The results of an admittedly small but telling new study suggest that Medicare and other insurers could be spending billions of dollars on screening smokers for lung cancer that would be better spent on helping them quit and keeping others from starting.
Although screening is considered “a teachable moment” that could be used to foster smoking cessation, the new study indicated that it more often bolstered smokers’ beliefs that they had dodged a bullet and could safely continue to smoke. Even when nodules were found that suggested cancer-in-the-making, most participants remained smokers because they believed screening could catch cancer early before it would threaten their lives.
“They compared how hard it was to quit smoking with how easy it was to be screened,” said Steven B. Zeliadt, the lead author of the study. “They engaged in magical thinking that now there’s this wonderful painless external test that can save lives.”
But, Zeliadt added, “If we want to save lives from smoking, we should take all this money being spent on screening and double down on smoking-cessation efforts.”
The study findings shed light on a common psychological problem called cognitive dissonance — a conflict between people’s beliefs and their behaviors that typically prompts them to adjust their attitudes and beliefs to make them consistent with their behavior, rather than change their behavior, which is more challenging.
“Smoking is a classic example,” Omid Fotuhi, a social and health psychologist at Stanford University, said. “Smokers think, ‘I know smoking is unhealthy for me, but I can’t change my behavior because I’m addicted.’ So they follow the path of least resistance and keep smoking.”
Zeliadt, a health economist at the VA Puget Sound Health Care System and the University of Washington in Seattle, and seven colleagues conducted the study of 37 smokers who were offered lung cancer screening at Department of Veteran Affairs. centers around the country.
After being screened with a low-dose CT chest scan and told the results, the participants were interviewed in-depth about their smoking-related health beliefs. For about half of those in whom cancer was not found, “screening lowered their motivation for cessation,” the team reported in July in JAMA Internal Medicine. A commonly expressed belief was that the screening provided the same health benefits as stopping smoking, even when precancerous lung nodules were detected.
The participants focused only on lung cancer, ignoring other effects of smoking, the researchers wrote. Even though many discussed their existing health problems, including chronic pulmonary disease, peripheral artery disease, previous heart attack or other conditions related to smoking, “there was little concern about how continuing to smoke” would affect these or other future ailments, they reported.
A national study published four years ago found that annual CT screening for lung cancer three years in a row could reduce deaths among heavy smokers by about 20 percent. In December 2013, the U.S. Preventive Services Task Force recommended screening current smokers ages 55 to 80 who had accumulated at least 30 pack-years of smoking (for example, having smoked one pack a day for 30 years, or half a pack daily for 60 years) or former heavy smokers who had quit within the previous 15 years. Despite objections from an advisory committee, last November Medicare decided to cover annual screening for current and former smokers until age 75.
The Medicare coverage includes a counseling session. But it is offered before screening to explain the exam and what it may reveal. Experts suggest that counseling might be more effective if offered by people’s primary care physicians when they receive screening results. One man screened in Zeliadt’s study said that when his doctor received the results, he told him: “You have nodules. You’re going to die of lung cancer. Stop smoking now!” The man did — at least for 30 days, the point at which he was interviewed.
“Counseling should focus more on the emotional meaning of screening than the technical details,” Zeliadt suggested. “Being told that a nodule of nine millimeters is serious allows the person to think, ‘Well, mine is not nine millimeters yet’ and continue to smoke.”
In a commentary accompanying the VA report, Dr. Russell P. Harris, a preventive medicine specialist at the University of North Carolina at Chapel Hill, noted that “nearly every participant described misperceptions about smoking that were exacerbated by screening.”
In an interview, Harris said, “Screening is being perceived by people as an alternative to stopping smoking. But stopping smoking would have huge benefits for the individual and society way beyond people not dying from lung cancer,” which causes almost 160,000 deaths a year, 90 percent of them from smoking.
“At best,” he said, “screening might reduce lung cancer deaths by 8,000 a year. But in the year 2000 alone, smoking cessation reduced lung cancer deaths by 70,000.”
Furthermore, smoking is linked to many other cancers, 11 of them by longtime research and two others, breast cancer and prostate cancer, in a recent report by the American Cancer Society. While the Surgeon General estimates that smoking causes more than 480,000 deaths a year from 21 diseases, the number is probably far higher when taking into account the “excess mortality observed among current smokers” from additional diseases, studies showed.
“Smoking harms nearly every organ of the body,” the Centers for Disease Control and Prevention says.
Fotuhi said that counseling for smokers should target the rationalizations they use to reduce cognitive dissonance. For example, a smoker who claims that smoking helps them cope with stress should be told that the effect is only temporary and that much of the stress is the result of nicotine withdrawal, which prompts them to smoke another cigarette and perpetuate the cycle. Once their system is cleared of nicotine, that stress will likely dissipate.
Harris agreed that rather than screening, money is better spent on smoking cessation and prevention. He suggested providing free stop-smoking aids, sponsoring antismoking advertising and raising taxes on tobacco products and the age at which people are allowed to buy them.
“We need to keep our eyes focused on the prize,” he said.”On how to reduce smoking-related deaths from lung cancer and other conditions, not on how many people we can get screened.”
Jane Brody is an American author on science and nutrition topics who reports for The New York Times as its “Personal Health” columnist.