This study was designed to understand how older current and former heavy smokers who undergo lung cancer screening perceive their risk of lung cancer and other SRDs. We developed a comprehensive risk perceptions measure that examined whether risk perceptions of lung cancer differed among participants who were current versus former smokers and examined factors associated with risk perceptions.
We developed a ten-item risk perception measure that queried both personal and comparative risk for lung cancer and SRDs, had high internal consistency, and was associated with smoking intentions. Similar to work conducted by Weinstein and colleagues in 2005 [30
], current smokers with quitting intentions had higher perceived risk than smokers who did not plan on quitting. In the next phase of our work, through longitudinal analyses of these data, we will ascertain whether these intentions translate into actual behaviors.
Most research examining smokers’ risk perceptions has used nonsmokers as a comparison group and deemed that smokers underestimate their lung cancer risk relative to nonsmokers [30
]. However, some studies have compared risk perceptions of current versus former smokers and have yielded mixed results as to whether current smokers have higher or lower risk perceptions compared to former smokers [28
]. Using our risk perception measure, we found that current smokers’ risk perceptions were higher than those of former smokers; this was true when group comparisons were made using the total risk perception measure and for each of the ten personal and comparative risk questions. Moreover, only approximately 10% of current smokers responded that their risk of getting lung cancer or a SRD was lower than that of other smokers. Therefore, this group of current, heavy smokers who undergo lung screening did not display an optimistic bias, as might have been expected based on previous research. These findings are also surprising in light of key work that suggests that heavy smoking and older age is associated with being more likely to underestimate risk [25
]. Our results indicate that older individuals with a significant smoking history who seek out lung cancer screening might hold different perceptions than would be otherwise expected.
Although it is believed that perceived risk can drive behavior change [52
], our finding that former, heavy smokers had lower risk perceptions than current, heavy smokers suggests that changing behavior may drive perceived risk; quitting smoking likely lowered former smokers’ risk beliefs. This finding is consistent with the risk reappraisal hypothesis [63
] that posits that if a change is made to decrease disease risk, in turn, risk perceptions decrease subsequent to this behavior change. This raises the question whether formerly heavy smokers who are undergoing lung screening overestimate the risk reduction achieved from quitting, which is potentially indicative of optimistic bias.
According to the HBM, in order to make a behavior change, individuals must believe that smoking would lead to serious health consequences and that quitting smoking will reduce the likelihood of getting lung cancer or a SRD. Accordingly, former smokers, compared to current smokers, endorsed greater perceived severity for lung cancer and SRDs and believed in greater perceived benefits from quitting. Former smokers recognized the threat, took action, and believed that this change would be of benefit. This is consistent with research that has shown that current smokers, compared to former smokers, report fewer benefits of quitting [32
] and that older, continuing smokers in particular are pessimistic about the benefits of quitting smoking [53
In examining factors associated with risk perceptions, our findings support the Self-Regulation Model in that they underscore the important role of emotional factors in driving risk perceptions. Although many behavior change models include only cognitive constructs, in our study, worry was a salient factor associated with risk perceptions of both current and former smokers. This finding is consistent with findings from breast and colon screening studies in which cancer-related worry was associated with perceived risk [65
]. In the cancer screening literature, it is unclear if worry leads to or deters from seeking cancer screening [56
] or if worry and risk, together, influence behavior [75
]. Similarly, for patients undergoing lung cancer screening, it is unclear at which level worry would positively influence risk perceptions and post-screening health promotion behaviors.
Our results also indicated that knowledge of smoking risks was an important factor associated with risk perceptions for both former and current smokers. Current and former smokers who underestimated a 1 pack per day smoker’s increased risk of lung cancer due to smoking had lower risk perceptions for lung cancer and SRDs. These findings are similar to previous research that demonstrated that smokers underestimate the impact on quality of life and disability from smoking [76
Among former smokers, past history of smoking within 30 min of waking, a proxy measure indicating greater nicotine dependence, was associated with elevated risk perception. It is possible that, within former smokers, those who had a higher level of nicotine dependence feel less of a sense of control over their future health and thus feel at greater risk for diseases.
Among former smokers, being Black was associated with lower risk perceptions for lung cancer and SRDs. Although there is a dearth of research conducted on racial differences and smoking-related risk perceptions, one study conducted among 144 smokers found that Black smokers were more likely to underestimate their lung cancer risk, compared to nonsmokers, and were less likely to believe that quitting smoking would reduce their lung cancer risk [53
]. A population-based study also reported that Blacks were less likely than Whites to perceive cancer risk [62
]. Racial differences have been shown to influence lung cancer treatment decision making in that Black patients have lower rates of surgical treatment and are more likely to refuse surgery [78
], even after access to care has been demonstrated [79
]. Our results suggest that race could influence lung cancer risk perceptions, particularly for previously heavy smokers who quit smoking; this is an area for future research.
Some study limitations must be noted. The participants in this NLST sub-study are not representative of all older current or former heavy smokers. In this self-selected population of trial participants, one would assume that worry and risk perceptions would be relatively high. This is a high-risk group of individuals with smoking histories of at least 30 pack years who elected to participate in a screening trial; this may have restricted the range of responses for the risk perception outcomes since, at high levels of smoking consumption, there are decreasing increments of risk [80
]. The majority of NLST participants was White and had a fairly high education level. Lastly, about 25% of participants did not answer the question about smokers’ years of life lost; perhaps it was a potentially uncomfortable question to quantify. Because of the missing data, and since this question was associated with the knowledge of a pack per day smoker’s increased risk of lung cancer, it was not included in the multivariable model.
Our findings have important implications for prescreening risk assessments. We found that risk perceptions and risk knowledge among current and former heavy smokers is a complex issue, particularly when addressing risks for both lung cancer and SRDs; this implies that a prescreening assessment must include an assessment of both risk perception and risk knowledge. Our results also suggest that current, heavy smokers undergoing lung screening may not have an optimistic bias and, in fact, may be pessimistic about the value of quitting. Likewise, former, heavy smokers undergoing lung screening may benefit from reinforcement of the importance of staying quit. Therefore, prescreening comprehensive risk assessments would maximize the utility of lung screening as a teachable moment to promote smoking cessation and relapse prevention.
Once risk is assessed, prescreening risk communication sessions can be guided by the contextualized approach to risk communication [81
]. The main features of this approach are that (1) information is provided on antecedents, (2) information is provided on consequences, and (3) information is given on how to minimize risk. Our findings indicate that, for lung cancer screening patients, antecedents
to focus upon might be increasing recognition of risk due to an individual’s smoking and medical history; care must be taken to do so in a way that would appropriately elevate worry. Our study showed that adverse consequences
, such as smoking morbidity, might be an important area in which to focus and educate upon. For current smokers, minimizing risk
could be done by emphasizing benefits to be gained by quitting and offering encouragement by sharing research on how older smokers successfully quit. This could be particularly salient for current smokers, given previous research that indicates their proclivity to diminish the benefits of quitting. For former smokers, minimizing risk
could be done by supporting their quit status while including a cautionary note about the importance of maintaining quit and decreasing exposure.
In closing, this study demonstrated differences in risk perceptions and risk knowledge between current versus former smokers who were participating in NLST. Our results indicate that older, current heavy smokers who are undergoing lung cancer screening have higher risk perceptions compared to older, former heavy smokers. These findings suggest that lung cancer screening presents a unique opportunity to intervene with risk perceptions to potentially enhance smoking cessation and relapse prevention efforts in this group. As it is important to understand the determinants of risk perceptions in order to develop effective risk communication messages [81
], this work elucidated the prescreening determinants of risk and emphasized the particular importance of assessing and discussing worry, risk knowledge, and perception of addiction prior to screening.