Screening and Resistance to Cessation Efforts

Transcription

1 Screening and Resistance to Cessation Efforts Elyse R. Park, Ph.D., MPH Associate Professor in Psychiatry, Massachusetts General Hospital/Harvard Medical School

2 Funding Acknowledgements and Disclosures Funding NCI ACRIN/NLST Trial (U01 CA and U01 CA080098) NCI U54 (U54 CA156732) ACS (MRSG CPPB NCI K24CA Disclosures Royalties from UpToDate Pfizer supplying medications for RCT

3 Lung Screening Conversations What conversations are needed Shared decision making? At the time of screening? Following screening?

4 Factors Influencing Cessation Patient factors: Cognitive and emotional constructs Race Screening factors and communication: Physician interventions Numeracy Test result External factors: Stigma

5 Factors Influencing Cessation Patient factors: Cognitive and emotional constructs Race Screening factors and communication: Physician interventions Patient numeracy preferences Test result External factors: Stigma

6 Risk Perceptions and Substudy Design Phone Eligibility Screen Enrollment/Baseline forms + Risk Perception Questionnaire Randomize Experimental (CT Scan) Control (X-Ray) + Risk Perception Questionnaire 12-Month Survey Repeat CT scan 1 12-Month Survey Repeat X-Ray Repeat In-Person Scans at 2-year f/u Primary Outcome (mortality) at 8 year f/u

7 Participating Study Sites Brown University The CINJ Mayo Clinic Dartmouth Medical Center St. Elizabeth Health Center Jewish Hospital Moffitt Cancer Center Johns Hopkins University Providence, Rhode Island New Brunswick, New Jersey Rochester, Minnesota Lebanon, New Hampshire Youngstown, Ohio Louisville, Kentucky Tampa, Florida Baltimore, Maryland

8 NLST Risk Perception Survey (Baseline & Follow-up) Perceived personal risk Perceived comparative risk Perceived severity of lung cancer and SRDs Perceived benefits of quitting smoking Perceived benefits of screening Confidence to quit smoking Barriers to quitting smoking (for smokers only) Worry about lung cancer and SRDs Knowledge about lung cancer

9 Baseline Behavior Change Constructs Total ever smokers (n=630) Current smoker (n=345) Smoking risk perceptions scale, mean (SD) Risk perceptions for LC/SRD (10-50) Former smoker (n=285) p- value 35.2 (7.5) 36.9(7.3) 33.1 (7.1) <.001 Cognitive and emotional constructs, mean (SD) Perceived benefits of quitting (3-12) Confidence to quit/remain quit (1-5) Perceived severity of LC/ SRD (4-20) Worry about LC /SRD (4-16) 9.4 (2.2) 9.0 (2.2) 9.8 (2.0) < (1.4) 2.7 (1.2) 4.6 (0.8) < (2.1) 18.1 (2.3) 18.6 (1.7) (2.9) 9.8 (2.9) 8.9 (2.7) <.001

10 Risk by Smoking Intentions Percentage Low High P<.001 Smoking Intentions 1: I enjoy smoking so much I will never consider quitting 2: I never/rarely think about quitting but I might someday/have no plans 3: I sometimes/often think about quitting, but not in near future 4: I plan to quit in the next 30 days/have set a quit date 5: I have already quit but I worry about slipping back or relapsing 6: I have quit and I am 100% confident that I will never smoke again

11 One Year Follow-up: Current Smokers Current Smokers Baseline 1 year follow-up Mean SD Mean SD 95% C.I. Lung Cancer Risk (-0.23, 0.59) Smoking Related Disease Risk (-0.25, 0.74) Perceived Benefits of Quitting Smoking Perceived Confidence to Quit Smoking/Stay Quit (-0.39, 0.21) (-0.04, 0.29) Perceived Severity of LC/SRD s (-0.26, 0.24) Worry about LC and SRD s (-0.18, 0.46) Perceived Benefits of Lung Screening Percent of Smokers who will get LC One Pack/Day Smoker's Risk of Developing LC (-0.14, 0.23) (-3.25, 1.95) (-0.11, 0.16)

12 One Year Follow-up: Former Smokers Former Smokers Baseline 1 year followup Mean SD Mean SD 95% C.I. Lung Cancer Risk (-0.43, 0.43) Smoking Related Disease Risk (-0.43, 0.62) Perceived Benefits of Quitting Smoking Perceived Confidence to Quit Smoking/Stay Quit (0.20, 0.67) (-0.22, 0.03) Perceived Severity of LC/SRD s (-0.47, 0.03) Worry about LC and SRDs (-0.21, 0.40) Perceived Benefits of Lung Screening Percent of Smokers who will get LC One Pack/Day Smoker's Risk of Developing LC (-0.25, 0.20) (-1.95, 4.63) (-0.05, 0.25)

13 Changes in Risk Perception as Predictors of Smoking at 12 Months Odds Ratio 95% Cl Former Smokers at Baseline Changes in Lung Cancer Risk 1.08 (0.91, 1.28) Changes in Smoking-Related Disease Risk Current Smokers at Baseline 0.99 (0.86, 1.14) Changes in Lung Cancer Risk 1.08 (0.93, 1.26) Changes in Smoking-Related Disease Risk 1.05 (0.93, 1.19)

14 Conclusions Current and former smokers have different risk perceptions Rates of smoking behavior changes were similar to population based results Drivers of risk perception- main driver: worry Overall, the lung cancer screening experience did not appear to change participants perceived risk or promote smoking cessation Park et al., Annals of Behavioral Medicine, 2009 Park et al., Cancer, 2013

15 Qualitative Substudy Among a subset of NLST participants to determine whether screening is a cue to action Participants randomly selected from 4 sites In-depth interviews 1-2 years post screen Interviewed 35 participants with a guide structured according to the Health Belief Model Content analyses conducted using Nvivo 10 by independent coders

16 Screening and Perceived Severity Overall, screening not described as stressful Just routine like giving blood Almost all perceived lung cancer as very severe -- death sentence. However, there was a great deal of uncertainty about how much smoking was a risk factor for lung cancer or other smoking-related diseases I think it's very serious, but I think that, smoking is definitely a contributing factor, but I think that there's a lot of other factors that come into play and I think that second hand smoke is an exaggeration.

17 Risk Perceptions, Worry & Confidence Many current smokers expressed high risk for lung cancer and a sense of inevitability If I don t die of something else. I probably will from lung cancer if I keep smoking or if I quit. Current smokers responses were vague I don t know I have no idea. Overall, participants reported low levels of worry and worry intensity was described as low and frequency as not often The majority of current smokers endorsed low confidence to quit I ve tried many things, believe me.

18 Behavior Change and Intentions No one quit as a result of the screening process but many made smoking changes and other health behavior changes Regardless of test result, half of all participants changed a behavior or planned to change a behavior after the screen

19 Conclusions Expected HBM constructs did not fit Although smokers risk perceptions were high and mostly attributed to smoking - There was uncertainty about how much smoking contributed to lung cancer and SRDs - The quality of responses suggests that smokers avoid thinking about risks or worrying Post-screening behaviors indicate that smokers tried to lower their risk -Harm reduction and compensatory health behaviors

20 Racial Differences in Risk Perceptions and Smoking Behaviors Previous work in small studies suggests that blacks have lower perceived risk of lung cancer Previous research has shown that Black smokers have poorer cessation outcomes and lower tobacco treatment engagement We examined risk perceptions and smoking behavior at 1 year follow-up among black and white NLST participants who were smoking at trial enrollment

21 Risk factors for tobacco use and lung cancer among Black adults Risk Factors Tobacco Use Lung Cancer Incidence Socioeconomic factors (SES, education, environmental smoke exposure, stress) Menthol cigarette use Informed about tobacco risk Socioeconomic factors (SES, education, environmental tobacco smoke exposure) Medical comorbidities Treatment access & utilization Provider advice to quit Engagement in behavioral & pharmacological treatment Enrollment in clinical trials Delayed identification Rates of surgery offered & accepted Enrollment in clinical trials Poor lung cancer treatment outcomes Park et al., The Oncologist, 2012

22 Baseline Tobacco Use and Second Hand Smoke Exposure

23 Smoking Cessation Efforts at 12- Month Follow-Up

24 Percentage of participants Smoking outcomes-12 Month Follow-Up 60 p=< p= White Black 10 p= hour quit 7 day quit 6 month quit Length of quit attempt Kumar et al, In Press, The Oncologist

25 Clinical History and Risk Constructs Former and Current Smokers at 4 sites Personal History of, N (%) White (N=1743) Black (N=194) P Value Asthma 129 (7.40) 24 (12.37) 0.05 Chronic Bronchitis 230 (13.20) 22 (11.34) 0.68 Emphysema 168 (9.64) 6 (3.09) Heart Disease/Heart Attack 264 (15.15) 24 (12.37) 0.46 Stroke 52 (2.98) 7 (3.61) 0.75 Had personal history of cancer, N (%) 177 (10.15) 13 (6.70) 0.31 Had personal history of SRD, N (%) 494 (28.34) 39 (20.10) 0.05 Had family history of lung cancer, N (%) 424 (24.33) 45 (23.20) 0.83 Baseline screening result, N (%) Negative 1434 (82.27) 158 (81.44) 0.68 Significant for non-lung cancer abnormalities 113 (6.48) 10 (5.15) Positive 191 (10.96) 26 (13.40) Unknown 5 (0.29) 0 (0.00) Risk Perceptions, mean (SD) Risk perceptions for lung cancer and SRDs (7.50) (9.32) <.01 Cognitive and emotional constructs, Mean (SD) Perceived benefits of screening 4.86 (1.38) 4.79 (1.52) 0.50 Perceived severity of lung cancer and SRDs (1.93) (2.69) 0.21 Worry about lung cancer and SRDs 9.57 (2.81) 9.91 (3.48) 0.15

26 Lathan et al, ASCO, 2013

27 Linear Regression Model of Factors Associated with Risk Perceptions

28 Factors Influencing Cessation Patient factors: Cognitive and emotional constructs Race Screening factors and communication: Physician interventions Numeracy Test result External factors: Stigma

29 A matched case-control study of 3336 NLST participants who were smokers at enrollment examined participants rates and patterns of 5A delivery f JAMA Intern Med. doi: /jamainternmed Published online June 15, Matched case control study (n=7075) of smokers at enrollment.

30 5A Delivery of Study Quitters and Continued Smokers in NLST (n=7075) MD visits Asked Advised Assessed Assisted Arranged 0 Year 1 Year 2 Year 3 Year 4 Year 5 "A" Delivery by Year

31 Assist Delivery of Study Quitters and Continued Smokers in NLST (n=7075) MD visits 3000 Talk about quit 2000 Medication Counseling Year 1 Year 2 Year 3 Year 4 Year 5

32 Reported 5A Delivery of Study Quitters and Continued Smokers (n=3336) with PCP visits post screening

33 Factors Associated with Quitting, Following 5A Delivery

34 HINTS Numeracy Questions (n= 131 current smokers and n= 157 former smokers)

35 HINTS Numeracy Questions I feel uncomfortable with health information that has a lot of numbers and statistics. CS=50% FS=39.9% (p=.059) Do you prefer words or numbers or no preference? CS=27.0% FS=43.9% (p=.008) I depend on numbers and statistics to help me make decisions about my health. CS=57.6% FS=67.5% (p=.057)

36 The Test Result

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38 The Test Result

39 Factors Influencing Cessation Patient factors: Cognitive and emotional constructs Race Screening factors and communication: Physician interventions Referral modality Numeracy Test result External factors: Stigma

40 Reactions to Cancer Article

41 Study Design An online news article summarized findings of smoking prevalence among 2,456 lung cancer and 3,063 colorectal cancer patients enrolled in the CanCORS trial 432 written comments were posted on a public discussion board. We conducted a document analysis to establish a framework to explain factors underlying stigmatic attitudes.

42 Stigma Model Personal Experiences Never/non-smoker No experience with cancer Cancer Beliefs Smoking causes cancer Cancer is fatal Health Numeracy Misunderstanding Biased Interpretation Smoking Beliefs Smokers should be able to quit Smokers who don t quit are foolish Taxpayers should not have to cover costs Intrinsic factors are responsible (e.g., smokers are stupid) Stigmatic Attitudes

43 Lung Screening Conversations What conversations are needed Shared decision making? At the time of screening? Following screening?

44 EXTRAS

45 12-Month Smoking Status by Baseline Screening Result % Participants Negative 91.1% 93.0% 8.9% 7.0% Significant for Non- Lung Abnormalities 5.9% 94.1% Current Former Current Former Current Former Baseline Smoking Status Positive 100.0% 95.0% 0.0% 19.0% 81.0% N=179 N=186 N=17 N=7 N=21 N=20 5.0% 12-Month Smoking Status Not Smoking Smoking

46 Baseline Characteristics Current (n=345) Former (n=245) p-value Age (M, SD) 60.3 (4.6) 61.6 (5.2).001 Education (%) < Hs grad Hs grad/ged Some college Female Gender (%) Marital status (%) Never married Married W/D/S Race/Ethnicity (%) White Black

47 % Participants Change in Self-Reported Smoking Behaviors at 12- Month Follow-up by Baseline Smoking Status 9.7% 90.3% 93.4% 6.6% N=21 N=196 Current Smokers at N=199 N=14 Former Smokers at Baseline Baseline 12-Month Smoking Status Not Smoking Smoking

48 Baseline Smoking & Medical History Smoking History Current Former p- value # Years smoked Mean (SD) 43.4 (5.4) 45.0 (5.7) <.001 # Years been quit Mean (SD) (4.9) -- Average # cigarettes/day Mean (SD) 35.6 (15.4) 37.2 (17.0).22 Quit attempt in past year 42.6% Medical History Family history of lung cancer 24.6% 19.3%.12 Personal history of cancer 10.1% 10.5%.88 Personal history of smoking related disease (SRD) 27.8% 25.3%.47

49 Change in SRD Risk based on Baseline Screening Result and Smoking Status T0 Screening Result Negative Significant for nonlung cancer abnormalities Positive Former Smoker at Baseline (n=186) Current Smoker at Baseline (n=179) Former Smoker at Baseline (n=7) Current Smoker at Baseline (n=17) Former Smoker at Baseline (n=20) Current Smoker at Baseline (n=21) P Mean SD Mean SD Mean SD Mean SD Mean SD Mean SD Δ in SRD Risk

50 Change in LC Risk based on Baseline Screening Result and Smoking Status T0 Screening Result Negative Significant for nonlung cancer abnormalities Positive Former Smoker at Baseline Current Smoker at Baseline Former Smoker at Baseline Current Smoker at Baseline Former Smoker at Baseline Current Smoker at Baseline P (n=186) (n=179) (n=7) (n=17) (n=20) (n=21) Mean SD Mean SD Mean SD Mean SD Mean SD Mean SD Δ in Lung Cancer Risk

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52 Baseline Characteristics