Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2024 Jun 10;42(17):2026-2037.
doi: 10.1200/JCO.23.01780. Epub 2024 Mar 27.

Pack-Year Smoking History: An Inadequate and Biased Measure to Determine Lung Cancer Screening Eligibility

Alexandra L Potter  1 , Nuo N Xu  2 , Priyanka Senthil  1 , Deepti Srinivasan  1 , Hang Lee  3 , G Scott Gazelle  4   5 , Lydia Chelala  6 , Wei Zheng  7   8 , Florian J Fintelmann  4 , Lecia V Sequist  9 , Jessica Donington  10 , Julie R Palmer  2 , Chi-Fu Jeffrey Yang  1
Affiliations

Pack-Year Smoking History: An Inadequate and Biased Measure to Determine Lung Cancer Screening Eligibility

Alexandra L Potter et al. J Clin Oncol. .

Abstract

Purpose: Pack-year smoking history is an imperfect and biased measure of cumulative tobacco exposure. The use of pack-year smoking history to determine lung cancer screening eligibility in the current US Preventive Services Task Force (USPSTF) guideline may unintentionally exclude many high-risk individuals, especially those from racial and ethnic minority groups. It is unclear whether using a smoking duration cutoff instead of a smoking pack-year cutoff would improve the selection of individuals for screening.

Methods: We analyzed 49,703 individuals with a smoking history from the Southern Community Cohort Study (SCCS) and 22,126 individuals with a smoking history from the Black Women's Health Study (BWHS) to assess eligibility for screening under the USPSTF guideline versus a proposed guideline that replaces the ≥20-pack-year criterion with a ≥20-year smoking duration criterion.

Results: Under the USPSTF guideline, only 57.6% of Black patients with lung cancer in the SCCS would have qualified for screening, whereas a significantly higher percentage of White patients with lung cancer (74.0%) would have qualified (P < .001). Under the proposed guideline, the percentage of Black and White patients with lung cancer who would have qualified for screening increased to 85.3% and 82.0%, respectively, eradicating the disparity in screening eligibility between the groups. In the BWHS, using a 20-year smoking duration cutoff instead of a 20-pack-year cutoff increased the percentage of Black women with lung cancer who would have qualified for screening from 42.5% to 63.8%.

Conclusion: Use of a 20-year smoking duration cutoff instead of a 20-pack-year cutoff greatly increases the proportion of patients with lung cancer who would qualify for screening and eliminates the racial disparity in screening eligibility between Black versus White individuals; smoking duration has the added benefit of being easier to calculate and being a more precise assessment of smoking exposure compared with pack-year smoking history.

PubMed Disclaimer

Conflict of interest statement

The following represents disclosure information provided by authors of this manuscript. All relationships are considered compensated unless otherwise noted. Relationships are self-held unless noted. I = Immediate Family Member, Inst = My Institution. Relationships may not relate to the subject matter of this manuscript. For more information about ASCO's conflict of interest policy, please refer to www.asco.org/rwc or ascopubs.org/jco/authors/author-center.

Open Payments is a public database containing information reported by companies about payments made to US-licensed physicians (Open Payments).

No potential conflicts of interest were reported.

Figures

FIG 1.
FIG 1.
Distribution of smoking duration (years), smoking intensity (cigarettes per day), and pack-year smoking history among SCCS participants diagnosed with lung cancer. SCCS, Southern Community Cohort Study.
FIG 2.
FIG 2.
Scatterplots of pack-year smoking history versus age at lung cancer diagnosis (A and B) and smoking duration versus age at lung cancer diagnosis (C and D) among SCCS participants with lung cancer who currently smoked at the time of diagnosis, stratified by race. Each blue dot represents an individual diagnosed with lung cancer. (A and B) The red dashed lines indicate the 2021 US Preventive Services Task Force lung cancer screening eligibility criteria (ie, age 50-80 years, ≥20 pack-year smoking history). (C and D) The red dashed lines indicate the proposed lung cancer screening eligibility criteria (ie, age 50-80 years, ≥20-year smoking duration). Blue dots located in the red-shaded regions of the graph represent individuals with lung cancer who would have been ineligible for screening under each guideline. SCCS, Southern Community Cohort Study.
FIG 3.
FIG 3.
Scatterplots of pack-year smoking history versus years since quitting smoking (A and B) and smoking duration versus years since quitting smoking (C and D) among SCCS participants with lung cancer who formerly smoked at the time of diagnosis, stratified by race. Each blue dot represents an individual diagnosed with lung cancer. (A and B) The red dashed lines indicate the 2021 US Preventive Services Task Force lung cancer screening eligibility criteria (ie, quit smoking ≤15 years ago, ≥20 pack-year smoking history). (C and D) The red dashed lines indicate the proposed lung cancer screening eligibility criteria (ie, quit smoking ≤15 years ago, ≥20-year smoking duration). Blue dots located in the red-shaded regions of the graph represent individuals with lung cancer who would have been ineligible for screening under each guideline. SCCS, Southern Community Cohort Study.
FIG 4.
FIG 4.
Smoking patterns among Black women with lung cancer in the BWHS. Scatterplots of (A) pack-year smoking history versus age at lung cancer diagnosis among BWHS participants with lung cancer who currently smoked at the time of diagnosis, (B) smoking duration versus age at lung cancer diagnosis among BWHS participants with lung cancer who currently smoked at the time of diagnosis, (C) pack-year smoking history versus years since quitting smoking among BWHS participants with lung cancer who formerly smoked at the time of diagnosis, and (D) smoking duration versus years since quitting smoking among BWHS participants with lung cancer who formerly smoked at the time of diagnosis. Each blue dot represents an individual diagnosed with lung cancer. Blue dots located in the red-shaded regions of the graph represent individuals with lung cancer who would have been ineligible for screening under each guideline. BWHS, Black Women's Health Study.
Using smoking duration, rather than pack-years, in lung cancer screening eligibility criteria eliminates the racial disparity in screening eligibility.
See this image and copyright information in PMC

Similar articles

See all similar articles

Cited by

References

    1. de Koning HJ, van der Aalst CM, de Jong PA, et al. : Reduced lung-cancer mortality with volume CT screening in a randomized trial. N Engl J Med 382:503-513, 2020 - PubMed
    1. National Lung Screening Trial Research Team, Aberle DR, Adams AM, et al. : Reduced lung-cancer mortality with low-dose computed tomographic screening. N Engl J Med 365:395-409, 2011 - PMC - PubMed
    1. US Preventive Services Task Force, Krist AH, Davidson KW, et al. : Screening for lung cancer: US Preventive Services Task Force recommendation statement. JAMA 325:962-970, 2021 - PubMed
    1. Potter AL, Yang C-FJ, Woolpert KM, et al. : Evaluating eligibility of US Black women under USPSTF lung cancer screening guidelines. JAMA Oncol 8:163-164, 2022 - PMC - PubMed
    1. Liu A, Siddiqi N, Tapan U, et al. : Black race remains associated with lower eligibility for screening using 2021 US Preventive Services Task Force recommendations among lung cancer patients at an urban safety net hospital. J Racial Ethn Health Disparities 10:2836-2843, 2022 - PubMed