Chest
Volume 154, Issue 1, July 2018, Pages 110-118
Journal home page for Chest

Original Research: Lung Cancer
Tobacco Dependence Predicts Higher Lung Cancer and Mortality Rates and Lower Rates of Smoking Cessation in the National Lung Screening Trial

Portions of these data were presented at the Society for Research on Nicotine and Tobacco Annual Meeting, March 8-11, 2017, Florence, Italy, and the American College of Radiology Annual Meeting, May 21-25, 2017, Washington, DC.
https://doi.org/10.1016/j.chest.2018.04.016Get rights and content

Background

Incorporating tobacco treatment within lung cancer screening programs has the potential to influence cessation in high-risk smokers. We aimed to better understand the characteristics of smokers within a screening cohort, correlate those variables with downstream outcomes, and identify predictors of continued smoking.

Methods

This study is a secondary analysis of the National Lung Screening Trial randomized clinical study. Tobacco dependence was evaluated by using the Fagerstrӧm Test for Nicotine Dependence, the Heaviness of Smoking Index, and time to first cigarette (TTFC); descriptive statistics were performed. Clinical outcomes (smoking cessation, lung cancer, and mortality) were assessed with descriptive statistics and χ2 tests stratified according to nicotine dependence. Logistic and Cox regression models were used to study the influence of dependence on smoking cessation and mortality, respectively.

Results

Patients with high dependence scores were less likely to quit smoking compared with low dependence smokers (TTFC OR, 0.50 [95% CI, 0.42-0.60]). Indicators of high dependence, as measured according to all three metrics, were associated with worsening clinical outcomes. TTFC showed that patients who smoked within 5 min of waking (indicating higher dependence) had higher rates of lung cancer (2.07% for > 60 min after waking vs 5.92% ≤ 5 min after waking; hazard ratio [HR], 2.56 [95% CI, 1.49-4.41]), all-cause mortality (5.38% for > 60 min vs 11.21% ≤ 5 min; HR, 2.19 [95% CI, 1.55-3.09]), and lung cancer-specific mortality (0.55% for > 60 min vs 2.92% for ≤ 5 min; HR, 4.46 [95% CI, 1.63-12.21]).

Conclusions

Using TTFC, a one-question assessment of tobacco dependence, at the time of lung cancer screening has implications for personalizing tobacco treatment and improving risk assessment.

Section snippets

Subjects and Methods

This study was approved by the Medical University of South Carolina Institutional Review Board (No. 00054733). It is a secondary analysis of subjects from the American College of Radiology Imaging Network (ACRIN) arm of the NLST randomized controlled trial.

Participant Demographic Characteristics

Of the 7,057 current smokers, 3,504 underwent spiral CT imaging, and 3,553 underwent radiography. Participant demographic characteristics are presented in Table 1. Approximately one half of the current smokers were female (45.9%), and the majority were white (89.8%), with a mean 55.2 ± 22.0 pack-year history of smoking. Lung nodules were detected in 19.5% of the current smokers (across 3 years of annual screening). The mean FTND score was 6.1 ± 2.3, and the mean HSI score was 4.2 ± 1.4,

Discussion

Successful tobacco cessation is critical within the context of lung cancer screening, but how best to implement tobacco treatment has yet to be determined. To our knowledge, our study is the first to investigate the relationship between degree of nicotine dependence and both likelihood to quit smoking and clinical cancer and mortality outcomes in a cohort of screened patients. It found that current smokers participating in lung cancer screening are more dependent on tobacco compared with the

Conclusions

Current smokers presenting for lung cancer screening have varying levels of tobacco dependence that predicts both ability to quit and clinical outcomes of lung cancer diagnosis, all-cause mortality, and lung cancer-specific mortality. Identifying individuals with higher levels of nicotine dependence through the use of the TTFC, which is a single-question assessment, at the time of screening has the potential to influence tobacco treatment efforts and increase cessation success within the

Acknowledgments

Author contributions: A. M. R. had full access to the study data and takes responsibility for the integrity of the data and the accuracy of the analyses. A. M. R., N. T. T., J. G. R., G. A. S., and B. A. T. were responsible for conception, design, interpretation, and drafting of the manuscript. L. D. and M. G. were responsible for design, analysis, interpretation, and drafting of the manuscript.

Financial/nonfinancial disclosures: The authors have reported to CHEST the following: B. A. T.

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