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PCP intervention can improve smoking cessation following lung cancer screening
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Individuals who undergo lung cancer screening are more likely to quit smoking if their cessation intervention originated from their primary care provider, according to study results.
Although there was a reduction in lung cancer mortality among participants in the National Lung Screening Trial (NLST) who were screened with a low-dose CT scan compared with a chest radiography — results of which served as the basis for CMS’s decision to cover lung cancer screening in the Medicare population — the frequency and effectiveness of primary care clinicians delivering smoking cessation interventions after lung screening was unknown, according to study background.
Elyse R. Park
“Now that Medicare is covering low-dose screening for patients who are aged between 55 and 77 years with a smoking history, part of the coverage recommendation is that primary care physicians have a shared decision-making process with patients about getting screening and then counsel their patients for smoking cessation,” Elyse R. Park, PhD, MPH, a clinical associate in psychology in the department of psychiatry at Massachusetts General Hospital in Boston told HemOnc Today. “That process of clinicians counselling their patients has not been determined yet, but what’s important in this study is that it shows that a primary care provider’s involvement clearly makes a difference in whether patients quit smoking after having a lung screening.”
Park and colleagues conducted this matched case–control study to determine the association between reported clinician-delivered interventions following lung screening and possible changes in smoking behavior. Researchers considered individuals who quit smoking the cases, and those who did not quit smoking the controls.
Clinician-delivered intervention guidelines suggest the PCPs should conduct the “5 A’s” — ask, advise, assess, assist and arrange follow-up — with their patients who are smokers.
The investigators evaluated the rate of delivery of the “5 A’s” to individuals enrolled in the NSLT who were smokers at the time of enrollment, the effect of those guidelines on quitting behavior, and patient factors associated with cessation following the delivery of the guidelines.
The researchers identified 3,336 patients (mean age, 61 years; 90.5% white) who were smokers at the time of enrollment, 1,668 of whom quit smoking after screening.
Within the first year after screening 77.2% of individuals reported that their PCP “asked” about smoking, 75.6% reported their physician’s “advised” about smoking dangers and 63.4% of PCPs “assessed” the patient’s health and its association with smoking. Further, 56.4% of PCPs “assisted” their patients — meaning they talked about quitting, recommended medications used to help quit smoking, or recommended counselling to quit smoking — and 10.4% “arranged” for a follow-up consultation.
Overall, the use of “assist” (adjusted OR = 1.4; 95% CI, 1.21-1.63) and “arrange” (adjusted OR = 1.46; 95% CI, 1.19-1.79) both had an association with quitting.
However, delivery of “ask,” (adjusted OR = 1.1; 95% CI, 0.93-1.3), “advise” (adjusted OR = 0.99; 95% CI, 0.84-1.17) and “assess” (adjusted OR = 1.14; 95% CI, 0.98-1.32) did not significantly impact whether individuals quit smoking.
Age, race, marital status, positive medical history and screening were not associated with quitting; however, a higher education level (OR range = 1.14-1.26 for college degree or higher vs. high school education), lower nicotine dependence (OR = 0.94; 95% CI, 0.91-0.98) and a higher motivation to quit (OR = 1.28; 95% CI, 1.21-1.35) significantly increased the likelihood of quitting.
The researchers noted that patient-reported smoking status is a limitation to these findings. Additionally, questions about the guidelines presented by PCPs were asked of the patients simultaneously, which could lead to a biased recall of events with those who quit reporting more interventions. Finally, some physicians may have avoided following the guidelines because the smokers were considerably unmotivated to quit smoking.
“What’s important is that clinicians are involved in that they discuss with patients about their ability to quit smoking and they refer patients and give them resources toward smoking cessation treatment,” Park said. “In terms of intensity, maybe we can change that word to ‘involved.’ This strongly promotes the need for clinicians to endorse the importance of smoking cessation among these patients, but more importantly, it really shows that this support can be in the form of referral or resource provision. So, ‘intensity’ means we need to enhance clinician involvement in smoking cessation and direct patients toward what they need and really reinforcing the importance of it and provide guidance.
“If they can counsel patients themselves and bring it up in follow-up visits, that’s even better, Park added.”- by Anthony SanFilippo
For more information:
Elyse R. Park, PhD, MPH, can be reached at Massachusetts General Hospital, 55 Fruit St., Boston, MA 02114; email: epark@mgh.harvard.edu.
Disclosure: Park and one other researcher report expected royalties for this study from UpToDate. One other researcher reports a consultant role with Pfizer.
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