Multilevel approaches to address disparities in lung cancer screening: a study protocol.

BACKGROUND: Low-dose computed tomography (lung cancer screening) can reduce lung cancer-specific mortality by 20-24%. Based on this evidence, the United States Preventive Services Task Force recommends annual lung cancer screening for asymptomatic high-risk individuals. Despite this recommendation, utilization is low (3-20%). Lung cancer screening may be particularly beneficial for African American patients because they are more likely to have advanced disease, lower survival, and lower screening rates compared to White individuals. Evidence points to multilevel approaches that simultaneously address multiple determinants to increase screening rates and decrease lung cancer burden in minoritized populations. This study will test the effects of provider- and patient-level strategies for promoting equitable lung cancer screening utilization. METHODS: Guided by the Health Disparities Research Framework and the Practical, Robust Implementation and Sustainability Model, we will conduct a quasi-experimental study with four primary care clinics within a large health system (MedStar Health). Individuals eligible for lung cancer screening, defined as 50-80 years old, ≥ 20 pack-years, currently smoking, or quit < 15 years, no history of lung cancer, who have an appointment scheduled with their provider, and who are non-adherent to screening will be identified via the EHR, contacted, and enrolled (N = 184 for implementation clinics, N = 184 for comparison clinics; total N = 368). Provider participants will include those practicing at the partner clinics (N = 26). To increase provider-prompted discussions about lung screening, an electronic health record (EHR) clinician reminder will be sent to providers prior to scheduled visits with the screening-eligible participants. To increase patient-level knowledge and patient activation about screening, an inreach specialist will conduct a pre-visit phone-based educational session with participants. Patient participants will be assessed at baseline and 1-week post-visit to measure provider-patient discussion, screening intentions, and knowledge. Screening referrals and screening completion rates will be assessed via the EHR at 6 months. We will use mixed methods and multilevel assessments of patients and providers to evaluate the implementation outcomes (adoption, feasibility, acceptability, and fidelity). DISCUSSION: The study will inform future work designed to measure the independent and overlapping contributions of the multilevel implementation strategies to advance equity in lung screening rates. TRIAL REGISTRATION: ClinicalTrials.gov, NCT04675476. Registered December 19, 2020.

The tobacco quitline setting as a teachable moment: The Educating Quitline Users About Lung (EQUAL) cancer screening randomized trial.

Although lung cancer screening (LCS) using low-dose CT is recommended for high-risk individuals, screening adherence remains low. We conducted a randomized trial to compare two methods of providing LCS education to Maryland Tobacco Quitline (MTQ) callers in order to assess whether this setting may serve as a teachable moment for LCS-eligible individuals. MTQ callers (50-80 years, 20+ pack-years, prior LCS ≥12 months) completed the baseline and were randomized to the Print- or Web-based version of ShouldIScreen.com. Participants completed 1- and 4-month follow-up assessments to evaluate intervention engagement and LCS-related outcomes. Participants (Print = 152, Web = 146) were 61.7 (SD = 6.3) years old and reported 63.5 pack-years (SD = 36.0). Most identified as Black (54.2%), female (66.1%), having internet access (78.9%), completing other recommended cancer screenings (86.3%), and that they would undergo LCS if recommended by their provider (91.3%). By 4 months, significantly more Print (75.0%) than Web (61.6%) participants had read the materials (P = .01). Most reported the interventions contained "the right amount" of information (92.6%) and prepared them to talk with their doctor (57.2%). Regarding screening-related outcomes, 42.8% (Print) and 43.8% (Web) had scheduled or completed a low-dose CT scan or a shared decision-making visit (P = .86). In a racially diverse sample of LCS-eligible quitline callers, offering LCS educational materials resulted in high intervention engagement and screening-related appointments. As >20% did not have internet access, providing participants' preferred modality (web/print) may improve intervention engagement and knowledge. Improving LCS awareness represents an important opportunity to increase screening among eligible but unscreened quitline callers.

Although annual lung cancer screening (LCS) using low-dose CT is recommended for high-risk individuals, screening adherence remains low. In partnership with the Maryland Tobacco Quitline (MTQ), we compared Print (N = 152) versus Web (N = 146) methods for educating quitline callers about LCS. MTQ callers (50­80 years, 20+ pack-years) completed the baseline and the 1- and 4-month follow-up assessments to evaluate intervention engagement and LCS-related outcomes. Over half of participants identified as Black (54.4%), female (66.2%), and reported having internet access (78.9%), completing other recommended cancer screenings (86%), and would undergo LCS if recommended by their provider (91%). Significantly more Print (75.0%) than Web (61.9%) participants read the materials. Half of participants reported the interventions prepared them to talk with their doctor (57.4%). Regarding screening-related outcomes, 42.8% (Print) and 43.8% (Web) had scheduled or completed a CT scan or a shared decision-making visit. In a racially diverse sample of LCS-eligible quitline callers, offering LCS educational materials resulted in high intervention engagement and screening-related appointments. As >20% did not have internet access, offering the preferred intervention modality may result in improved intervention engagement and knowledge. Effectively improving awareness represents an opportunity to increase screening among LCS-eligible quitline callers.

Integrating Tobacco Use Assessment and Treatment in the Oncology Setting: Quality Improvement Results from the Georgetown Lombardi Smoking Treatment and Recovery Program.

As part of the NCI's Cancer Center Cessation (C3i) initiative, we initiated, expanded, and maintained an evidence-based tobacco treatment program at the Georgetown Lombardi Comprehensive Cancer Center. We present a quality improvement (QI) assessment of the implementation process and patient-level outcomes. At two hematology/oncology outpatient clinical sites, five oncology-based teams (clinical administrators, clinical staff, pharmacy, information technology, and tobacco treatment staff) developed implementation strategies for opt-out patient assessment and enrollment, centralized tobacco treatment, audit, feedback, and staff training. Among eligible patients (tobacco use in ≤30 days), we assessed demographic, clinical, and tobacco-related characteristics to examine predictors of enrollment (baseline completed), treatment engagement (≥one sessions completed), and self-reported 7-day abstinence (6 months post-enrollment). Across both sites, medical assistants screened 19,344 (82.4%) patients for tobacco use, which identified 1345 (7.0%) current tobacco users, in addition to 213 clinician referrals. Of the 687/1256 (54.7%) eligible patients reached, 301 (43.8%) enrolled, and 199 (29.0%) engaged in treatment, of whom 74.5% were African American and 68% were female. At the larger site, significant multivariate predictors of enrollment included African American race (vs. white/other) and clinician referral (vs. MA assessment). Treatment engagement was predicted by greater nicotine dependence, and abstinence (27.4%) was predicted by greater treatment engagement. In summary, the systematic utilization of multiple oncology-based teams and implementation strategies resulted in the development and maintenance of a high-quality, population-based approach to tobacco treatment. Importantly, these strategies addressed inequities in tobacco treatment, as the program reached and engaged a majority-African-American patient population. Finally, the opt-out patient assessment strategy has been implemented in multiple oncology settings at MedStar Health through the Commission on Cancer's Just Ask program.

Development and Evaluation of Brief Web-Based Education for Primary Care Providers to Address Inequities in Lung Cancer Screening and Smoking Cessation Treatment.

Annual lung cancer screening (LCS) is recommended for individuals at high risk for lung cancer. However, primary care provider-initiated discussions about LCS and referrals for screening are low overall, particularly among Black or African Americans and other minoritized racial and ethnic groups. Disparities also exist in receiving provider advice to quit smoking. Effective methods are needed to improve provider knowledge about LCS and tobacco-related disparities, and to provide resources to achieve equity in LCS rates. We report the feasibility and impact of pairing a self-directed Lung Cancer Health Disparities (HD) Web-based course with the National Training Network Lung Cancer Screening (LuCa) course on primary care providers' knowledge about LCS and the health disparities associated with LCS. In a quasi-experimental study, primary care providers (N = 91) recruited from the MedStar Health System were assigned to complete the LuCa course only vs. the LuCa + HD courses. We measured pre-post-LCS-related knowledge and opinions about the courses. The majority (60.4%) of providers were resident physicians. There was no significant difference between groups on post-test knowledge (p > 0.05). However, within groups, there was an improvement in knowledge from pre- to post-test (LuCa only (p = 0.03); LuCa + HD (p < 0.001)). The majority of providers (81%) indicated they planned to improve their screening and preventive practices after having reviewed the educational modules. These findings provide preliminary evidence that this e-learning course can be used to educate providers on LCS, smoking cessation, and related disparities impacting patients.

National Cancer Institute Smoking Cessation at Lung Examination Trials Brief Report: Baseline Characteristics and Comparison With the U.S. General Population of Lung Cancer Screening-Eligible Patients.

Introduction: The National Cancer Institute Smoking Cessation at Lung Examination (SCALE) Collaboration includes eight clinical trials testing smoking cessation interventions delivered with lung cancer screening (LCS). This investigation compared pooled participant baseline demographic and smoking characteristics of seven SCALE trials to LCS-eligible smokers in three U.S. nationally representative surveys. Methods: Baseline variables (age, sex, race, ethnicity, education, income, cigarettes per day, and time to the first cigarette) from 3614 smokers enrolled in SCALE trials as of September 2020 were compared with pooled data from the Tobacco Use Supplement-Current Population Survey (2018-2019), National Health Interview Survey (2017-2018), and Population Assessment of Tobacco and Health (wave 4, 2016-2017) using the U.S. Preventive Services Task Force 2013 (N = 4803) and 2021 (N = 8604) LCS eligibility criteria. Results: SCALE participants have similar average age as the U.S. LCS-eligible smokers using the 2013 criteria but are 2.8 years older using the 2021 criteria (p < 0.001). SCALE has a lower proportion of men, a higher proportion of Blacks, and slightly higher education and income levels than national surveys (p < 0.001). SCALE participants smoke an average of 17.9 cigarettes per day (SD 9.2) compared with 22.4 (SD 9.3) using the 2013 criteria and 19.6 (SD 9.7) using the 2021 criteria (p < 0.001). The distribution of time to the first cigarette differs between SCALE and the national surveys (p < 0.001), but both indicate high levels of nicotine dependence. Conclusions: SCALE participants smoke slightly less than the LCS-eligible smokers in the general population, perhaps related to socioeconomic status or race. Other demographic variables reveal small but statistically significant differences, likely of limited clinical relevance with respect to tobacco treatment outcomes. SCALE trial results should be applicable to LCS-eligible smokers from the U.S. population.

A Randomized Trial of Telephone-Based Smoking Cessation Treatment in the Lung Cancer Screening Setting.

BACKGROUND: Lung cancer mortality is reduced via low-dose computed tomography screening and treatment of early-stage disease. Evidence-based smoking cessation treatment in the lung screening setting can further reduce mortality. We report the results of a cessation trial from the National Cancer Institute's Smoking Cessation at Lung Examination collaboration. METHODS: Eligible patients (n = 818) aged 50-80 years were randomly assigned (May 2017-January 2021) to the intensive vs minimal arms (8 vs 3 phone sessions plus 8 vs 2 weeks of nicotine patches, respectively). Bio-verified (primary) and self-reported 7-day abstinence rates were assessed at 3, 6, and 12 months post random assignment. Logistic regression analyses evaluated the effects of study arm. All statistical tests were 2-sided. RESULTS: Participants reported 48.0 (SD = 17.2) pack-years, and 51.6% were not ready to quit in less than 30 days. Self-reported 3-month quit rates were statistically significantly higher in the intensive vs minimal arm (14.3% vs 7.9%; odds ratio [OR] = 2.00, 95% confidence interval [CI] = 1.26 to 3.18). Bio-verified abstinence was lower but with similar relative differences between arms (9.1% vs 3.9%; OR = 2.70, 95% CI = 1.44 to 5.08). Compared with the minimal arm, the intensive arm was more effective among those with greater nicotine dependence (OR = 3.47, 95% CI = 1.55 to 7.76), normal screening results (OR = 2.58, 95% CI = 1.32 to 5.03), high engagement in counseling (OR = 3.03, 95% CI = 1.50 to 6.14), and patch use (OR = 2.81, 95% CI = 1.39 to 5.68). Abstinence rates did not differ statistically significantly between arms at 6 months (OR = 1.2, 95% CI = 0.68 to 2.11) or 12 months (OR = 1.4, 95% CI = 0.82 to 2.42). CONCLUSIONS: Delivering intensive telephone counseling and nicotine replacement with lung screening is an effective strategy to increase short-term smoking cessation. Methods to maintain short-term effects are needed. Even with modest quit rates, integrating cessation treatment into lung screening programs may have a large impact on tobacco-related mortality.

Cost-Effectiveness of a Telephone-Based Smoking Cessation Randomized Trial in the Lung Cancer Screening Setting.

BACKGROUND: There are limited data on the cost-effectiveness of smoking cessation interventions in lung cancer screening settings. We conducted an economic analysis embedded in a national randomized trial of 2 telephone counseling cessation interventions. METHODS: We used a societal perspective to compare the short-term cost per 6-month bio-verified quit and long-term cost-effectiveness of the interventions. Trial data were used to micro-cost intervention delivery, and the data were extended to a lifetime horizon using an established Cancer Intervention Surveillance and Modeling Network lung cancer model. We modeled the impact of screening accompanied by 8 weeks vs 3 weeks of telephone counseling (plus nicotine replacement) vs screening alone based on 2021 screening eligibility. Lifetime downstream costs (2021 dollars) and effects (life-years gained, quality-adjusted life-years [QALYs]) saved were discounted at 3%. Sensitivity analyses tested the effects of varying quit rates and costs; all analyses assumed nonrelapse after quitting. RESULTS: The costs for delivery of the 8-week vs 3-week protocol were $380.23 vs $144.93 per person, and quit rates were 7.14% vs 5.96%, respectively. The least costly strategy was a 3-week counseling approach. An 8-week (vs 3-week) counseling approach increased costs but gained QALYs for an incremental cost-effectiveness ratio of $4029 per QALY. Screening alone cost more and saved fewer QALYs than either counseling strategy. Conclusions were robust in sensitivity analyses. CONCLUSIONS: Telephone-based cessation interventions with nicotine replacement are considered cost-effective in the lung screening setting. Integrating smoking cessation interventions with lung screening programs has the potential to maximize long-term health benefits at reasonable costs.

Race & sex disparities related to low-dose computed tomography lung cancer screening eligibility criteria: A lung cancer cases review.

INTRODUCTION: The United States Preventive Services Task Force (USPSTF) recommendations do not account for race and sex differences in lung cancer risk. We compared the sensitivity for finding lung cancer cases eligible for lung cancer screening (LCS) by USPSTF 2013 recommendations versus the PLCOm2012 model at an equivalent threshold. METHODS: Using Georgetown University Hospital tumor registry, we identified lung cancer cases (≥55 years old) between 2014 and 2018. Medical chart review collected age, sex, race, education, smoking, and clinical characteristics. We compared the percentage meeting eligibility criteria overall, and by race and sex. RESULTS: The cases (N = 447) were 36.6% Black and 52.6% female. The PLCOm2012 and USPSTF 2013 criteria identified 71.4% and 45.6% of cases, respectively (p < 0.0001). This difference was consistent across race and sex sub-groups (p < 0.0001). The PLCOm2012 was more sensitive than the USPSTF in Blacks (69.9% vs. 46.6%, p < 0.0001) and in women (69.8% vs. 41.3%, p < 0.0001). The USPSTF had poor sensitivity for both race groups (Black 46.6%, White 45.9%, p = 0.886) and had lower sensitivity in women vs. men (41.3% vs. 51.4%, p = 0.032). The PLCOm2012 had higher sensitivities in women and men, and difference between sexes was not significant (69.8% vs. 72.6%, p = 0.506). CONCLUSIONS: Compared to the USPSTF 2013 recommendations, the PLCOm2012 model selected a larger proportion of lung cancer cases in all race-sex strata and removed the sex disparity observed for the USPSTF. The PLCOm2012 risk model could be used to identify those who will benefit from LCS.

Engaging Patients in Smoking Cessation Treatment within the Lung Cancer Screening Setting: Lessons Learned from an NCI SCALE Trial.

Offering smoking cessation treatment at lung cancer screening (LCS) will maximize mortality reduction associated with screening, but predictors of treatment engagement are not well understood. We examined participant characteristics of engagement in an NCI SCALE cessation trial. Eligible LCS patients (N = 818) were randomized to the Intensive arm (8 phone counseling sessions +8 weeks of nicotine replacement therapy (NRT)) vs. Minimal arm (3 sessions + 2 weeks of NRT). Engagement was measured by number of sessions completed (none, some, or all) and NRT mailed (none vs. any) in each arm. In the Intensive arm, those with ≥some college (OR = 2.1, 95% CI = 1.1, 4.0) and undergoing an annual scan (OR = 2.1, 95% CI = 1.1, 4.2) engaged in some counseling vs. none. Individuals with higher nicotine dependence were more likely (OR = 2.8, 95% CI = 1.3, 6.2) to request NRT. In the Minimal arm, those with higher education (OR = 2.1, 95% CI = 1.1, 3.9) and undergoing an annual scan (OR = 2.0, 95% CI = 1.04, 3.8) completed some sessions vs. none. Requesting NRT was associated with more pack-years (OR = 1.9, 95% CI = 1.1, 3.5). Regardless of treatment intensity, additional strategies are needed to engage those with lower education, less intensive smoking histories, and undergoing a first scan. These efforts will be important given the broader 2021 LCS guidelines.

Lung cancer screening use and implications of varying eligibility criteria by race and ethnicity: 2019 Behavioral Risk Factor Surveillance System data.

BACKGROUND: In 2021, the US Preventive Services Task Force (USPSTF) expanded the eligibility criteria for low-dose computed tomographic lung cancer screening (LCS) to reduce racial disparities that resulted from the 2013 USPSTF criteria. The annual LCS rate has risen slowly since the 2013 USPSTF screening recommendations. Using the 2019 Behavioral Risk Factor Surveillance System (BRFSS), this study 1) describes LCS use in 2019, 2) compares the percent eligible for LCS using the 2013 versus 2021 USPSTF criteria, and 3) determines the percent eligible using the more detailed PLCOm2012Race3L risk-prediction model. METHODS: The analysis included 41,544 individuals with a smoking history from states participating in the BRFSS LCS module who were ≥50 years old. RESULTS: Using the 2013 USPSTF criteria, 20.7% (95% confidence interval [CI], 19.0-22.4) of eligible individuals underwent LCS in 2019. The 2013 USPSTF criteria was compared to the 2021 USPSTF criteria, and the overall proportion eligible increased from 21.0% (95% CI, 20.2-21.8) to 34.7% (95 CI, 33.8-35.6). Applying the 2021 criteria, the proportion eligible by race was 35.8% (95% CI, 34.8-36.7) among Whites, 28.5% (95% CI, 25.2-31.9) among Blacks, and 18.0% (95% CI, 12.4-23.7) among Hispanics. Using the 1.0% 6-year threshold that is comparable to the 2021 USPSTF criteria, the PLCOm2012Race3L model selected more individuals overall and by race. CONCLUSIONS: Using data from 20 states and using multiple imputation, higher LCS rates have been reported compared to prior BRFSS data. The 2021 expanded criteria will result in a greater number of screen-eligible individuals. However, risk-based screening that uses additional risk factors may be more inclusive overall and across subgroups. LAY SUMMARY: In 2013, lung cancer screening (lung screening) was recommended for high risk individuals. The annual rate of lung screening has risen slowly, particularly among Black individuals. In part, this racial disparity resulted in expanded 2021 criteria. Survey data was used to: 1) describe the number of people screened in 2019, 2) compare the percent eligible for lung screening using the 2013 versus 2021 guidelines, and 3) determine the percent eligible using more detailed criteria. Lung screening rates increased in 2019, and the 2021 criteria will result in more individuals eligible for screening. Using additional criteria may identify more individuals eligible for lung screening.

Improved motivation and readiness to quit shortly after lung cancer screening: Evidence for a teachable moment.

BACKGROUND: For patients at high risk for lung cancer, screening using low-dose computed tomography (lung cancer screening [LCS]) is recommended. The purpose of this study was to examine whether screening may serve as a teachable moment for smoking-related outcomes. METHODS: In a smoking-cessation trial, participants (N = 843) completed 2 phone interviews before randomization: before LCS (T0) and after LCS (T1). By using logistic and linear regression, the authors examined teachable moment variables (perceived risk, lung cancer worry) and outcomes (readiness, motivation, and cigarettes per day [CPD]). RESULTS: Participants were a mean ± SD age of 63.7 ± 5.9 years, had 47.8 ± 7.1 pack-years of smoking, 35.2% had a high school diploma or General Educational Development (high school equivalency) degree or less, and 42.3% were undergoing their first scan. Between T0 and T1, 25.7% of participants increased readiness to quit, 9.6% decreased readiness, and 64.7% reported no change (P < .001). Motivation to quit increased (P < .05) and CPD decreased between assessments (P < .001), but only 1.3% self-reported quitting. Compared with individuals who reported no lung cancer worry/little worry, extreme worry was associated with readiness to quit in the next 30 days (odds ratio, 1.8; 95% CI, 1.1-3.0) and with higher motivation (b = 0.83; P < .001) at T1. Individuals undergoing a baseline (vs annual) scan were more ready to quit in the next 30 days (odds ratio, 1.8; 95% CI, 1.3-2.5). CONCLUSIONS: During the brief window between registering for LCS and receiving the results, the authors observed that very few participants quit smoking, but a significant proportion improved on readiness and motivation to quit, particularly among individuals who were undergoing their first scan and those who were extremely worried about lung cancer. These results indicate that providing evidence-based tobacco treatment can build upon this teachable moment.

Lung cancer screening decisional needs among African American smokers of lower socioeconomic status.

OBJECTIVES: Adherence to most evidence-based cancer screenings is lower among African Americans due to system- and individual-level factors that contribute to persistent disparities. Given the recommendation for low-dose computed tomography (LDCT) screening among individuals at high risk for lung cancer, we sought to describe aspects of decision-making for LDCT among African Americans and to examine associations between select components of decision-making and screening-related intentions. DESIGN: African Americans (N = 119) with a long-term smoking history, aged 55-80 years, and without lung cancer were recruited to participate in a cross-sectional survey. We measured knowledge, awareness, decisional conflict, preferences, and values related to lung cancer screening. RESULTS: The majority of the study population was of lower socioeconomic status (67.2% had an annual income of ≤$20,000) and long-term current (79%) smokers. Participants had a median 20 pack-years smoking history. Most participants (65.8%) had not heard of LDCT and the total lung cancer screening knowledge score was M = 7.1/15.0 (SD = 1.8). Participants with higher scores on the importance of the pros and cons of screening expressed greater likelihood of talking with a doctor, family, and friends about screening (p's < .10). CONCLUSIONS: Findings have implications for addressing the decisional needs of lower socioeconomic African American current and former smokers to promote informed decision-making for LDCT.

Predictors of Enrollment of Older Smokers in Six Smoking Cessation Trials in the Lung Cancer Screening Setting: The Smoking Cessation at Lung Examination (SCALE) Collaboration.

SIGNIFICANCE: Increased rates of smoking cessation will be essential to maximize the population benefit of low-dose CT screening for lung cancer. The NCI's Smoking Cessation at Lung Examination (SCALE) Collaboration includes eight randomized trials, each assessing evidence-based interventions among smokers undergoing lung cancer screening (LCS). We examined predictors of trial enrollment to improve future outreach efforts for cessation interventions offered to older smokers in this and other clinical settings. METHODS: We included the six SCALE trials that randomized individual participants. We assessed demographics, intervention modalities, LCS site and trial administration characteristics, and reasons for declining. RESULTS: Of 6285 trial- and LCS-eligible individuals, 3897 (62%) declined and 2388 (38%) enrolled. In multivariable logistic regression analyses, Blacks had higher enrollment rates (OR 1.5, 95% CI 1.2,1.8) compared to Whites. Compared to "NRT Only" trials, those approached for "NRT + prescription medication" trials had higher odds of enrollment (OR 6.1, 95% CI 4.7,7.9). Regarding enrollment methods, trials using "Phone + In Person" methods had higher odds of enrollment (OR 1.6, 95% CI 1.2,1.9) compared to trials using "Phone Only" methods. Some of the reasons for declining enrollment included "too busy" (36.6%), "not ready to quit" (8.2%), "not interested in research" (7.7%), and "not interested in the intervention offered" (6.2%). CONCLUSION: Enrolling smokers in cessation interventions in the LCS setting is a major priority that requires multiple enrollment and intervention modalities. Barriers to enrollment provide insights that can be addressed and applied to future cessation interventions to improve implementation in LCS and other clinical settings with older smokers. IMPLICATIONS: We explored enrollment rates and reasons for declining across six smoking cessation trials in the lung cancer screening setting. Offering multiple accrual methods and pharmacotherapy options predicted increased enrollment across trials. Enrollment rates were also greater among Blacks compared to Whites. The findings offer practical information for the implementation of cessation trials and interventions in the lung cancer screening context and other clinical settings, regarding intervention modalities that may be most appealing to older, long-term smokers.

Predictors of attrition in a smoking cessation trial conducted in the lung cancer screening setting.

SIGNIFICANCE: Although it is a requirement that tobacco treatment is offered to cigarette smokers undergoing low-dose computed tomographic lung cancer screening (LCS), not all smokers engage in treatment. To understand the barriers to tobacco treatment in this setting, we evaluated predictors of attrition in a smoking cessation trial among individuals undergoing LCS. METHODS: Prior to LCS, 926 participants, 50-80 years old, completed the baseline (T0) phone assessment, including demographic, clinical, tobacco, and psychological characteristics. Following LCS and receipt of the results, participants completed the pre-randomization (T1) assessment. RESULTS: At the T1 assessment, 735 (79%) participants were retained and 191 (21%) dropped out. In multivariable analyses, attrition was higher among those who: smoked >1 pack per day (OR = 1.44, CI 1.01, 2.06) or had undergone their first (vs. annual) LCS scan (OR = 1.70, CI 1.20, 2.42). Attrition was lower among those with: more education (associates (OR = 0.67, CI = 0.46, 0.98) or bachelor's degree (OR = 0.56, CI 0.35, 0.91) vs. high school/GED), some (vs. none/a little) worry about lung cancer (OR = 0.60, CI 0.39, 0.92), or a screening result that was benign (OR = 0.57, CI 0.39, 0.82) or probably benign (OR = 0.38, CI 0.16, 0.90) vs. negative. CONCLUSIONS: This study illuminated several LCS-related factors that contributed to trial attrition. Increasing tobacco treatment in this setting will require targeted strategies for those who report little lung cancer worry, are undergoing their first LCS exam, and/or who have a negative LCS result. Addressing attrition and reducing barriers to tobacco treatment will increase the likelihood of cessation, thereby reducing the risk of developing lung cancer.

A qualitative study exploring older smokers' attitudes and motivation toward quitting during the COVID-19 pandemic.

Older individuals who smoke are at increased risk of having severe outcomes from COVID-19, due to their long-term smoking and underlying health conditions. In this qualitative study, we explored the impact of COVID-19 on attitudes toward smoking and motivation to quit. Participants (N = 30) were enrolled in a larger ongoing randomized controlled smoking cessation trial conducted in the lung cancer screening setting. From March to May 2020, we assessed quantitative and qualitative responses to participants' overall concern about COVID-19, changes in amount smoked, and motivation to reduce/quit smoking. Responses to the quantitative questions indicated that 64.3% of participants were extremely concerned with COVID-19, 20.7% reported reductions in amount smoked, and 37.9% reported increased motivation to quit. The qualitative responses, which were transcribed and coded using Consensual Qualitative Research guidelines, expanded upon these findings by providing the content of participants' concerns, which included perceived risk of contracting COVID-19, the added stressors caused by COVID-19, and a variable impact on the amount smoked and motivation to quit. Although half of participants expressed extreme concern regarding COVID-19, fewer indicated increased motivation or reduced smoking. Qualitative themes suggested that the initial two months of the pandemic prompted some smokers to reduce or quit, but it exacerbated smoking triggers for others. Understanding how the pandemic continues to affect this vulnerable group will aid in adapting methods to support their efforts to stop smoking and remain abstinent.

An Approach to Adapting a Community-Based Cancer Control Intervention to Organizational Context.

There has been increasing attention in implementation science to optimizing the fit of evidence-based interventions to the organizational settings where they are delivered. However, less is known about how to maximize intervention-context fit, particularly in community-based settings. We describe a new strategy to customize evidence-based health promotion interventions to community sites. Specifically, leaders in African American churches completed a memorandum of understanding where they were asked to identify two or more health promotion implementation strategies from a menu of 20 and select a planned implementation time frame for each. In a pilot phase with three churches, the menu-based strategy and protocols were successfully implemented and finalized in preparation for a subsequent randomized trial. The three pilot churches identified between two and nine strategies (e.g., form a health ministry, allocate space or budget for health activities, include health in church communications/sermons). The selected strategies varied widely, reinforcing the need for interventions that can be customized to fit the organizational context. Despite the challenges of integrating health promotion activities into non-health focused organizations, this approach has promise for fostering sustainable health activities in community settings.

Correction to: Development of Decisional Values Statements for Lung Cancer Screening among African American Smokers.

The original version of this article unfortunately contained mistakes in Tables 1 and 3.

Do neighborhood characteristics contribute beyond individual demographics to cancer control behaviors among African American adults?

BACKGROUND: Recent years have seen increased interest in the role of neighborhood factors in chronic diseases such as cancers. Less is known about the role of neighborhood factors beyond individual demographics such as age or education. It is particularly important to examine neighborhood effects on health among African American men and women, considering the disproportionate impact of cancer on this group. This study evaluated the unique contribution of neighborhood characteristics (e.g., racial/ethnic diversity, income) beyond individual demographics, to cancer control behaviors in African American men and women. METHODS: Individual-level data were drawn from a national survey (N = 2,222). Participants' home addresses were geocoded and merged with neighborhood data from the American Community Survey. Multi-level regressions examined the unique contribution of neighborhood characteristics beyond individual demographics, to a variety of cancer risk, prevention, and screening behaviors. RESULTS: Neighborhood racial/ethnic diversity, median income, and percentage of home ownership made modest significant contributions beyond individual factors, in particular to smoking status where these factors were associated with lower likelihood of smoking (ps < .05). Men living in neighborhoods with older residents, and greater income and home ownership were significantly more likely to report prostate specific antigen testing (ps < .05). Regional analyses suggested different neighborhood factors were associated with smoking status depending on the region. CONCLUSION: Findings provide a more nuanced understanding of the interplay of social determinants of health and neighborhood social environment among African American men and women, with implications for cancer control interventions to eliminate cancer disparities.

Development of Decisional Values Statements for Lung Cancer Screening Among African American Smokers.

Lung cancer screening via low-dose computed tomography (LDCT) has been underutilized by high-risk current and former smokers since its approval in 2013. Further, lower use of other evidence-based cancer screening tests (e.g., colorectal cancer, breast cancer) has been noted among African Americans when compared with other racial and ethnic groups. Reasons for low uptake are multilayered but include the need for consideration of patients' personal values about the screening decision. The goal of the present study was to (1) identify positive and negative factors specific to lung cancer screening via LDCT and (2) develop statements to capture values about the screening test for use in a new measure of decisional values. Key informant interviews (n = 9) identified several benefits and risks of lung cancer screening that may be important to African American smokers. Based on these interviews, a pool of items with the values statements was administered to a convenience sample of 119 African Americans [aged 55-80 years, current or former smokers (who quit < 15 years), and without lung cancer]. An exploratory factor analysis revealed two components explaining 64% of the variance: cons of screening (e.g., "make you feel badly about your smoking history") and pros of screening (e.g., "lowering your risk of dying from lung cancer"). The final 12-item measure had very good internal consistency (α = 0.89 overall; α = 0.86 and 0.88 for subscales, respectively). This tool provides a promising values measure for lung cancer screening among African Americans and could inform future values clarification tools promoting informed and shared decision-making.

Unique contribution of education to behavioral and psychosocial antecedents of health in a national sample of African Americans.

Education has demonstrated consistent links with many aspects of physical health and is theorized to relate to a variety of behavioral and psychosocial antecedents of health that may ultimately account for these associations. However, many of these associations and the extent to which they manifest specifically for African Americans have not been thoroughly tested. We examined associations of education-distinct from income-with established behavioral and psychosocial antecedents of health in a national sample of African Americans. Education favorably related to many behavioral (e.g., fruit/vegetable intake, lifetime smoking) and psychosocial (e.g., self-efficacy, personality traits, self-esteem, psychological well-being) antecedents of health, but not to all. Some evidence of stronger salutary relations of education for women was found. Results suggest that, for African Americans, education is generally favorably associated with an array of behavioral and psychosocial antecedents of physical health, partially explaining health disparities and providing a point of intervention moving forward.