Reducing Smoking Requirements for Lung Screening to Address Health Disparities in a Community Cohort

Importance Many individuals with lung cancer are not eligible for lung cancer screening (LCS). Race-based and sex-based differences in smoking patterns reduce the effectiveness of LCS criteria. Objective To assess the value of expanding LCS criteria beyond US Preventive Services Task Force (USPSTF) 2021 guidelines by relaxing cigarette smoking exposure criteria. Design, Setting, and Participants This cohort study included individuals enrolled in an incidental pulmonary nodule (IPN) program with non–screening-detected, potentially malignant pulmonary nodules, or enrolled in a LCS program from 2015 to 2023. Participants were treated in a community-based health care system serving more than 125 counties in Mississippi, Tennessee, Arkansas, Kentucky, Missouri, and Alabama. Data were examined from October 1, 2024, to May 29, 2025. Exposures LCS eligibility criteria included USPSTF 2021, Potter criteria (20-year smoking history), and American Cancer Society criteria ([ACS] 20 pack-years, no quit duration), and expansions to 10 years or 10 pack-years. Main Outcomes and Measures The main outcomes were proportions of individuals eligible for LCS and diagnosis of lung cancer. Characteristics between groups were compared using the χ 2 test for categorical variables and the Wilcoxon-Mann-Whitney test for continuous variables. Results In this study, 43 521 individuals were evaluated, including 13 770 (32%) from LCS and 29 751 (68%) from IPN programs. Of the 29751 individuals in IPN programs, 3840 (13%) were eligible for LCS by USPSTF 2021 criteria, 4905 (16%) by IPN-Potter criteria, 5263 (18%) by IPN-ACS criteria, and 6307 (21%) by IPN-Potter-ACS criteria. There were 1103 additional individuals eligible by IPN-Potter criteria (606 female [55%] and 382 Black [35%]), 1423 by IPN-ACS criteria (628 female [44%]; 237 Black [17%]), and 2467 by IPN-Potter-ACS criteria (1200 female [49%]; 615 Black [25%]). There were significant differences in the number of additional eligible individuals who were female (55% vs 48%; P < .001) and Black (35% vs 22%; P < .001) between the IPN-Potter and USPSTF 2021 criteria. Lung cancer was diagnosed in 504 of 13 770 of LCS enrollees (4%) and 1714 of 29 751 of IPN enrollees (6%), including 872 of 4905 (18%) eligible by IPN-Potter criteria, 955 of 5263 (18%) by IPN-ACS criteria, and 1051 of 6307 (17%) by IPN-Potter-ACS criteria. The additional eligible individuals with lung cancer in IPN programs who were female included 70 of 128 (55%) by IPN-Potter criteria, 89 of 208 (43%) by IPN-ACS criteria, and 143 of 304 (47%) by IPN-Potter-ACS criteria, with statistically significant differences between the IPN-Potter criteria and USPSTF 2021 criteria (55% vs 48%; P < .001). The additional eligible individuals who were Black included 50 of 128 (39%) by IPN-Potter criteria, 32 of 208 (15%) by IPN-ACS criteria, and 73 of 304 (24%) by IPN-Potter-ACS criteria, with statistically significant differences between IPN-Potter criteria and IPN-USPSTF 2021 criteria (39% vs 22%; P < .001). When LCS criteria were expanded to individuals older than 50 years who had smoked for 10 years or 10 pack-years, 7993 of 29 751 individuals (27%) from IPN programs would have been eligible. Among these, 1251 of 7993 (16%) were diagnosed with lung cancer. Conclusions and Relevance In this cohort study, changing smoking criteria from 20 pack-years to a 20-year smoking history was associated with improved access to LCS while maintaining diagnostic efficiency. Expansion to individuals with a 10-year or 10 pack-years smoking history should be explored.