The former smoker who quit twenty years ago is the one being missed

Design

nationwide cross-sectional study using 2024 National Health Interview Survey data with survey-weighted multivariable logistic regression

Population

5,987 US adults aged 50-80 with a computable pack-year history and no prior lung cancer, representing about 37.5 million adults

Primary outcome

lung cancer screening in the past 12 months, and any reported screening

Effect

past-12-month screening 17.8% (USPSTF-eligible), 8.0% (ACS-only), 3.9% (neither); ACS-only vs neither OR 1.62 (95% CI 1.12-2.35) for recent screening, no increase in any reported screening

The 2023 American Cancer Society guideline widened lung cancer screening eligibility by removing the requirement that a former smoker have quit within 15 years. This cross-sectional analysis of the 2024 National Health Interview Survey — 5,987 adults aged 50 to 80 with a computable pack-year history, representing about 37.5 million US adults who have smoked — asked whether the newly eligible are actually being screened.

Of the sample, 35.2% met the older USPSTF criteria, 13.5% were eligible only under the new ACS criteria, and 51.2% met neither. Screening in the past 12 months was reported by 17.8%, 8.0% and 3.9% respectively. Against the neither-eligible group, USPSTF eligibility carried an odds ratio of 4.54 (95% CI 3.44-5.98) for recent screening; ACS-only eligibility carried 1.62 (1.12-2.35) for recent screening but no increase in ever having been screened. Within the ACS-only group, non-Hispanic Black race and telehealth use were associated with higher uptake.

Eight per cent is movement, and the absence of any increase in lifetime screening confirms it is recent movement rather than historical. But it is under half the rate in the currently eligible group, and the reason is structural: a patient who stopped smoking twenty years ago is not flagged by any system, and often does not consider themselves at risk. The people to find are in the records already — the question is whether anything is set up to find them.

• Search your records for patients with 20 or more pack-years who quit over 15 years ago — nothing flags them automatically
• Ask about smoking as pack-years and quit date, not as a yes-or-no current-smoker field
• Tell long-quit former smokers explicitly that risk does not return to baseline; many believe it does
• Telehealth contact was associated with higher uptake in this group — a phone call may be enough
• There is no organised lung cancer screening programme in India; the transferable point is the risk conversation, not the CT

Why it matters

It identifies a group at real risk that no electronic flag currently catches and who do not believe they are at risk.

Don't overread it

Self-reported screening in a cross-sectional survey, with US eligibility criteria and a US health system behind it.

The statistics, in plain English

An odds ratio of 1.62 for recent screening in the newly eligible group sits against absolute rates of 8.0% versus 3.9% — so most of the newly eligible are still not screened. That ACS-only eligibility raised recent but not lifetime screening is the internally consistent finding: it is what you would expect if the guideline change had only just started to take effect.

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