Investigating the psychosocial aspects of lung cancer screening: a focus on smoking-related stigma

Abstract

Recent landmark trials have demonstrated that lung cancer screening (LCS) using low-dose computed tomography (LDCT) can reduce lung cancer mortality by 20–24%. In response, many LCS programs globally are in active design or early implementation, including in Australia where the National Lung Cancer Screening Program (NLCSP) commenced on 1 July 2025. Psychosocial aspects of LCS are important considerations for screening services, both in terms of harm to participants and barriers to appropriate uptake. Current evidence suggests that psychosocial harms for LCS participants are minimal and/or short-term. However, these findings are primarily from clinical effectiveness trials, undertaken in motivated trial participants, and limited to use of standard outcome measures/constructs and measurement timepoints that are not reflective of the entire screening and assessment pathway. Increasingly, qualitative literature and studies outside of clinical trial environments highlight the complexity of psychosocial outcomes in LCS, and the influence of moderating factors. LCS also differs from other types of cancer screening in multiple ways, including its screening modality (LDCT of the chest), presentation and management of lung nodules, and eligibility criteria based on smoking status and history. Smoking-related stigma can create or compound psychosocial harms. While there is a substantial body of work around stigma for those with a diagnosis of lung cancer or other respiratory diseases, there is limited evidence on stigma in the screening context. Recognising these evidence gaps, this thesis synthesised the current literature and took a qualitative and participatory methods approach to investigate the psychosocial impacts and determinants of LCS, with a particular focus on smoking-related stigma. This program of work was conducted alongside development of the Australian NLCSP, offering a unique opportunity to directly impact program design