Attitudes towards the integration of smoking cessation into lung cancer screening in the United Kingdom: A qualitative study of individuals eligible to attend

Abstract Introduction There is limited research exploring how smoking cessation treatment should be implemented into lung cancer screening in the United Kingdom. This study aimed to understand attitudes and preferences regarding the integration of smoking cessation support within lung cancer screening from the perspective of those eligible. Methods Thirty‐one lung cancer screening eligible individuals aged 55–80 years with current or former smoking histories were recruited using community outreach and social media. Two focus groups (three participants each) and 25 individual telephone interviews were conducted. Data were analysed using the framework approach to thematic analysis. Results Three themes were generated: (1) bringing lung cancer closer to home, where screening was viewed as providing an opportunity to motivate smoking cessation, depending on perceived personal risk and screening result; (2) a sensitive approach to cessation with the uptake of cessation support considered to be largely dependent on screening practitioners' communication style and expectations of stigma and (3) creating an equitable service that focuses on ease of access as a key determinant of uptake, where integrating cessation within the screening appointment may sustain increased quit motivation and prevent loss to follow‐up. Conclusions The integration of smoking cessation into lung cancer screening was viewed positively by those eligible to attend. Screening appointments providing personalized lung health information may increase cessation motivation. Services should proactively support participants with possible fatalistic views regarding risk and decreased cessation motivation upon receiving a good screening result. To increase engagement in cessation, services need to be person‐centred. Patient or Public Contribution This study has included patient and public involvement throughout, including input regarding study design, research materials, recruitment strategies and research summaries.

telephone interviews were conducted. Data were analysed using the framework approach to thematic analysis.
Results: Three themes were generated: (1) bringing lung cancer closer to home, where screening was viewed as providing an opportunity to motivate smoking cessation, depending on perceived personal risk and screening result; (2) a sensitive approach to cessation with the uptake of cessation support considered to be largely dependent on screening practitioners' communication style and expectations of stigma and (3) creating an equitable service that focuses on ease of access as a key determinant of uptake, where integrating cessation within the screening appointment may sustain increased quit motivation and prevent loss to follow-up.
Conclusions: The integration of smoking cessation into lung cancer screening was viewed positively by those eligible to attend. Screening appointments providing personalized lung health information may increase cessation motivation. Services should proactively support participants with possible fatalistic views regarding risk and decreased cessation motivation upon receiving a good screening result.
To increase engagement in cessation, services need to be person-centred.
Patient or Public Contribution: This study has included patient and public involvement throughout, including input regarding study design, research materials, recruitment strategies and research summaries.
cancer prevention, lung cancer, lung cancer screening, qualitative, smoking cessation

| INTRODUCTION
Successfully stopping tobacco smoking is the most important behaviour change required to reduce lung cancer risk and mortality. 1 In the United Kingdom (UK), the prevalence of quit attempts has decreased since 2007. 2 Individuals from deprived communities have the highest smoking prevalence and disproportionately worse health outcomes. For example, Manchester and Liverpool, two areas in the North of England within the most deprived decile in England, have the highest premature lung-related mortality rates in the country. 3,4 Research has demonstrated that low-dose computed tomography scan (LDCT) screening detects early-stage disease and reduces lung cancer-specific mortality in high-risk individuals. [5][6][7][8][9] In trials such as the National Lung Screening Trial, individuals were classed as highrisk if they had 30 pack years and had smoked within 15 years. 5 As such, lung cancer screening programmes have been implemented in some countries, including the United States of America (US) and China, while the UK National Health Service has funded a 'Targeted Lung Health Check Programme' (TLHC) following the success of multiple pilot projects. 7,[10][11][12] The TLHC is running in areas of England with high lung cancer mortality 13 and inviting 55-74-year-old individuals who have ever smoked to a free face-to-face, telephone or video appointment. Here, the attendees' risk of lung cancer is calculated using set questions, and in some cases, noninvasive tests such as spirometry are performed. If an individual is above a designated risk threshold, they are invited for an LDCT scan at a local screening facility. 14 During the TLHC appointment, an attendee may be offered a smoking cessation intervention; however, there is currently no standardized approach for provision across facilities in England.
Lung cancer risk assessment, and the screening process itself, may trigger a cessation-related teachable moment: a point in time when an individual has increased desire to change behaviour [15][16][17] and greater receptivity to cessation support. Indeed, screening attendance as part of a research trial has been associated with increased cessation compared to usual care, particularly among attendees who receive a positive scan result. 18,19 Best available evidence suggests that these differences can be maintained for 5 years. 19 This success has been replicated in a UK community setting where 55% of attendees who made a successful quit attempt in the year after screening, attributed this to participation in the TLHC. 20 Implementation of smoking cessation is additionally associated with increasing the cost-effectiveness of lung cancer screening. 21,22 Quantitative and qualitative evidence in the US has demonstrated that screening eligible individuals believe offering cessation support as part of lung cancer screening is appropriate. 23 [27][28][29] However, research has also highlighted concerns within the lung cancer screening population, including fatalism 29 32,33 It has also been used as a tool to develop several smoking cessation interventions. 34,35 Therefore, the TDF is well suited to underpinning exploration of attitudes and preferences for smoking cessation provision, allowing researchers to identify clear targets for tailored intervention development with the aim of successful behaviour change.
The protocol for TLHC, 14 alongside a European position statement, 36 recommends that smoking cessation should be incorporated into lung cancer screening. However, no further guidance on optimal implementation or delivery has been disseminated. Gaining insight from stakeholders rather than relying solely on published literature, which is still limited given the novelty of lung cancer screening, will aid the development of UK-based guidelines that consider the wider contextual factors affecting implementation. Therefore, the aim of this study was to understand attitudes and preferences regarding the offer and provision of smoking cessation at the time of lung cancer screening, from the perspective of those eligible to attend.

| Design
A qualitative design involving focus groups and semi-structured interviews was used to explore individuals' opinions of smoking cessation provision at lung cancer screening, and preferences for cessation support delivery. Data collection began in February 2019 and was adapted from focus groups to telephone interviews from March to August 2020, due to the COVID-19 pandemic.
Virtual focus groups were not used due to limited computer access highlighted by previous participants. This study adopted a limited realist approach, assuming meaning can be shared across participants, with potential relevance to wider populations (realist ontology), while acknowledging that participant and researcher experience is inevitably shaped by context (constructivist epistemology). 37

| Participants
Inclusion criteria were based on eligibility for lung cancer screening: (a) aged 55-80, (b) who currently smoked, or had quit within 3 months before study participation date and, (c) lived in one of four areas where lung cancer screening was ongoing during the data collection period. The quit period of 3 months was specified to facilitate participant recollection of their experience as a person who smokes, alongside their current experience of cessation. Three months has also been used as an endpoint to measure short-term smoking cessation. 38

| Procedure
A topic guide (see File S1) was developed in consultation with a lay research partner who is screening eligible. Interviews were piloted with other researchers with expertize in health psychology to assess flow, clarity and prompts to be used. The semi-structured topic guide was used flexibly to ensure that all topics of interest and any new views raised by participants were explored.
Participants were initially invited to take part using community outreach recruitment methods. This included visits to community locations to advertise the study to those eligible to participate in four screening-active areas, staff members in local organizations advertising the study to visitors and disseminating paper and online posters across networks. Due to the COVID-19 pandemic, in person recruitment was suspended, and social media advertising was

| Data analysis
Focus group and interview recordings were transcribed verbatim by an external transcription company. Transcripts were checked for accuracy and anonymized. Data were analysed using reflexive thematic analysis using the framework approach for data organization. 40 Each transcript was read to get an overall sense of the data and a coding framework was developed using Nvivo-12 software (S. G.). Where possible, themes were organized around the TDF 30,31 to assist with understanding the barriers and facilitators associated with cessation delivery preferences. Simultaneous inductive coding using no pre-existing framework was conducted to explore wider underpinning views and experiences. The initial codebook was developed using three initial transcripts and discussed with a smaller research team to resolve discrepancies in coding and to formulate an initial framework matrix (S. G., L. M. and G. M.). The matrix was iteratively modified throughout analyses to confirm all relevant codes were captured. Data were charted into the matrix for interpretation and theme generation. Focus group data were treated as a single case in the matrix to account for the unique dynamics within each group.
Participant smoking status was displayed next to each case name to allow the researchers to consider the impact of the participants' current smoking context alongside the data. The analysis focused on attitudes and experiences of screening eligible individuals regarding smoking and cessation attempts, and how this shapes preferences for cessation integration within a lung cancer screening context.

| Sample
Thirty-one participants took part in this study (six took part in two focus groups, N = 3 in each, and 25 in individual telephone interviews). Twenty-six participants currently smoked and five had recently quit. For additional sample characteristics, see Table 1. Focus groups and interviews ranged from 16 (incomplete interview due to participant becoming unavailable unrelated to participation, and unable to reschedule) to 69 min (median: 48 min).
Data are presented as three themes: (1) bringing lung cancer closer to home; (2) a sensitive approach to smoking cessation and; (3) creating an equitable service. Quotes are presented as pseudonyms with age (years) and smoking status (currently smokes [CS] or recently quit smoking [RQS]).

Theme 1: Bringing lung cancer closer to home
The impact of smoking on health, including its causal role in lung cancer development, was widely acknowledged by partici-  terms was viewed as the most likely pathway to successful cessation.
Although self-initiated cessation was emphasized as important, a sense of feeling 'trapped' in a self-described addiction was endorsed by many, alongside internalized stigma in the form of self-blame.
These feelings were intensified for some by low perceived knowledge of effective methods for quitting, or by past unsuccessful cessation attempts leading to a frustrating cycle of wanting to quit, but not knowing how, or why they cannot achieve their goal.  Indeed, research has shown that abnormal spirometry results, 28,41 abnormal screening results including the need for further tests 18,19,28 or a lung cancer diagnosis 42 may lead to increased motivation and the likelihood of cessation. Additionally, the time between registering for lung cancer screening and receipt of results is associated with increased 'readiness to quit', particularly among individuals attending their first screening. 43 In comparison, cessation discussions when deciding whether to have screening itself, before registering for lung cancer screening, has been viewed as unlikely to impact cessation GROVES ET AL.
| 1711 from the perspective of both clinicians and individuals offered screening. 44 The caveat of potential decreased motivation resulting from receiving an 'all clear' has also been identified as a concern among screening staff 45 and the current study participants. There is currently no evidence to support that a 'licence to smoke' occurs in practice 46 although a US-based smoking cessation trial found that attrition was higher for participants who had negative LDCT scan results. 47  Fatalism was also acknowledged as a potential response to considering quitting, which has been previously identified, alongside the low perceived efficacy of smoking cessation in reducing the risk of lung cancer, as a barrier to lung cancer screening engagement among eligible individuals in the United Kingdom. 29,[50][51][52][53] The present study extends these findings by demonstrating that fatalism may also influence those who have already made the decision to attend, acting as a barrier to cessation uptake. Discussing the benefits of cessation regardless of age, current health or smoking history with attendees may increase intention to quit. For example, even following the diagnosis of lung cancer, smoking cessation is associated with reduced progression and mortality across cancer stages indicating that it is never 'too late' to consider quitting. 54 The adoption of an 'opt-out' service delivery model for discussion of smoking cessation would ensure all attendees are able to discuss their views surrounding risk and has been shown to improve cessation uptake. 55 Previous research has illustrated that individuals eligible for lung cancer screening report smoking-associated external and internalized stigma. 29 receiving screening at a centre with integrated smoking cessation had greater odds of cessation compared to attendees at other screening centres. 62 Additionally, a trial in England has shown that the provision of immediate smoking cessation within a TLHC is associated with an increase in quit rates at a 3-month follow-up. 63 Integrating cessation interventions within the screening appointment and disclosure of screening results may increase cessation uptake by ensuring accessibility of the service, providing readily available treatment, and preventing referral-related disengagement. However, the ability to integrate is largely dependent on the model of lung cancer screening service delivery. Yet, this remains an important consideration as poor referral processes, and appointment delays are significant barriers to cessation service uptake. 57 The need for tailoring and flexibility of services regarding ongoing support modality (face-to-face, telephone, online), treatment method (e.g., nicotine replacement products, medications, e-cigarettes and individual or group support) and discussion content (e.g., exploring and debunking any myths regarding cessation that an attendee has concerns about) were emphasized by participants as key to creating acceptable, effective cessation services. Indeed, the ability to provide tailored, multimodal cessation interventions has been shown to potentially support smoking cessation among older individuals who smoke, from deprived backgrounds, many of whom may be eligible for lung cancer screening. 64 The ability to be flexible has also been identified as an important facilitator of successful implementation of smoking cessation services within hospitals, 65 and appears to also be important within a lung cancer screening To the research team's knowledge, this is the first qualitative study conducted in the UK, which investigates attitudes towards and preferences for cessation delivery as part of lung cancer screening.
Using qualitative methods facilitated the collection of rich data, for example, eligibility, uptake and follow-up care. 67 Finally, throughout interviews, participants who had RQS largely discussed how cessation support could be provided to attendees who smoke, rather than those who had previously quit. Future research could explore the role that lung cancer screening may play in relapse prevention among individuals who previously smoked, regardless of eligibility for LDCT scanning.

| CONCLUSION
To conclude, integrating smoking cessation within lung cancer screening was viewed by those eligible as necessary and expected, regardless of smoking status and plans to quit. The ability of lung cancer screening to provide attendees with personalized information regarding the impact of smoking on their health was viewed as a key factor affecting the potential uptake of smoking cessation. A nonjudgemental, accessible and inclusive service, which addresses patient-level barriers, such as fatalism, anxiety, and avoidance provides a unique opportunity to engage attendees in smoking cessation.

AUTHOR CONTRIBUTIONS
All authors meet the four criteria for ICMJE authorship. Presented below is each author's contribution relative to CRediT Classification: