Getting Lung Cancer Screening Staff Involved Improved Tobacco Cessation

Integrating smoking cessation into a lung cancer screening program had the biggest benefit for patients who wanted to quit, a randomized trial showed.

Self-reported tobacco abstinence was greater at both 3 and 6 months with higher levels of integration of smoking cessation assistance in the lung cancer screening program, reported Paul Cinciripini, PhD, of the University of Texas MD Anderson Cancer Center in Houston, and colleagues in JAMA Internal Medicine.

Patients who received 12-week nicotine replacement therapy or prescription pharmacotherapy and counseling by tobacco treatment specialists within the lung cancer screening program had the highest rate of abstinence (37.1% at 3 months and 32.4% at 6 months).

This was significantly better than the 25.2% and 20.5% rates among those given nicotine replacement therapy and counseling through the quitline without any lung cancer screening program clinician involvement (OR 1.75 at 3 months and 1.86 at 6 months, both P=0.01).

A hybrid intervention with quitline referral plus 12 weeks of nicotine replacement therapy or pharmacotherapy prescription by the lung cancer screening clinician also led to higher self-reported quit rates than the least integrated intervention at 3 months, but this didn’t differ significantly from either other group at 6 months (27.1% and 27.6% at the two time points).

“For those who smoke, lung cancer screening presents a critical opportunity for us to support them in quitting,” Cinciripini said in a statement.

In an accompanying editorial, Judith Prochaska, PhD, MPH, of Stanford University in Palo Alto, California, wrote that the trial “lends strong support for intensive, integrated tobacco cessation treatment within [lung cancer screening] programs and for considering integration more broadly.”

Smoking cessation counseling is already recommended for people who meet criteria for annual lung cancer screening, as approximately 60% of U.S. patients eligible for this screening currently use tobacco, she noted.

While it’s been known that formal smoking cessation programs increase the likelihood of quitting, “and evidence is strongest for interventions that provide multiple contacts with patients,” the most effective way of delivering this assistance hasn’t been clear, Prochaska added.

The quitline (1-800-QUIT-NOW) along with nicotine replacement therapy and medications like varenicline (Chantix) and bupropion (Zyban) are foundational tools, commented Joseph Spanier, MSPAS, PA-C, the lung nodule coordinator at Fox Chase Cancer Center’s lung cancer screening program in Philadelphia.

“However, in addition to these tools, this study highlights the importance of trained tobacco treatment professionals for the best chance of helping patients stop smoking and stay abstinent,” he said in a statement. “This includes intensive counseling, evaluation of psychological and social causes of smoking, and development of both a medical plan for treatment and a behavioral plan that is individualized for each patient.”

Cinciripini argued that facilities that can provide such dedicated and integrated smoking cessation care should prioritize doing so.

However, Prochaska acknowledged, the integrated care model is resource intensive and not available in many settings.

“The program staff was composed of a dedicated tobacco treatment team consisting of trained counselors and clinicians,” she wrote. “Patients underwent an initial intake and eight counseling sessions that used cognitive behavioral therapy and motivational interviewing techniques. Patients were offered the full range of medications, including combination therapies.”

Thus, the finding that the less resource-intensive hybrid approach also appeared effective was important, she suggested, as it may be more feasible in lower-resource settings.

Indeed, Cinciripini noted that it could be effective in other settings as well. “Given our results, it is conceivable that this approach could also be highly effective outside a screening environment, such as post-traumatic stress clinics and among patients with cancer, cardiovascular disease, or diabetes.”

The trial was conducted at a hospital-based tobacco treatment clinic in Houston, but the timing necessitated some changes. As the trial ran from July 2017 to June 2022, the original primary outcome of biochemically verified 7-day point prevalence abstinence at 6 months was changed to self-reported abstinence during the conduct of the study due to COVID-19 pandemic restrictions.

The 630 participants (50.8% male, median age 59) who smoked a median 20 cigarettes per day were randomized in equal proportions to treatment with one of the three interventions.

The median number of counseling sessions was four for both the quitline-only and hybrid groups and eight for the integrated intervention.

In a bayesian analysis, the integrated intervention had a 98% to 99% probability of being better for smoking abstinence than the other interventions at 3 months and a 86% to 99% probability of maintaining that advantage at 6 months.

“Our exploratory analysis did not reveal a statistically significant interaction between treatment and psychiatric comorbidities, suggesting the [integrated care] model has similar efficacy across both subgroups, which might be related to the mental health expertise available in the [integrated care] condition,” Cinciripini and team wrote.

Limitations to the study included a predominantly non-Hispanic white population and a lack of exhaled carbon monoxide verification of abstinence for the entire cohort, “although the overall results between the subsamples with and without verification were similar,” the researchers noted.

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