Improving Non-smoking Rate - Rationale

Introduction 

Smoking cessation measures can help facilities determine the extent to which smoking cessation counseling and interventions affect their lung cancer screening (LCS) program so that performance improvement activities can be initiated as needed.   

This project rationale describes the potential improvement opportunity for LCS programs related to smoking cessation as documented in peer-reviewed literature and national guideline documents (see References below). This information is presented to provide facility personnel with an overview of the Lung Cancer Screening Registry (LCSR) measures and the impact on patient care.  

This information is a first step in completing a performance improvement project using the PDSA model and is intended to provide a stepwise understanding of smoking cessation counseling and patient non-smoking rates in your practice’s LCS program. The project is based on your data entered in the LCSR, including comparison to national data, and tailored to practices like yours.

Smoking Cessation Measures

The table below describes the measures to consider for evaluating performance relative to improving smoking cessation rates for patients.

Project Rationale: Why is the Measure Important in Clinical Practice?

In the past 20 years, though the rate of smoking on average is lower, there has been an increase in the total number of smokers. Cigarette smoking is the number one risk factor for lung cancer. It causes about 90% of lung cancer cases [1]. The risk increases with the number of years and packs per day the person smoked. Using other tobacco products such as cigars or pipes also increases the risk for lung cancer [2]. 

The USPSTF recommends that smoking cessation counseling be offered to current smokers as part of an LCS program [3]. The prevalence of smoking among individuals presenting for annual LCS is considerably higher than among those in the community with 48–70% of those undergoing LCS actively smoking [4]. LCS is therefore an opportunity for intervention with this high-risk population, including current smokers and recent former smokers. Cessation rates after LCS alone range from 16-42%; thus, adding smoking cessation counseling amplifies the benefit of LCS [5]. Those who quit smoking during the period of LCS eligibility gain an average of four life-years, which is more than the number of life-years gained through early lung cancer detection [6]. Underserved populations including patients who are Black or Latino, live in rural communities, and/or have a low socioeconomic status are overrepresented among patients eligible for LCS yet are less likely to successfully quit; therefore, targeted smoking cessation interventions may begin to reduce health inequities [7].

Radiologist Involvement in Smoking Cessation

Smoking is highly addictive and many patients who smoke have difficulty in quitting. Even in those individuals who are motivated to quit smoking, there are many obstacles in initiating this process including hesitancy for health care professionals to initiate the discussion given fears of compromising rapport with patients, lack of patient awareness of available resources, insufficient smoking cessation counseling after the initial clinical encounter, and overall difficulty of changing habitual behavior. 

Although many radiologists are supportive of engaging more directly with patients by conveying imaging results and answering questions, radiologists classically were not involved with smoking cessation efforts with patients. Hurdles include high clinical workloads, discomfort with patient interaction, absence of payment structure for time spent with patients or in quality roles, and lack of patients’ awareness of the role of radiologists in their care. However, the images of patient’s smoking-related lung disease and radiology reports are potential tools to encourage patients to consider smoking cessation. LCS programs present a unique opportunity for radiologists to facilitate patient-centered care. Radiologists can play a more active role promoting discussion of the deleterious effects of smoking either directly with patients or through the radiology report.

References

1. American Lung Association. Lung Cancer Causes & Risk Factors. Available at https://www.lung.org/lung-health-diseases/lung-disease-lookup/lung-cancer/basics/what-causes-lung-cancer. Updated November 17, 2022. Accessed March 30, 2023.

2. Centers for Disease Control and Prevention. What are the risk factors for lung cancer? Available at https://www.cdc.gov/cancer/lung/basic_info/risk_factors.htm. Updated October 25, 2022. Accessed March 9, 2023.

3. US Preventative Services Task Force. Final recommendation statement: lung cancer: screening. Available at https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/lung-cancer-screening. Updated March 09, 2021. Accessed March 9, 2023.

4. Steliga MA, Yang P. Integration of smoking cessation and lung cancer screening. Transl Lung Cancer Res. 2019;8:S88-S94. doi: 10.21037/tlcr.2019.04.02

5. Joseph AM, Rothman AJ, Almirall D, et al. Lung cancer screening and smoking cessation clinical trials. SCALE (Smoking Cessation within the Context of Lung Cancer Screening) collaboration. Am J Respir Crit Care Med. 2018;197(2):172-182. doi: 10.1164/rccm.201705-0909CI

6. Tanner NT, Kanodra NM, Gebregziabher M, et al. The association between smoking abstinence and mortality in the National Lung Screening Trial. Am J Respir Crit Care Med. 2016;193:534-541. doi: 10.1164/rccm.201507-1420OC

7. Kohn R, Vachani A, Small D, et al. Comparing smoking cessation interventions among underserved patients referred for lung cancer screening: a pragmatic trial protocol. Ann Am Thorac Soc. 2022 Feb;19(2):303-314. doi: 10.1513/AnnalsATS.202104-499SD