Tobacco Treatment Specialist Training for Lung Cancer Screening Providers

Based on the results of the National Lung Screening Trial,¹ the U.S. Preventive Services Task Force (USPSTF) recommends lung cancer screening with a low-dose computed tomography scan (LDCT) as a screening tool for early detection of lung cancer.² More specifically, this LDCT scan is recommended for high-risk individuals who have at least a 20–pack year smoking history, are currently smoking or have quit in the last 15 years, and are aged 50–80 years.² At the time of writing, the Centers for Medicare and Medicaid Services (CMS) approved annual lung cancer screening as a covered benefit for those patients who meet the criteria outlined in the 2013 USPSTF recommendation (i.e., 30–pack year history, age 55–77 years).^3,4 CMS is expected to approve the new USPSTF guidelines in the future to offer coverage for additional individuals meeting the revised criteria. Nearly 8 million Americans met the 2013 eligibility criteria for lung cancer screening in 2018,⁵ and an additional 6 million adults will be eligible under the new recommendations.⁶ Importantly, if every eligible person took advantage of annual LDCT screening, >12,000 lung cancer deaths could be prevented each year.¹

The American College of Chest Physicians and American Thoracic Society issued a policy statement on the components necessary for high-quality lung cancer screening,⁷ and recommended that annual lung cancer screening include a shared decision making (SDM) visit that occurs in advance of the LDCT. An SDM visit is a meeting between the patient and provider to discuss the benefits and risks of the LDCT screening, such as the patient’s personalized risk, false positive rate, follow-up diagnostic tests, overdiagnosis, and radiation exposure.¹ The provider conducting the SDM visit will also determine if the patient meets the eligibility criteria for the LDCT. In conjunction with an SDM visit, the USPSTF, American College of Chest Physicians, and American Thoracic Society recommend that tobacco treatment should be provided to those patients who are still smoking.^2,7 Specifically, the new USPSTF guidelines recommend incorporation of tobacco treatment interventions into all screening programs.² Further, the 2015 CMS memo states that reimbursement for LDCT will only be given if the physician or qualified non-physician delivering the SDM visit counsels the patient on smoking cessation, in addition to the other required SDM components. However, neither the USPTF nor the CMS specify the ideal components of tobacco treatment, when the treatment should be offered, the qualifications of the provider delivering this service, or the clinical competencies for tobacco treatment in this clinical setting.²

The importance of high-quality tobacco treatment for lung cancer screening patients who currently smoke is paramount as cessation is crucial for reducing lung cancer risk and premature mortality.⁸ The SDM visit for lung cancer screening offers a unique opportunity to discuss smoking cessation with a high-risk population who may not otherwise seek these services. Indeed, a recent study demonstrated that in people who smoke and were attending lung cancer screening, 44% reported that screening made them consider quitting smoking, 29% said it made them try to stop, and 25% said it made them reduce their smoking.⁹ However, only 10% of people who smoke said lung cancer screening had made them look for help to stop. Providing comprehensive tobacco treatment at the point of screening can capture a population on the crest of change and guide them in the direction of smoking-cessation success.

Acknowledging the lack of specific direction on tobacco treatment in lung cancer screening from CMS, USPSTF, and other major medical and professional organizations, a committee of professionals from the leading treatment and scientific organizations of tobacco use and dependence in the U.S. developed specific and executable recommendations for how tobacco treatment can be integrated into lung cancer screening programs.¹⁰ The committee recommends that individuals who smoke and participate in lung cancer screening should be encouraged to quit smoking at each annual screening and at any point during the subsequent diagnostic odyssey, regardless of the lung cancer screening results or level of motivation to quit. Further, comprehensive, evidence-based tobacco treatment interventions should either be provided by the SDM visit provider or other clinicians who may be in the position to offer a brief intervention, or the patient should be referred to a dedicated tobacco treatment service.¹⁰ Though the committee makes some specific recommendations on how to integrate treatment into these visits, they also call for more research to be conducted on tobacco treatment in this context. To that end, research is currently underway through the Smoking Cessation at Lung Examination collaboration, consisting of 7 clinical trials funded by the National Cancer Institute and 1 by the Veterans Health Administration, to address these gaps in the literature.¹¹

Ideally, a dedicated tobacco treatment program with qualified specialists, counselors, and pharmacists would facilitate evidence-based, comprehensive, ongoing cessation support for patients attending lung cancer screening.¹² Patients could be referred by the SDM provider to this type of service if one exists within the healthcare setting. However, many systemic barriers exist in individual healthcare settings that prevent dedicated tobacco treatment services from being implemented, including lack of organizational support and lack of reimbursement for providers.¹³ Providers could also refer patients to the state smokers’ quitline (1-800-QUIT-NOW) for cessation support. However, patients may not call the quitline on their own as this would require patients to opt in to treatment instead of being given tobacco treatment in an opt-out fashion at the time of their SDM visit.¹⁴ As Fucito and colleagues¹⁰ have outlined, one promising alternative to relying on a referral to tobacco treatment services for the cessation counseling component of the SDM visit is to have the SDM provider deliver tobacco treatment during the same appointment. However, SDM visit providers (e.g., Advance Practice Providers, Primary Care Providers) often do not have the necessary tobacco treatment training to deliver comprehensive behavioral counseling and pharmacological support for cessation.¹³ Delivering effective treatment for tobacco use requires the cultivation of specialized knowledge, skills, and competencies consistent with the level of intensity of the treatment to be provided.¹⁵ At present, the majority of healthcare practitioners have not received even the minimal training needed to effectively deliver a brief, low-intensity evidence-based treatment.¹⁵ A recent evaluation of reported clinician-delivered 5A’s (Ask, Advise, Assess, Assist [talk about quitting or recommend stop-smoking medications or recommend counseling], and Arrange follow-up) in a large sample of lung screening patients in the first year after lung cancer screening found that the 5A’s were delivered as follows: Ask, 77.2%; Advise, 75.6%; Assess, 63.4%; Assist, 56.4%; and Arrange follow-up, 10.4%.¹⁶ This is not a unique phenomenon within lung cancer screening, but instead is indicative of a trend that medical professionals in the U.S. are aware of the importance of quitting but are less likely to assist with a tobacco quit attempt and arrange follow-up. This is likely due to lack of institutional support, training, and allotted clinical time.^13,17,18 The authors propose that SDM visit providers receive specialized training¹⁹ in tobacco treatment such that they can offer brief, evidence-based, comprehensive cessation support in the context of lung cancer screening.

Tobacco Treatment Specialists (TTSs) are professionals who are trained to provide treatment for individuals seeking to stop using tobacco.¹⁵ A TTS has to demonstrate a high level of proficiency in the treatment of tobacco dependence by completing coursework and passing an examination, facilitated through one of the accredited programs of the Council for Tobacco Treatment Training Programs supported by the Association for the Treatment of Tobacco Use and Dependence.¹⁹ Through the TTS training program network, a medical professional can choose among trainings with different levels of training intensity at institutions across the country or online. The TTS training involves a minimum of 24 hours of training content, typically organized in a 3- to 5-day course completed either online or in person, with many programs offering continuing medical education credit for the training. Some programs offer self-paced modules or a mix of asynchronous modules and synchronous virtual sessions, which may be preferable to practitioners whose schedules cannot accommodate a multiday scheduled course. During training, attendees can expect to learn core competencies of tobacco treatment including assessment of tobacco use, counseling skills, treatment planning, pharmacotherapy, relapse prevention, and diversity and special health issues. Following the completion of the training course, providers can then serve as an educational resource for their organizations, other healthcare providers, and the general public regarding tobacco treatment. This type of brief training course could significantly improve provider skills in a meaningful way for patient care, including an increased likelihood of patient cessation and longer-term abstinence.^20,21

Training for TTSs requires an investment of training time and a fee on the provider’s part, yet has the potential to result in far-reaching, long-term benefits across the cancer care spectrum. A medical provider cross-trained as a TTS could deliver comprehensive tobacco treatment at the time of the SDM visit and aid in providing necessary cessation support and education in the context of lung cancer screening, likely before the patient has lung cancer. Given that lung cancer is the leading cause of cancer death in the U.S.,²² capturing the lung cancer screening patient in a teachable moment to deliver comprehensive tobacco treatment will increase the likelihood of cessation and reduce the likelihood of future morbidity and mortality. Further, the provider’s skill in delivering comprehensive tobacco treatment could be applied to other patient populations, making this skill set highly desirable for healthcare systems on the whole.¹²

Maximizing the availability and reach of comprehensive tobacco treatment for lung cancer screening patients should be prioritized as one of the critical components of a comprehensive lung cancer screening program. This can be achieved at relatively low cost to the provider or healthcare system by training SDM providers as TTSs. Lung cancer screening should be viewed as an opportunity to deliver comprehensive, evidence-based tobacco treatment that would meet reimbursement requirements for the SDM visit as outlined by the CMS reimbursement guidelines. The treatment that is offered should be the most effective treatment possible, and this treatment can be feasible (i.e., brief) and effective when delivered via a TTS-trained SDM visit provider. Ideally, tobacco treatment services would be better integrated within medical and nursing education and healthcare system delivery. The authors also support CMS policy revisions to allow for TTS service billing to make dedicated tobacco treatment services more financially desirable to healthcare systems. However, brief provider training in the context of lung cancer screening has the opportunity to offer a more immediate impact on high-risk patient health than waiting years for the education, healthcare, and insurance fields to adopt such policies and procedures. Future empirical evidence from the Smoking Cessation at Lung Examination collaboration will hopefully help guide any additional recommendations for optimizing tobacco treatment interventions in this population.¹¹ In the interim, optimizing SDM visits for tobacco treatment by employing professionals specifically trained to provide evidence-based tobacco treatment interventions is a straightforward way to expand the reach of these cessation services.