Examining Tobacco Treatment Perceptions and Barriers among Black versus Non-Black Adults Attending Lung Cancer Screening

Lung cancer is the leading cause of cancer-related death in both men and women in the United States (1, 2) and up to 87% of lung cancer–related deaths are attributable to cigarette smoking (3). Although rates of cigarette use have declined in recent years, approximately 34 million adults in the United States reported currently smoking cigarettes in 2019 (4), and the risk for developing lung cancer among those who smoke is 25 times higher than those who do not smoke (1). Furthermore, cigarette smoking is a leading cause of health disparities in the United States; despite smoking fewer cigarettes per day, Black individuals, specifically Black men, have higher rates of lung cancer and mortality compared with other groups (5, 6). In an effort to reduce the morbidity and mortality associated with lung cancer, the US Preventive Services Task Force (USPSTF) recommends annual lung cancer screening for early detection of patients at high risk for lung cancer based on age and long-term smoking history. Updated guidelines now require a lower threshold for smoking (20 pack years instead of 30 pack years) and age (50+) in an effort to include more Black individuals in screening to decrease health disparities (7).

While early detection through lung cancer screening can reduce the relative risk of mortality (8), especially for Black individuals who complete lung cancer screening (9), the mortality risk is further reduced by successfully stopping smoking (10–12). However, evidence suggests that completing a low-dose CT scan (LDCT) for lung cancer detection may not substantially promote cessation among current smokers (13–15). While some reports indicate that undergoing LDCT may motivate quit attempts (16, 17) particularly among Black patients (18), smoking abstinence is often not sustained, suggesting targeted interventions are needed at the time of lung cancer screening to promote quitting. In addition, one study of qualitative interviews from people who currently smoke showed that 49% of participants indicated that completing lung cancer screening counterintuitively lowered their motivation to quit smoking, perhaps due to misperceptions that screening protects against developing lung cancer or that a cancer-free scan indicates they have avoided any harms from smoking (19).

Thus, lung cancer screening is a potential opportunity to identify and engage people in tobacco treatment who currently smoke and are at high risk for negative health consequences. However, few studies have examined perceptions of quitting smoking or potential barriers to engaging in treatment among those who are attending lung cancer screening, or whether differences exist among Black patients who are at especially high risk for morbidity and mortality from lung cancer. Thus, the current study aims to fill these gaps by examining survey data collected from patients attending lung cancer screening at two sites (New Haven, CT and Charleston, SC) to investigate patient characteristics, treatment perceptions, and potential barriers to quitting smoking in an effort to inform ways to better engage patients in tobacco treatment. Furthermore, responses were examined by race/ethnicity in order to provide information to address tobacco-related health disparities specifically among Black individuals.

Survey responses were collected from patients at two lung cancer screening programs in 2017–2018: Smilow Cancer Hospital at Yale-New Haven Hospital (N = 74) and the Medical University of South Carolina (N = 73). Patients were eligible to participate in the survey if they were attending a lung cancer screening visit and reported current cigarette smoking. We invited participants to complete a brief anonymous survey at the time of their visit. While updated guidelines now require a lower threshold for smoking (20 pack years) and age (50+), lung cancer screening eligibility at the time of the survey was at least 30 pack years of smoking and 55+ years old.

This study was approved by the Institutional Review Board at both sites. Informed consent was obtained from all patients. Specifically, all participants were informed of the purpose of the study as well as the fact that participation was voluntary, and all data were anonymous. Completion of the anonymous survey served as written consent to participate. The study was conducted in accordance with recognized ethical guidelines including the Declaration of Helsinki and Belmont Report.

The survey assessed demographic information including age, sex, and race/ethnicity.

Smoking history was measured with items assessing motivation to quit, time to first cigarette in the morning, and number of cigarettes per day. Quitting motivation was measured as intention to quit smoking in the next month (0 = very definitely no to 10 = very definitely yes). The heaviness of smoking index (HSI) was calculated from time to first cigarette and cigarettes per day as a measure of nicotine dependence (20) and scored as 0 to 2 = low, 3 to 4 = moderate, 5 to 6 = high (21).

Perceptions and concerns about tobacco treatment or quitting smoking were measured by a series of statements (e.g., “I am concerned about withdrawal symptoms”) with response options being “Yes = 1” or “No = 0” [See Fig. 1 for response options adapted from related questionnaires (22, 23)]. In addition, some of the items assessing barriers to quitting were novel items generated for this survey based on previous patient feedback (e.g., “I smoke less now and do not need to make more changes”).

Data were entered and managed using REDCap electronic data capture tools hosted at MUSC. Statistical analyses were conducted using SPSS software (version 28). Descriptive statistics characterized the patient sample and rates of endorsing specific perceptions and concerns about quitting smoking. χ² and independent sample t tests were used to examine differences by race/ethnicity. Logistic regression models were used to examine associations between patient characteristics (nicotine dependence and demographic variables: age, gender, race/ethnicity) and endorsing specific perceptions and concerns about quitting smoking. In order to provide information to address tobacco-related health disparities specifically among Black individuals, race/ethnicity was coded as non-Hispanic (NH) Black vs. Other for analysis. There were no significant differences between the patients at the two sites [Smilow Cancer Hospital at Yale-New Haven Hospital (N = 74) and the Medical University of South Carolina (N = 73)] in terms of demographic or smoking characteristics (e.g., age, gender, race/ethnicity, heaviness of smoking index (HSI), quit intention; ps > 0.06) or perceptions and concerns about quitting smoking (ps > 0.22), therefore results are presented for the total sample overall.

Data were generated by the authors and are available upon request.

Patients were 55 to76 years old (M = 63.3, SD = 5.3) and N = 64 (43.5%) were female. In terms of race/ethnicity, 21.1% (N = 31) reported NH Black, 70.7% (N = 103) reported non-Hispanic White, 4.8% (N = 7) reported Hispanic, 0.7% (N = 1) reported Asian, 0.7% (N = 1) reported more than 1 race, and 5.4% (N = 8) reported Other.

Patients smoked 16.3 cigarettes per day on average (SD = 9.2) and 31.5% reported having their first cigarette within 5 minutes of waking. In terms of smoking history, the survey did not assess number of years smoked, however all patients had a minimum smoking history of 30 pack years to be eligible for lung cancer screening at the time of the survey. On average, nicotine dependence measured in the low to moderate range on the HSI (M = 2.8, SD = 1.3, range 0–6). Interest in quitting smoking in the next month was moderate (M = 5.6, SD = 3.1, measured from 0 = “very definitely no” to 10 = “very definitely yes”). When examined by race/ethnicity, patients identifying as NH Black versus Other smoked significantly fewer cigarettes per day on average (M = 12.7, SD = 9.9 vs. M = 17.2, SD = 8.8), t(143) = -2.39, P = 0.01, while other measures of smoking (time to first cigarette, nicotine dependence measured by HSI, and interest in quitting smoking) did not differ significantly between groups (P > 0.28).

Figure 1 presents rates of endorsing specific perceptions and concerns about quitting smoking among patients. Most patients reported that their family and friends support them quitting (76.9%). The most frequently endorsed concerns about quitting smoking were missing smoking (70.7%), worry about strong urges to smoke (63.9%), concern about withdrawal symptoms (59.9%), and worry about strong negative feelings such as stress or anger (52.4%). When examined by race/ethnicity, patients identifying as NH Black versus Other were significantly less likely to endorse concerns about withdrawal symptoms [41.9% vs. 64.7%, χ² (N = 147) = 5.26, P = 0.02] and were significantly more likely to endorse that they smoke less now and do not need to make more changes [32.3% vs. 14.7%, χ² (N = 147) = 5.06, P = 0.025]. Other perceptions or concerns about quitting smoking did not differ significantly between patients identifying as NH Black versus Other (ps > 0.12).

Logistic regression models were used to explore associations between patient characteristics and endorsement of specific perceptions and concerns about tobacco treatment (Table 1). When controlling for other variables (age, gender, nicotine dependence), significant differences remained in the associations between race/ethnicity and rates of endorsing specific concerns about tobacco treatment. Specifically, patients who identified as NH Black (compared with other races/ethnicities) indicated a significantly lower likelihood of endorsing concerns about withdrawal symptoms and were over 2.5 times more likely to endorse beliefs that they smoke less now and do not need to make more changes. Figure 2 shows the rates of endorsing these specific perceptions and concerns about tobacco treatment between Black versus non-Black patients. Furthermore, across models, patients with greater nicotine dependence (measured by the HSI) were significantly more likely to endorse concerns about quitting smoking related to missing smoking, withdrawal symptoms, worrying about strong negative feelings, and being afraid to fail at quitting. In addition, females were over 2 times more likely to endorse concerns related to weight gain from quitting.

The current study evaluates survey data to investigate patient characteristics and understand treatment perceptions and potential barriers to tobacco treatment among patients attending lung cancer screening who continue to smoke cigarettes. Identifying ways to promote tobacco treatment for these high-risk patients is important for reducing morbidity and mortality. Our findings identified perceptions of barriers to quitting smoking among this group of patients and specifically among Black individuals to inform ways to increase treatment engagement and help address tobacco-related health disparities.

Patients who attended the lung cancer screening are at high risk for medical problems due to their history of smoking (3). Yet our findings indicated that on average these patients had only a moderate interest in quitting smoking in the next month suggesting efforts to enhance quitting motivation are needed for many patients in this group, in line with conclusions from other studies (19). Furthermore, our findings expand on earlier studies identifying predictors of quitting smoking among patients attending lung cancer screening (16) by identifying specific concerns about tobacco treatment that could be addressed to help overcome barriers to quitting and increase engagement, including discussing ways to cope with urges, withdrawal, and negative feelings when quitting. Smoking cessation treatment options are often provided during the shared decision-making visit or at the time of the LDCT scan (24, 25), and this could be a critical opportunity to provide tobacco interventions including brief coping skills and motivation enhancement (26, 27).

Furthermore, our findings identified concerns about tobacco treatment among specific patient populations that could be used to inform targeted interventions. For instance, females were more likely to endorse concerns related to weight gain from quitting, consistent with other studies (28), suggesting that targeted motivational strategies that emphasize other physical benefits of quitting such as through gain-framed messaging (29) may be useful. In addition, patients with greater nicotine dependence were significantly more likely to endorse several concerns about tobacco treatment, including withdrawal symptoms, dealing with negative feelings, and fear of failure with quitting. There are healthcare-based programs that have shown efficacy in increasing utilization of tobacco treatment and improving quitting success, such as opt-out treatment protocols and medication sampling (30, 31), suggesting that similar methods may be beneficial for providing tobacco treatment in the context of lung cancer screening.

Furthermore, identifying barriers to quitting smoking specifically among Black patients is important for addressing tobacco-related health disparities (32). In particular, patients identifying as NH Black were less likely to report concerns about withdrawal symptoms and more likely to report beliefs that they smoke less now and do not need to make more changes. Our findings align with other studies that identify lower risk perceptions among Black individuals who smoke (33, 34) suggesting this may also be a barrier to engaging in treatment among Black patients attending lung cancer screening. Furthermore, we observed that NH Black patients smoked fewer cigarettes per day on average compared with others, consistent with literature from the general population (35). However, despite smoking fewer cigarettes per day, Black individuals are at greater risk for lung cancer and death compared with other groups (1, 6), yet perceive lower risk for lung cancer (36), suggesting that targeted educational interventions could be important for delivering accurate messaging about tobacco-related harms to these vulnerable groups of patients. In particular, it is important to educate and inform these patients that smoking reduction does not eliminate health risk because research indicates that even light smoking (i.e., 1–4 cigarettes per day) produces significantly elevated cardiovascular risk (37, 38) and markedly increases cancer risk (38). Therefore, it is important to engage in efforts to increase motivation to quit smoking completely for this population.

Given that Black individuals smoke less but are at increased risk of lung cancer and mortality compared with other groups (5, 6), the USPSTF has recently modified lung cancer screening recommendations to lower the smoking history threshold (20 pack year history instead of 30 pack year history) and lower the age requirement (to 50 instead of 55) to qualify for screening (7). Lowering the threshold to qualify for lung cancer screening may help address disparities in lung cancer rates and mortality by increasing early detection (39, 40). However, efforts to increase access to and annual utilization of lung cancer screening are also critically needed as only 2 percent of 7.6 million eligible cigarette smokers were screened in 2016 (41). Factors related to low utilization of lung cancer screening may also contribute to lung cancer health inequity, including lack of knowledge about annual screening, lack of health insurance, or lack of access to the proper care such as physician referral to lung cancer screening (32, 42–44).

Results should be considered in the light of study limitations. The results are limited by the small sample size, and represent survey data from adults who smoke cigarettes who are attending lung cancer screening at two sites. Furthermore, there were only n = 31 NH Black patients in the sample and some confidence intervals (CI) for the estimates were large, thus these data may not be representative of larger populations. The study was designed to be a brief cross-sectional anonymous survey so we do not have data to examine other tobacco product use or detailed patient medical history, including outcomes of LDCT or subsequent smoking cessation outcomes. The survey data were collected prior to the change in recommendations from the USPSTF (7), so future work is needed to understand whether the perceptions and concerns about smoking and tobacco treatment reported here generalize to those patients who are now eligible for lung cancer screening (i.e., age 50–55 and 20–30 pack years). Given the sample characteristics, we are unable to make comparisons for smaller subgroups of patients by race and ethnicity. However, these data provide valuable initial information for understanding perceptions and barriers to quitting smoking for NH Black patients (vs. Other), a population at high risk for lung cancer and related mortality. In addition, future studies may consider alternative wording and item validation for the novel items generated for this survey.

The current study provides new information about patient characteristics and tobacco treatment perceptions and barriers among patients attending lung cancer screening who continue to smoke cigarettes. Examining perceptions of tobacco treatment by race identified specific treatment barriers among Black patients, including differences in concerns about withdrawal symptoms and low perceived need to quit that may help inform ways to increase treatment engagement and help address tobacco-related health disparities. Identifying ways to promote tobacco treatment for these high-risk patients attending lung cancer screening is important for reducing morbidity and mortality.

B.A. Toll reports other support from Pfizer and other support (expert testimony) outside the submitted work. L.M. Fucito reports other support from Imbrium Therapeutics outside the submitted work. No disclosures were reported by the other authors.

The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH. The study sponsor had no role in study design; collection, analysis, and interpretation of data; writing the report; and the decision to submit the report for publication.

K.W. Bold: Conceptualization, data curation, formal analysis, supervision, investigation, methodology, writing–original draft. S. Cannon: Data curation, formal analysis, writing–original draft, writing–review and editing. B.B. Ford: Data curation, investigation, writing–review and editing. S. Neveu: Investigation, writing–review and editing. P. Sather: Investigation, writing–review and editing. B.A. Toll: Conceptualization, funding acquisition, methodology, project administration, writing–review and editing. L.M. Fucito: Conceptualization, funding acquisition, methodology, project administration, writing–review and editing.

This research was supported by NIH grants (R01CA207229, P50CA196530, awarded to B.A. Toll) and (K12DA000167, awarded to K.W. Bold).

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