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Challenges to Educating Smokers About Lung Cancer Screening: a Qualitative Study of Decision Making Experiences in Primary Care

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Abstract

We sought to qualitatively explore how those at highest risk for lung cancer, current smokers, experienced, understood, and made decisions about participation in lung cancer screening (LCS) after being offered in the target setting for implementation, routine primary care visits. Thirty-seven current smokers were identified within 4 weeks of being offered LCS at seven sites participating in the Veterans Health Administration Clinical Demonstration Project and interviewed via telephone using semi-structured qualitative interviews. Transcripts were coded by two raters and analyzed thematically using iterative inductive content analysis. Five challenges to smokers’ decision-making lead to overestimated benefits and minimized risks of LCS: fear of lung cancer fixated focus on inflated screening benefits; shame, regret, and low self-esteem stemming from continued smoking situated screening as less averse and more beneficial; screening was mistakenly believed to provide general evaluation of lungs and reassurance was sought about potential damage caused by smoking; decision-making was deferred to providers; and indifference about numerical educational information that was poorly understood. Biased understanding of risks and benefits was complicated by emotion-driven, uninformed decision-making. Emotional and cognitive biases may interfere with educating and supporting smokers’ decision-making and may require interventions tailored for their unique needs.

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Acknowledgements

The findings and conclusions in this article are those of the author(s) and do not necessarily represent the official position of the Department of Veterans Affairs or the Centers for Disease Control and Prevention. We would like to acknowledge Dr. Kim Hamlett-Berry in VHA’s Office of Tobacco and Health and Dr. Linda Kinsinger (retired) in VHA’s National Center for Health Promotion and Disease Prevention for the support and guidance as well as the contributions of Carol Simons and Jennifer Williams for the assistance with data collection.

Funding

This study was supported by the Centers for Disease Control and Prevention’s Health Promotion and Disease Prevention Research Centers Program through a Special Interest Project (grant DP9001911-05S2; SIP13–038: Low Dose CT Lung Cancer Screening: Informed Decision-making and Smoking Cessation to S.B. Zeliadt, and the US Department of Veterans Affairs Health Services Research and Development Postdoctoral Fellowship Program to P. A. Greene and the VA Puget Sound Health Care System.

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Authors and Affiliations

  1. Health Services Research & Development (HSR&D), Center of Innovation for Veteran-Centered Value-Driven Care, VA Puget Sound Health Care System, 1660 S. Columbian Way, Mailstop S-152, Seattle, WA, 98108, USA

    Preston A. Greene, George Sayre, David H. Au & Steven B. Zeliadt

  2. Department of Health Services, University of Washington, Seattle, WA, USA

    George Sayre, David H. Au & Steven B. Zeliadt

  3. Tobacco and Health Behavior Science Research Group, Fred Hutchinson Cancer Research Center, Seattle, WA, USA

    Jaimee L. Heffner

  4. Swedish Medical Group, Swedish Medical Center, Seattle, WA, USA

    Deborah E. Klein

  5. New York Harbor VA Health Care System, New York, NY, USA

    Paul Krebs

  6. School of Medicine, New York University, New York, NY, USA

    Paul Krebs

  7. Division of Pulmonary and Critical Care Medicine, University of Washington, Seattle, WA, USA

    David H. Au

Authors
  1. Preston A. Greene
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  2. George Sayre
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  3. Jaimee L. Heffner
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  4. Deborah E. Klein
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  5. Paul Krebs
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  6. David H. Au
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  7. Steven B. Zeliadt
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Corresponding author

Correspondence to Preston A. Greene.

Ethics declarations

All study procedures were reviewed and approved by the VA Puget Sound Health Care System Institutional Review Board and the University of Washington Institutional Review Board. All participants returned signed written informed consent forms by mail before the interviews were conducted.

Classifications

Health Literacy; Secondary-Screening; Smoking Cessation; Qualitative.

Conflict of Interest

Dr. Au reported receiving grant funding from Gilead Sciences, travel and honorarium from Boehringer Ingelheim, and honorarium from the Society of Hospital Medicine for topics related to chronic obstructive pulmonary disease quality of care. No other conflicts of interest were reported.

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Greene, P.A., Sayre, G., Heffner, J.L. et al. Challenges to Educating Smokers About Lung Cancer Screening: a Qualitative Study of Decision Making Experiences in Primary Care. J Canc Educ 34, 1142–1149 (2019). https://doi.org/10.1007/s13187-018-1420-y

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  • DOI: https://doi.org/10.1007/s13187-018-1420-y

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