Active clinician support and assistance are critical to successfully quitting smoking

Does participation in the annual lung cancer screening currently recommended for people with high-risk smoking histories encourage those who are still smoking to quit? A new study from a Massachusetts General Hospital research team (MGH) finds that the answer may depend on the level of support given by patients' primary care providers. In the report receiving online publication in JAMA Internal Medicine, the team finds that, while providers' asking such patients about smoking did not increase their likelihood of quitting, providing more direct assistance - such as talking about how to quit smoking, recommending or prescribing nicotine replacement or pharmaceutical aids, and following up on recommendations - significantly improved patients' success in becoming smoke-free.

"Our findings demonstrate the importance of clinicians' active assistance - referring patients to counseling, prescribing a stop-smoking medication, and following up to see how they are doing - in increasing the likelihood that patients will quit smoking," says Elyse R. Park, PhD, MPH, of the MGH Tobacco Treatment Center, lead author of the study. "While all of the participants in this study had sought screening for lung cancer and their primary care physicians were aware of that screening and its results, only half of these high-risk smokers reported that their PCPs even talked to them about how to quit smoking, and even fewer received the level of help we now know can make a critical difference."

The current report analyzed data collected in the National Lung Screening Trial (NLST), a 2011-published study that compared two screening methods - standard X-ray studies and low-dose CT screens - for early detection of lung cancer in patients with long-term smoking histories. Based on the results of that study, the U.S. Preventive Services Task Force recommended in 2013 that high-risk individuals - those aged 55 to 80 with a 30 pack-year (pack a day for a year) smoking history - receive low-dose CT screening annually, a recommendation supported by Medicare's decision earlier this year to cover the costs of such screening for appropriate patients. But the question of whether screening participation would encourage those not receiving a lung cancer diagnosis to quit smoking had not previously been investigated.

To address that question, the research team analyzed data from assessment questionnaires completed at six-month intervals after screening by NLST participants who had not received a lung cancer diagnosis. They selected participants who had been smoking prior to screening (NLST also enrolled individuals who had quit fewer than 15 years prior to study enrollment), reported having smoked at some time during the previous six months and who had at least one visit with a primary care provider during that period. From that group they compared the 1,668 who reported they had stopped smoking since the previous assessment with an equal group who still smoked - matched by factors such as age, sex, study site and type of screening received.

In addition to asking about participants' current smoking status, the questionnaires also asked whether patients' providers had delivered any of what are referred to as the "five As" during those primary care visits:

• Ask about smoking status
• Advise smokers to quit
• Assess interest in quitting
• Assist by talking to about how to quit, recommending counseling or smoking cessation medication
• Arrange follow-up calls or visits related to stop-smoking efforts

The comparison found little difference between the participants who had quit smoking and those who had not in terms of whether their providers had provided ask, advise or assess. But receiving assist increased the likelihood that a participant would quit by 40 percent, and arrange increased the chance of successful quitting by 46 percent.

"These results indicate that clinicians can indeed support and influence high-risk smokers to become smoke-free and potentially reduce their risk of developing lung cancer," says Park, an associate professor of Psychology at Harvard Medical School. "A 2011 study from the Institute of Technology Assessment here at MGH found the cost-effectiveness of the recommended CT screening program will probably be linked to its influence on smoking cessation, and our findings point to clinician-delivered cessation interventions as important influences on successful efforts. Now we need to investigate ways of integrating patient-centered and risk-tailored interventions into lung screening programs."