, we will be conducting a clinical trial testing whether delivering an inpatient shared decision making and tobacco treatment intervention in a large safety net hospital can promote engagement with LDCT screening and tobacco treatment among low income and minority smokers.

While we await the results of these trials, clinicians can improve the rate of smoking cessation among their current smokers undergoing lung cancer screening by improving their counseling skills (5As), familiarizing themselves with tobacco clinical guidelines, incorporating reminders into practice systems, and increasing their knowledge of pharmacotherapy. As outlined in the PHS and SRNT/ATTUD guidelines, all smokers should be offered counseling and pharmacological treatment at each screening visit and when feasible be offered the most intensive intervention available, regardless of lung cancer screening results and motivation to quit.

Acknowledgements

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned by the Guest Editors (Ricardo Sales dos Santos, Myrna Godoy, Juliana Franceschini and Hiran C. Fernando) for the series “Update on Lung Cancer Screening and the Management of CT Screening Detected Pulmonary Nodules” published in AME Medical Journal. The article has undergone external peer review.

Conflicts of Interest: The author has completed the ICMJE uniform disclosure form (available at http://dx.doi.org/10.21037/amj.2017.09.03). The series “Update on Lung Cancer Screening and the Management of CT Screening Detected Pulmonary Nodules” was commissioned by the editorial office without any funding or sponsorship. The author has no other conflicts of interest to declare.

Ethical Statement: The author is accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. American Cancer Society. Cancer Facts and Figures. Atlanta: American Cancer Society, 2016.
2. U.S. Cancer Statistics Working Group. United States Cancer Statistics: 1999-2013. Incidence and Mortality Web-based Report. Atlanta (GA): Department of Health and Human Services, Centers for Disease Control and Prevention, and National Cancer Institute, 2016.
3. Centers for Disease Control and Prevention. Best Practices User Guide: Health Equity in Tobacco Prevention and Control. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2015.
4. Franks P, Jerant AF, Leigh JP, et al. Cigarette prices, smoking, and the poor: implications of recent trends. Am J Public Health 2007;97:1873-7. [Crossref] [PubMed]
5. Clegg LX, Reichman ME, Miller BA, et al. Impact of socioeconomic status on cancer incidence and stage at diagnosis: selected findings from the surveillance, epidemiology, and end results: National Longitudinal Mortality Study. Cancer Causes Control 2009;20:417-35. [Crossref] [PubMed]
6. WHO International Agency for Research on Cancer (IARC). IARC monographs on the evaluation of carcinogenic risks to humans. Lyon, France: International Agency for Research on Cancer, 2012.
7. National Center for Chronic Disease Prevention and Health Promotion (US) Office on Smoking and Health. The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General. Atlanta (GA): Centers for Disease Control and Prevention (US), 2014.
8. Cox LS, Okuyemi K, Choi WS, et al. A review of tobacco use treatments in U.S. ethnic minority populations. Am J Health Promot 2011;25:S11-30. [Crossref] [PubMed]
9. Murray RP, Connett JE, Buist AS, et al. Experience of Black participants in the Lung Health Study smoking cessation intervention program. Nicotine Tob Res 2001;3:375-82. [Crossref] [PubMed]
10. Lee CS, Hayes RB, McQuaid EL, et al. Predictors of retention in smoking cessation treatment among Latino smokers in the Northeast United States. Health Educ Res 2010;25:687-97. [Crossref] [PubMed]
11. Centers for Disease Control and Prevention (CDC). Quitting smoking among adults--United States, 2001-2010. MMWR Morb Mortal Wkly Rep 2011;60:1513-9. [PubMed]
12. Aberle DR, Adams AM, Berg CD, et al. Reduced lung-cancer mortality with low-dose computed tomographic screening. N Engl J Med 2011;365:395-409. [Crossref] [PubMed]
13. Moyer VAU.S. Preventive Services Task Force. Screening for lung cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med 2014;160:330-8. [PubMed]
14. Ma J, Ward EM, Smith R, et al. Annual number of lung cancer deaths potentially avertable by screening in the United States. Cancer 2013;119:1381-5. [Crossref] [PubMed]
15. Humphrey LL, Deffebach M, Pappas M, et al. Screening for lung cancer with low-dose computed tomography: a systematic review to update the US Preventive services task force recommendation. Ann Intern Med 2013;159:411-20. [Crossref] [PubMed]
16. Tanner NT, Gebregziabher M, Hughes Halbert C, et al. Racial Differences in Outcomes within the National Lung Screening Trial. Implications for Widespread Implementation. Am J Respir Crit Care Med 2015;192:200-8. [Crossref] [PubMed]
17. Wiener RS, Gould MK, Arenberg DA, et al. An official American Thoracic Society/American College of Chest Physicians policy statement: implementation of low-dose computed tomography lung cancer screening programs in clinical practice. Am J Respir Crit Care Med 2015;192:881-91. [Crossref] [PubMed]
18. Fucito LM, Czabafy S, Hendricks PS, et al. Pairing smoking-cessation services with lung cancer screening: A clinical guideline from the Association for the Treatment of Tobacco Use and Dependence and the Society for Research on Nicotine and Tobacco. Cancer 2016;122:1150-9. [Crossref] [PubMed]
19. 2008 PHS Guideline Update Panel La, and Staff. Treating tobacco use and dependence: 2008 update U.S. Public Health Service Clinical Practice Guideline executive summary. Respir Care 2008;53:1217-22. [PubMed]
20. Park ER, Gareen IF, Japuntich S, et al. Primary Care Provider-Delivered Smoking Cessation Interventions and Smoking Cessation Among Participants in the National Lung Screening Trial. JAMA Intern Med 2015;175:1509-16. [Crossref] [PubMed]
21. Levinson AH. Where the U.S. tobacco epidemic still rages: Most remaining smokers have lower socioeconomic status. J Health Care Poor Underserved 2017;28:100-7. [Crossref] [PubMed]
22. Blumenthal DS. Barriers to the provision of smoking cessation services reported by clinicians in underserved communities. J Am Board Fam Med 2007;20:272-9. [Crossref] [PubMed]
23. Browning KK, Ferketich AK, Salsberry PJ, et al. Socioeconomic disparity in provider-delivered assistance to quit smoking. Nicotine Tob Res 2008;10:55-61. [Crossref] [PubMed]
24. Anthenelli RM, Benowitz NL, West R, et al. Neuropsychiatric safety and efficacy of varenicline, bupropion, and nicotine patch in smokers with and without psychiatric disorders (EAGLES): a double-blind, randomised, placebo-controlled clinical trial. Lancet 2016;387:2507-20. [Crossref] [PubMed]
25. Ashraf H, Tønnesen P, Holst Pedersen J, et al. Effect of CT screening on smoking habits at 1-year follow-up in the Danish Lung Cancer Screening Trial (DLCST). Thorax 2009;64:388-92. [Crossref] [PubMed]
26. Ashraf H, Saghir Z, Dirksen A, et al. Smoking habits in the randomised Danish Lung Cancer Screening Trial with low-dose CT: final results after a 5-year screening programme. Thorax 2014;69:574-9. [Crossref] [PubMed]
27. Styn MA, Land SR, Perkins KA, et al. Smoking behavior 1 year after computed tomography screening for lung cancer: Effect of physician referral for abnormal CT findings. Cancer Epidemiol Biomarkers Prev 2009;18:3484-9. [Crossref] [PubMed]
28. Slatore CG, Baumann C, Pappas M, et al. Smoking behaviors among patients receiving computed tomography for lung cancer screening. Systematic review in support of the U.S. preventive services task force. Ann Am Thorac Soc 2014;11:619-27. [Crossref] [PubMed]
29. Zeliadt SB, Heffner JL, Sayre G, et al. Attitudes and Perceptions About Smoking Cessation in the Context of Lung Cancer Screening. JAMA Intern Med 2015;175:1530-7. [Crossref] [PubMed]
30. Bade M, Bähr V, Brandt U, et al. Effect of smoking cessation counseling within a randomised study on early detection of lung cancer in Germany. J Cancer Res Clin Oncol 2016;142:959-68. [Crossref] [PubMed]
31. Marshall HM, Courtney DA, Passmore LH, et al. Brief Tailored Smoking Cessation Counseling in a Lung Cancer Screening Population is Feasible: A Pilot Randomized Controlled Trial. Nicotine Tob Res 2016;18:1665-9. [Crossref] [PubMed]
32. Luh DL, Chen SL, Yen AM, et al. Effectiveness of advice from physician and nurse on smoking cessation stage in Taiwanese male smokers attending a community-based integrated screening program. Tob Induc Dis 2016;14:15. [Crossref] [PubMed]
33. Ferketich AK, Otterson GA, King M, et al. A pilot test of a combined tobacco dependence treatment and lung cancer screening program. Lung Cancer 2012;76:211-5. [Crossref] [PubMed]
34. van der Aalst CM, de Koning HJ, van den Bergh KA, et al. The effectiveness of a computer-tailored smoking cessation intervention for participants in lung cancer screening: a randomised controlled trial. Lung Cancer 2012;76:204-10. [Crossref] [PubMed]
35. Clark MM, Cox LS, Jett JR, et al. Effectiveness of smoking cessation self-help materials in a lung cancer screening population. Lung Cancer 2004;44:13-21. [Crossref] [PubMed]
36. Kathuria H, Detterbeck F, Fathi J, et al. An Official ATS Research Policy Statement: Stakeholder Research Priorities for Smoking Cessation Interventions within LDCT Screening Programs. Am J Respir Crit Care Med 2017; In Press.
37. Available online: http://grants.nih.gov/grants/guide/rfa-files/RFA-CA-15-011.html
38. Tobacco Use and Cessation in Cancer Screening, Diagnosis, Treatment, and Survivorship. Available online: https://cancercontrol.cancer.gov/brp/tcrb/research_topic-tobacco-use.html