Impact assessment

Equality impact assessment: screening for lung cancer

Published 24 July 2025

The general equality duty that is set out in the Equality Act 2010 requires public authorities, in the exercise of their functions, to have due regard to the need to:

• eliminate unlawful discrimination, harassment and victimisation and other conduct prohibited by the act

• advance equality of opportunity between people who share a protected characteristic and those who do not

• foster good relations between people who share a protected characteristic and those who do not

The general equality duty does not specify how public authorities should analyse the effect of their existing and new policies and practices on equality, but doing so is an important part of complying with the general equality duty.

Summary

Ministers at the Department of Health and Social Care (DHSC) agreed to introduce a national targeted lung cancer screening programme in England because the evidence strongly suggests it would reduce deaths from lung cancer. This is due to the nature of lung cancer’s clinical presentation so that when people display symptoms of lung cancer the disease is already at an advanced stage. 

Cancer Research UK (CRUK) data shows there is a high prevalence of morbidity and mortality for lung cancer in the UK. Around 35,000 people die and 49,000 people are diagnosed with lung cancer each year.^{[footnote 1]} It has one of the lowest survival rates of all cancers with 40.6% of people living beyond 1 year and 16.2% living beyond 5 years. ^{[footnote 2]} These outcomes are largely attributed to lung cancer being diagnosed at a late stage when treatment is much less likely to be effective.

The general equality duty does not specify how public authorities should analyse the effect of their existing and new policies and practices on equality. But such analysis is an important part of complying with the general equality duty.

The introduction of a national targeted lung cancer screening programme would have the potential to prevent thousands of deaths from lung cancer. This benefit will be disproportionally higher in more deprived areas delivering a reduction in inequalities.

The UK National Screening Committee (UK NSC) recommended that smoking cessation services be embedded in the lung cancer screening programme. This is so any current smokers who are contacted over the phone for initial evaluation and anyone who attends a computed tomography (CT) scan can be referred for smoking cessation support. The screening programme is a prime opportunity to contact those people who still smoke. UK NSC is the independent scientific committee that advises ministers and the NHS in all 4 UK countries on all aspects of screening programmes. Evidence for implementing a new screening programme or amending an existing programme first has to be reviewed by UK NSC for a formal recommendation to be made.

Smoking causes at least 15 different types of cancer as well as other diseases such as heart disease, diabetes and chronic obstructive pulmonary disease (COPD). Through the embedded smoking cessation support within the targeted lung cancer screening programme, people will be able to access support to quit smoking. Quitting smoking would reduce these people’s risk of developing the conditions mentioned above.

Intended aims of the analysis

This equalities analysis examines the potential impact of the rollout of a national targeted lung cancer screening programme in accordance with the Equality Act 2010. In addition, with respect to England, this document considers issues relevant to the Secretary of State’s duty to have regard to the need to reduce inequalities for the population of England relating to the benefits they can obtain from the NHS, under section 1C of the National Health Service Act 2006.

On 26 June 2023, the government approved the UK NSC recommendation that a national targeted lung cancer screening programme should be introduced for people aged between 55 to 74 and identified as being at high risk of lung cancer. For the purposes of identifying the cohort, those who have a history of smoking recorded in their GP records are given a risk assessment over the phone. On the basis of this assessment, if they meet the risk threshold they will be considered at ‘high risk of lung cancer’ and offered a low dose CT scan. People who have possible cancer detected on the scan will be referred for further investigation and treatment if needed. Individuals who have nodules identified via the scan will be invited to be re-screened in accordance with nodule management guidance. Those who have no signs of cancer or nodules will be reinvited for a low dose CT scan every 2 years. The main findings supporting UK NSC’s recommendation were that:

• screening will significantly increase the identification and treatment of people at an earlier stage of lung cancer allowing for timely treatment of thousands more people

• the public, patients and health professionals in the UK are likely to consider lung cancer screening to be beneficial - performance of the targeted lung health check (TLHC) programme to date suggests that at least half of people invited may take up the offer to participate

Background information about screening

Screening is the process of identifying people who are asymptomatic (have no symptoms) but have an increased risk of developing a disease or condition. NHS screening programmes are an efficient and proven method for early detection while minimising false positive and negative results as much as possible. Early detection for some conditions has real benefits, and individuals identified as being at greater risk of developing a condition can be supported to take preventative measures to reduce their likelihood of becoming unwell. For those where a condition is detected, individuals can make informed decisions around their treatment with early detection likely to make any required treatment more effective and therefore lead to better health outcomes.

Targeted screening programmes are nationally delivered and aimed at large groups of people identified, based on age and/or gender and at least one other risk factor, as being at elevated or above average risk of a specific condition. Compared with the general population, the people targeted may have a higher risk because of lifestyle factors, genetic variants or having another health condition.

Smoking statistics show 191,903 deaths attributed to smoking during 2017 to 2019.^{[footnote 3]} Smoking mortality and admission rates were the highest in the most deprived areas, with smoking prevalence high in the most deprived decile, at 16.4% in 2021.^{[footnote 3]} While this data is not directly comparable via the same period, the message remains the same: smoking has a huge negative impact on health.

Smoking causes around 72% of lung cancer cases in the UK.^{[footnote 4]} The symptoms of lung cancer appear in the later stages of the disease, meaning this is often when people are diagnosed, when treatment is less effective. Diagnosing lung cancer at an earlier stage when it is easier to treat will lead to more favourable outcomes. According to CRUK, more than 55% of people survive lung cancer for 5 years after diagnosis at stage 1 compared with 15% at stage 3 and 5% at stage 4.^{[footnote 4]}

UK NSC’s recommendation for a national lung screening programme targeting people aged 55 to 74 with a history of smoking, is to enable the detection of lung cancer early so that individuals can be referred for treatment when outcomes are likely to be more favourable.

UK NSC’s recommendation indicates that the NHS England TLHC pilot is a practical and demonstrably feasible starting point for implementing a nationally delivered NHS lung cancer screening programme in England. 

As at 2024 NHS England is delivering the TLHC programme in over 40 sites across every Cancer Alliance. The programme targets current or former smokers aged 55 to 74 in areas with the highest mortality rates from lung cancer, many of which are in the north of England. People are invited to attend an initial lung health check involving a lung specialist nurse, often in a  mobile unit similar to those used in the breast screening programme, parked in sites such as a supermarket or football ground car park. People found to be at high risk are offered a low dose CT scan. Those who have a suspected cancer are referred straight to specialist care. Those with lung nodules are re-scanned at 3, 12 or 24 months as advised in the nodule management guidance. Current smokers are also offered referral to smoking cessation services and given advice and support to help them stop smoking.

It is known that people from poorer socio-economic backgrounds are more likely to suffer from ill health and less likely to receive healthcare. This is particularly true for lung cancer, as rates of smoking and therefore rates of lung cancer increase as deprivation increases. In 2018, the likelihood of smoking was 4 times higher in England’s most deprived areas than in the least deprived.^{[footnote 5]} Around 72% of lung cancers are caused by smoking.^{[footnote 6]}

Screening impact on the general public

The lung cancer screening programme is targeted at people between the ages of 55 and 74 who are current smokers or have a history of smoking.

Smoking has a much higher prevalence in deprived areas (4 times higher in England’s most deprived areas than the least deprived).^{[footnote 5]} As such, people in lower socio-economic groups will benefit in much larger numbers from this programme (more than those in higher socio-economic groups) by virtue of their increased risk of lung cancer through smoking.  

The programme will benefit older people as the target cohort is 55 to 74. Although some lung cancers do occur under the age of 55, the chance of developing lung cancer after reaching the 55 to 74 age range is significantly higher. This is due to cancers being more likely to develop the older someone is, and the fact that this cohort will be more likely to have been smoking for longer. People aged 75 and over will not be invited for lung screening as the evidence for the benefits of screening outweighing the harms was strongest in the 55 to 74 years cohort. UK NSC does remain open to new developments and screening programmes can be modified to follow the latest science.

As smoking causes 72% of lung cancers, current and former smokers between 55 to 74 are at a higher risk of developing lung cancer than those who have never smoked. However, there are other ways in which people’s chances of developing lung cancer can increase, such as:

• being in environments with high amounts of second-hand smoke
• working with materials that can cause lung cancer
• exposure to radiation through radon gas or other sources  

People who develop lung cancer through causes other than smoking will not be helped by the current form of this programme. As smoking is shown to be the highest risk factor for developing lung cancer and is the most accessible record of risk, it has been selected as the qualification for this programme. UK NSC will keep the programme under review and consider other groups who could be easily identified and added to the programme.

Screening impact on NHS England

The rollout of a national targeted lung cancer screening programme will have workforce implications, including the need to recruit more administrators, radiographers, radiologists, nurses, respiratory physicians, oncologists and thoracic surgeons. The estimation of staff requirements are:

• radiologists: 75
• radiographers: 184
• nurses (without triage): 278
• nurses (with triage): 94
• thoracic surgeons: 29
• respiratory consultants: 176

The implementation of this programme without the relevant workforce capacity and planning in place could move an already stretched workforce away from other NHS services using radiographers and radiologists. This could lead to longer waiting times for diagnosis and treatment of other conditions which could potentially lead to poorer outcomes. However, as set out in the NHS Long Term Workforce Plan, the government will invest more than £2.4 billion to fund a 27% expansion in training places, for all clinical staff, by 2028 to 2029. This will enable more than half a million trainees to begin clinical training over the next 6 years, an addition of nearly 60,000 compared with maintaining current training levels.

As part of this ambition, the plan commits to:

• doubling the number of medical school places, taking the total number of places to 15,000 by financial year 2031 to 2032, and working towards this expansion by increasing medical school places by a third, to 10,000 by financial year 2028 to 2029

• increasing adult nursing training places by 92%, taking the total number of places to nearly 38,000 by financial year 2031 to 2032

• increasing allied health professional training places to 17,000 by financial year 2028 to 2029

• completing the planned increase in medical specialty training places by September 2024 to more than 2,000 over 3 years, as well as 1,000 additional specialty training places focusing on areas with the greatest shortages; this expansion is supporting existing planned growth for mental health, cancer and diagnostic services, elective recovery, urgent and acute care, maternity services and public health medicine

National targeted lung cancer screening will also increase demand for equipment such as CT scanners which are already in short supply. This would also increase the demands on NHS budgets with the potential need to purchase or lease more equipment. This has been factored into the plans for rolling out the programme to minimise wider impacts.

Evidence

The UK NSC completed an evidence review of 5 important questions around lung cancer screening:

• 3 contextual questions on the natural history and epidemiology of the condition, the accuracy of testing and the cost-effectiveness of screening
• 2 main questions on the clinical effectiveness of screening and the acceptability of screening

Refer to the full UK NSC recommendation on lung cancer screening for the review findings. Below, we have summarised their findings in relation to the impact on protected characteristics.

The reviewers assessed the literature overall and by subgroups - for example, by gender, ethnicity, socio-economic status and occupation. However, information by subgroups was not available for every main piece of evidence.

The review found that the risk of developing lung cancer is largely attributable to age and smoking status, with the incidence and mortality rates highest in older age groups of both men and women who are current or former heavy smokers. Lung cancer incidence and mortality are a third higher in men than women with 15.1% of men being current smokers and 11.5% of women being current smokers as of 2021.^{[footnote 7]} Smoking is estimated to cause 72% of lung cancer cases and 86% of lung cancer deaths. Other factors such as air pollution, occupational exposure to inhaled carcinogens, and pre-existing lung conditions, also increase the risk of developing lung cancer but not to the same degree. For example, asbestos exposure is linked to an estimated 6% to 8% of lung cancer deaths. Increasing deprivation is strongly associated with increasing incidence and mortality of lung cancer due to higher levels of smoking in these areas, as well as an inability to access healthcare and fatalistic views of a lung cancer diagnosis.

In relation to the acceptability of lung cancer screening, the review found mixed findings across the studies. One 2015 study on barriers to lung screening uptake (included in the review) found that:

• age, gender, smoking status and socio-economic group were significantly associated with lung cancer screening uptake
• people over the age of 65 were less likely to attend than those age 65 or younger
• women were less likely to take part than men
• current smokers were less likely to attend than former smokers
• people in the least deprived socio-economic quintile were more likely to attend than those in the most deprived quintile

The associations between the demographic risk factors and self-reported barriers to attendance included:

• people more concerned about the risk of lung cancer being more likely to cite comorbidities as a barrier to participation
• current smokers (rather than former smokers) being more likely to cite emotional barriers for non-participation

Another trial reporting in 2020 found that neither age nor gender was associated with uptake of lung cancer screening. However, the trial suggested current smokers were less likely than former smokers to attend the lung health check. Those in the least deprived socio-economic status quintile were nearly twice as likely to attend than those in the most deprived quintile. The trial also found the association between ethnicity and uptake depended on the type of invitation.

Results from the second round of the Manchester Lung Health Check pilot found that non attendees in a second screening round, a year after the first, were significantly more likely to be current smokers (63.6% vs 50.6%); but there were no differences associated with deprivation, gender, age group or lung cancer risk.

An estimated 46.9% of lung cancer deaths can be directly attributed to inequality^{[footnote 5]} and there is evidence of long standing and widespread disparities in lung cancer outcomes.^{[footnote 8]} Rates of smoking in the UK are highest in socio-economically deprived areas, where lung cancer incidence and survival are worse.^{[footnote 9]} Research suggests people from more deprived communities may be deterred from participating in screening because they believe lung cancer is always fatal - potentially leading to ‘uninformed non-participation’^{[footnote 10]} as outlined above. 

UK NSC recommends that smoking cessation services are embedded within the lung cancer screening programme. Evidence from studies and learning as part of the TLHC programme shows that smoking cessation interventions increase population health,^{[footnote 11]} but they do not decrease health inequalities.^{[footnote 12]}

Smoking cessation programmes are a cost-effective health intervention, but smokers in most deprived areas are less likely to use stop smoking services than those in the least deprived areas.^{[footnote 13]} Even when people in more deprived areas access smoking cessation services they are less likely to quit smoking.^{[footnote 14]}

These difficulties in quitting smoking can be attributed to lack of social support, higher nicotine dependency, challenging life circumstances and factors relating to the stop smoking service themselves. This could, without mitigation, result in those in more deprived areas not benefiting optimally from a screening programme that has integrated smoking cessation service provision.

Furthermore, people at highest risk - current smokers,^{[footnote 15] [footnote 16] [footnote 17]} those with longstanding smoking histories and those from socio-economically deprived communities^{[footnote 18]} - are least likely to participate in lung cancer screening.^{[footnote 13]} This remains a barrier to delivering the optimal benefits from a lung cancer screening programme.^{[footnote 15]}

These groups, as outlined above, are also least likely to take part in smoking cessation services. While those in the most deprived areas need the screening service the most due to higher levels of smoking and greater risk of lung cancer, the evidence suggests people in better off areas are more likely to gain the full benefit from the programme due to increased uptake.

Analysis of impacts

Evidence on what was found regarding the impact of screening on people with specific characteristics (protected and otherwise) is summarised in the evidence section above, with additional detail below.

Socio-economic status is not a protected characteristic, but it does fall within the Secretary of State’s duty to reduce inequalities within the population of England. The programme has the potential to save thousands of lives in the most deprived areas of England. However, research has shown that those in more deprived areas are less likely to take full advantage of such a programme. To realise the benefits of targeted lung cancer screening and maintain the substantial potential that this programme represents for reducing inequality, further effort to address these concerns and improve uptake among those in more deprived socio-economic groups will be required alongside careful oversight, to ensure socio-economic inequalities are not increased.

Disability

Evidence shows that people with a learning disability, autism or both are less likely to access screening.^{[footnote 19]} Guidance for health professionals to support people with a learning disability to access screening^{[footnote 19]} is already available on GOV.UK and can be used to support the establishment of a national targeted lung cancer screening programme. This publication includes guidance and resources for local screening providers, commissioners and other partners to help reduce barriers to screening for people with a learning disability, autism or both. It includes sections on informed choice, barriers to screening, improving access to screening and working with primary care.

Available evidence shows that levels of smoking in those with mild or moderate learning disabilities are similar to the rest of the population. But rates are higher for those with an intellectual disability who do not access specialist intellectual disability services, live in less restrictive residential settings, live with someone who smoked, or who are parents.^{[footnote 20]} Due to potentially higher rates of smoking, there is potential that the introduction of a national targeted lung cancer screening programme could be positive for this group.  Currently in other screening programmes, tailored videos and easy read material is available for people with intellectual disabilities to help them make a choice about whether to have screening. These types of resource would also be available for the national targeted lung cancer screening programme.

People who have limited physical activity or who would consider themselves to be in bad health are around twice as likely to smoke as those without limited activity or with good health.^{[footnote 21]}

People with physical disabilities who would like to take up an offer of lung cancer screening may be restricted about where they can be screened if facilities are difficult for them to access. This negative experience could deter individuals from attending their first or subsequent screening appointments.^{[footnote 22]}

Legally, providers of NHS screening services are required to make reasonable adjustments to ensure that their services are accessible to people with disabilities. Current guidance on access to screening programmes explains what providers can do to make reasonable adjustments.

Above average levels of smoking among some cohorts of people with learning disabilities^{[footnote 20]} and people with physical disabilities means that they would benefit from access to smoking cessation support. However, adjustments will need to be made to ensure people are given accessible information about screening and/or accessible locations to visit screening services.  Data shows that in England, people who are sick and/or disabled and unable to return to work have the fourth highest number of attempts to quit smoking - with 20,600 people attempting to quit from this group in 2021 to 2022.^{[footnote 23]} Of these people, 56.6% reported a successful quit attempt. This data shows that these people will benefit from smoking cessation support as there is a high appetite for quitting among this group.

Mental ill health

People with severe mental illness are known to have lower levels of screening uptake.^{[footnote 24]} They are:

• 18% less likely to have participated in breast screening
• 20% less likely to have participated in cervical screening
• 31% less likely to have participated in bowel screening

Smoking rates among those with severe mental illness are higher than the general population.^{[footnote 25]} Data from 2015 showed rates of smoking for individuals in mental health units at 64%.^{[footnote 26]}

High levels of smoking combined with lower levels of screening uptake call for mitigations to be considered in the rollout of the national lung cancer screening programme to help support the optimal benefits of screening.

Current evidence is that people with mental health conditions are shown to smoke more than the general population, but only a minority of people with mental health conditions receive effective smoking cessation interventions.^{[footnote 25]} Embedded smoking cessation support for people with mental health conditions could provide another route through to these services.  

Overall, people with the protected characteristic of disability should be disproportionately positively affected by the introduction of a national targeted lung cancer screening programme, assuming appropriate mitigations are successfully implemented. While people with a disability (or multiple disabilities) are a small proportion of the general population, they make up a larger proportion of smokers. This means there is potential for them to benefit more from screening.

Sex

Men are more likely to be smokers with 15.1% of them smoking currently compared with 11.5% of women smoking currently.^{[footnote 27] [footnote 10]} Lung cancer incidence and mortality are a third higher in men than women, meaning that the national targeted lung cancer screening programme would be more likely to benefit male participants with an early diagnosis of lung cancer.

No mitigations are required for sex, as the disproportionate benefit to men relates directly to their increased risk of lung cancer, and not to any prejudicial factors.

Access to smoking cessation services will benefit both men and women who are smokers and are eligible for lung cancer screening. As smoking is causally related to other diseases apart from lung cancer, those people who successfully quit will benefit from reduced risk of other diseases including other cancers, heart attack and stroke.

Women are more likely to attempt to quit smoking, with 96,516 quit attempts for women and 80,050 attempts for men between April 2022 and March 2023.^{[footnote 28]} In the same period, men self-reported a higher quit rate of 56% compared with 53% for women.^{[footnote 28]} Stop smoking services will be available via the lung cancer screening programme to support men and women to quit smoking. However, it appears likely that without mitigation, men would have a slightly higher quit rate than women despite more women attempting to quit.

The trend of less women quitting smoking compared with men is an international one. It is believed that there are different barriers to smoking cessation for women, relating to issues such as a fear of weight gain, changes in sex hormones and mood.^{[footnote 29]} Where possible, local smoking cessation services should try to mitigate for this.

Sexual orientation

Data collected in 2018 as a part of the ‘Adult smoking habits in the UK study’ by the Office for National Statistics (ONS) shows that there is a higher number of smokers who identify as gay or lesbian (22.3%) compared with heterosexual people (15.5%).^{[footnote 27]} This would suggest that more lesbian, gay and bisexual (LGB) people would benefit from the national targeted lung cancer screening programme.

However, LGB people are more likely to have had negative experiences of using healthcare systems.^{[footnote 30]} This could impact on whether they have spoken to their GP about their smoking habits (recorded smoking status will affect who is invited for screening), and whether they would attend if offered screening. Consideration will need to be given as to whether any mitigations might be needed to ensure that LGB people get full benefit from this programme. This will take place on a rolling basis through local NHS services as part of the normal processes for engaging hard to reach groups.

As LGB people are shown to have a higher smoking rate than the general population they will benefit from the smoking cessation support embedded as part of the targeted lung cancer screening programme. This will reduce their morbidity from other smoking related disease such as heart attack, stroke and other cancers associated with smoking.

Race

Data shows that adults of mixed ethnicity are more likely to be smokers (19.5%) than White adults (14.4%) though this must be understood in the context that numerically, the highest number of smokers are of White ethnicity.^{[footnote 31]} Further evidence shows that people who have emigrated to the UK are more likely to smoke, in particular those from Eastern Europe.^{[footnote 32]}

This would suggest that people with mixed ethnicity, and White people who have come to live in the UK would be likely to benefit disproportionately from the national targeted lung screening programme because of the higher prevalence of smoking in these groups.

However, there are known barriers to accessing healthcare for certain racial groups. There is evidence of racial disparities in the treatment of early-stage lung cancer^{[footnote 8]} and in the detection of cancer through screening pathways. Studies show that Black people are 38% less likely to be diagnosed with cancer via screening than White people.^{[footnote 33]} This has been linked to the lower uptake of screening among different ethnic groups. A study of bowel cancer screening provision between October 2006 and January 2009 showed that the most ethnically diverse areas had a lower screening uptake than other areas.^{[footnote 34]}

People who have emigrated to the UK from abroad may also not have registered with a GP and therefore be unaware of services they are entitled to access. This could create a barrier to their uptake of screening services.

People who do not speak English as their first language are also less able to access health services due to language barriers. People who do not speak English:

• report greater barriers accessing primary care than those who do
• have a poorer patient experience
• are more likely to be in poor health^{[footnote 35]}

Language barriers in the national targeted lung cancer screening programme  may impact people’s ability to make an informed choice about taking up the screening offer, as well as being able to provide the information needed during the initial phone call with a clinician as a part of the eligibility pathway for the programme. To help people to make an informed choice in the current NHS screening programmes, information leaflets and videos in 10 other languages are available and could also be made available for a national lung cancer screening programme.

Cultural factors will need to be considered when looking at the impacts of the national targeted lung cancer screening programme. Some cultures’ attitudes toward smoking mean people could feel socially pressured to keep the fact they smoke hidden from medical staff.^{[footnote 36]} Smoking history may therefore not be accurately given and/or recorded, and people may then inaccurately fall outside the screening eligibility criteria.  

Quit rates documented in 2021 to 2022 showed that by far the highest number of people who attempt to quit were of White ethnicity at 152,524 (86%) while the second highest number of quit attempts were Asian or Asian British people at 6,983 (4%).^{[footnote 23]} Studies show that UK Bangladeshi and Pakistani adults find it more difficult to quit smoking, with the majority of people relying on willpower alone to quit. Studies examining this group show that few people consider their family doctors to be accessible sources of advice on quitting. Healthcare professional and community members identified common barriers to quitting as language, religion and culture, negative attitudes to services, and lack of time and resources for professionals to develop necessary skills.^{[footnote 37]}

The factors outlined above will also need to be considered for embedded smoking cessation support. All smokers will benefit from access to smoking cessation support. However, to ensure equity of access, mitigation and adjustments will need to be made. Examples include:

• information in different languages
• using interpreters
• increased awareness of the local community

Mitigations to support people in accessing smoking cessation services would reduce morbidity not just from lung cancer but from other smoking-related diseases.

Age

The national targeted lung cancer screening programme will target those between the ages of 55 and 74. This group is expected to benefit the most from the programme, with increased rates of early lung cancer detection leading to better outcomes. Five-year survival for early stage (stages 1 and 2) cancers is significantly better than for later stages (stages 3 and 4).

People under the age of 55 and those over the age of 74 would not be included in the programme and would therefore not benefit from the effect of screening if they developed lung cancer.

Data from 2021 shows that the highest proportion of smokers were those aged 25 to 34 in the UK, making up 16.3% of smokers (around 1.4 million people). Targeted lung cancer screening will be available to people aged 55 to 74, with 55 to 64 year olds making up 13.6% of smokers in the UK, and people aged 65 and over making up 8.3% of smokers. The data does not specifically identify numbers of people aged over 74 who still smoke (these people are included in the 65 and over age bracket).^{[footnote 27]}

Younger people who smoke are still at risk of developing lung cancer, but the incidence is significantly lower than in people aged 55 or older. People aged 75 and over will not be invited for screening as evidence for screening benefits outweighing harms was strongest in the 55 to 74 age cohort. The UK NSC remains open to new evidence and screening programmes can be modified to follow the latest science.

There is estimated to be a 30-year lag time between starting smoking and lung cancer incidence, so current rates of lung cancer largely reflect patterns of cigarette smoking in the 1990s.^{[footnote 38]} This means rates are expected to fall with time as data reflects the reducing smoking rates after 1990.

Embedded smoking cessation support will greatly benefit people accessing the targeted lung cancer screening programme, as the age group 55 to 74 are at higher risk of developing other conditions such as cancer, heart attacks, strokes, diabetes and COPD. The likelihood of developing these conditions is greatly increased by smoking, so by following the smoking cessation advice, people will reduce their risk of developing these conditions.

NHS Digital stop smoking statistics for April 2021 to March 2022 show that older age groups have the highest self-reported quit rates, with people aged 45 to 59 having a 56.3% quit rate and people aged 60 and over having a 58.1% quit rate. This shows that there is a high desire to quit in these groups and they should be more likely to access and be supported to quit through smoking cessation services.

Gender reassignment (including transgender)

There is limited evidence about smoking prevalence within the transgender population. The few studies that have been done in this area indicate that smoking rates are higher among transgender people than in the general population and they would therefore be at greater risk of developing lung cancer.^{[footnote 39]} It is also known that transgender people have greater difficulties accessing healthcare, either because of a misunderstanding of their transition or because negative experiences impact how they view all healthcare provision.^{[footnote 40]} Due to this, many transgender people decline screening services when offered.^{[footnote 41]}

While the offer of lung cancer screening for people with a history of smoking should disproportionately benefit transgender people (due to their higher smoking prevalence), their greater chance of not accessing services could lead to them being disadvantaged within the ‘ever smoker’ population. This would need to be acknowledged and mitigated for.

This group will also benefit from the embedded smoking cessation support as they are more likely to be smokers. If they quit smoking they will see a reduction in their risk of lung cancer among other cancers and conditions. Some adjustments may need to be made to access smoking cessation services and services should engage with their local communities to identify the best way they can ensure their services support and feel accessible for transgender people.

Religion or belief

We have no data to suggest that any group of people will be directly impacted positively or negatively (in relation to lung cancer screening) specifically because of their religious beliefs.

We know that for other national screening programmes there is evidence that certain religious groups are less likely to take up screening offers due to their beliefs. For example, 40% of Muslim women decline bowel cancer screening.^{[footnote 42]} As such, there may be concerns that certain groups may not take up the offer of lung cancer screening. Further work will need to be carried out at a local level for mitigations to be identified and put in place.

While there is no evidence of religion impacting on smoking prevalence, there may be a need to make adjustments in smoking cessation services. This may include having women-only smoking support groups so that the service can be accessed by everyone.

Pregnancy and maternity

We have no data to indicate that either pregnant women or mothers will be impacted more positively or negatively by the lung cancer screening programme. It is possible that a woman over the age of 55 could be pregnant and eligible for lung cancer screening. However, this chance is extremely small and would be dealt with on a case-by-case basis by medical practitioners.

People caring for a young child or children may be affected by screening (in terms of access), but this is also true in other NHS screening programmes and in accessing other medical appointments or interventions.

Marriage and civil partnership

We have no data to suggest that people who are married or in a civil partnership would be any more or less impacted or benefited by lung cancer screening in comparison with the wider eligible population.

Other identified groups

Hard to reach groups with a higher prevalence of smoking (such as homeless people, of whom 70% to 80% smoke^{[footnote 43]}), and people who do not engage with state services due to their personal circumstances, will need specialist consideration on a local level to support their access to targeted lung cancer screening.  

People at highest risk (current smokers^{[footnote 15] [footnote 16] [footnote 17]}, those with longstanding smoking histories and those from socio-economically deprived communities^{[footnote 13]}) are the most likely to benefit from a national targeted lung cancer screening programme.

Evidence from other screening programmes indicates people from deprived communities are less likely to participate in screening programmes.^{[footnote 13]} While the lung screening programme will have a larger proportion of invited people from more deprived communities (due to higher smoking rates), more deprived people are less likely to attend screening than those from more affluent communities. Unless mitigations are put in place, this will be a barrier to optimal implementation of lung cancer screening.^{[footnote 15]}

Local identification of areas of missed opportunity and areas where improvements can be made to engage with more deprived people will need to be made. Mitigations currently in place in other screening programmes include:

• text message reminders
• locating screening vans in easily accessible areas
• weekend appointments to fit around work and life commitments

These mitigations could also be integrated into the targeted lung cancer screening programme. Bespoke solutions relevant to different communities will need to be developed at a local provider level.   

NHS England records the socio-economic status of people who engage with smoking cessation services. These classifications include employment status and type of employment. Data collected from current smoking cessation services shows that the top 2 recorded economic status groups that attempt to quit smoking are:  

• routine and manual occupations
• never worked or unemployed for over 1 year^{[footnote 28]}

The above 2 economic status groups are associated with higher levels of deprivation. Despite having the highest quit attempts of all the socio-economic groups, these 2 categories do not have the highest quit success rates.^{[footnote 28]} This suggests that these socio-economic groups may need more support to achieve success in quitting.

Smoking cessation support embedded within the targeted lung cancer screening programme is one way of actively supporting these quit attempts. Studies have also shown that people from more deprived areas are less likely to take up this support. This means mitigations will need to be developed on a local level - for example, the use of virtual appointments and text message reminders.

Mitigations will also need to be considered for people in prisons. This group has a higher level of smoking then the general population, with 80% of prisoners smoking^{[footnote 44]} before the introduction of smoke-free prisons. However, previously high rates of smoking in prisons means that people who are long-term current or former prisoners are more likely to be at high risk of developing lung cancer. The uptake for other screening programmes is low for people in prisons, and steps that have been taken to improve this in other screening programmes should also be applied for targeted lung cancer screening.

Engagement and involvement

Evidence and testing

In line with the standard evidence review process for screening recommendations, the UK NSC evidence team first consulted on the scope of the lung cancer screening review with stakeholders in the UK NSC’s Adult Reference Group (ARG) and stakeholders who participated in the consultation (see the UK NSC lung cancer screening recommendation page). Stakeholders included clinicians, scientists, clinical ethicists, and patient and public voice (PPV) representatives. Once the review was completed, it was again shared with ARG members for final review and comments, and sent to UK NSC members and PPVs.

In addition to the review, a cost-effectiveness model on lung cancer screening was developed. Stakeholders were involved throughout the process of developing and interpreting this model. Critically, the screening pathway was informed by and drew on the TLHC pilots. Stakeholders including clinicians, laboratory experts, screening programme managers and PPVs have inputted into the specification of the model, including the model structure and data inputs, and also checked the results and interpretation in the final report.

All of the evidence documents were shared with the public when UK NSC opened its 3-month public consultation - when any member of the public could submit comments. The team also proactively invited 29 stakeholder organisations. It received a total of 321 responses that were taken into consideration by UK NSC when making its final recommendation. All of the responses are available on the UK NSC website via the lung cancer screening recommendation page.  

Shaping policy

The national targeted lung cancer screening modelling and pathway task and finish groups have engaged with charities including CRUK and the Lung Cancer Foundation.

Since UK NSCs positive recommendation for targeted lung cancer screening, a lung screening group has been established to engage with stakeholders from the NHS and devolved governments on how to shape the programme. This group includes:

• NHS England

• NHS England consultant respiratory clinicians

• health economists

• CRUK

• behavioural scientists

• modellers

• local authority tobacco control commissioners

• Action on Smoking and Health (ASH)

Members of this group have provided advice on:

• matters relating to targeted lung screening

• how to further improve and optimise the programme

• information to support the 4 UK NHSs and policy leads on feasibility and development

In addition, a targeted lung cancer screening standards group has been established, and is working to identify appropriate standards, including inequalities standards, for measuring the effectiveness of the national programme once implemented. This group includes representatives from NHS England (including the Screening Quality Assurance Service), the TLHC pilot group, clinicians and DHSC.

Summary of analysis

People at highest risk (current smokers,^{[footnote 15] [footnote 16] [footnote 17]} those with longstanding smoking histories and those from socio-economically deprived communities^{[footnote 13]}) are the most likely to benefit from a national targeted lung cancer screening programme.

Evidence from other screening programmes indicates people from deprived communities are less likely to participate in screening.^{[footnote 45]} As such, while the lung screening programme will see numerically larger numbers of people from deprived communities (as a proportion of all people at a high risk of lung cancer), this group are likely to attend less than their less deprived peers. This remains a barrier to successful implementation of lung cancer screening.^{[footnote 15]}

Effective strategies are therefore needed to engage with high-risk groups to try to ensure equitable uptake.^{[footnote 10]} Strategies that have been successfully used in other national screening programmes include pre-invitation or advance notification letters, reminder letters for non-responders, scheduled appointments, GP-endorsed invitations, and text reminders.^{[footnote 46] [footnote 47] [footnote 48]} Re-invitation strategies can improve uptake among non-responders.^{[footnote 49]}

The programme should be designed to proactively engage at-risk individuals, especially populations which experience disadvantage and marginalisation. This will enable the programme to address inequalities in access to screening and ensure it does not exacerbate the existing inequities observed in lung cancer.

The approaches used should be appropriate for the local population. This should include:

• ensuring the language used to communicate about screening and lung cancer is appropriate and addresses potential fears or misunderstandings

• locating screening services close to the communities they serve

• involving community leaders and healthcare professionals to engage targeted populations

Programme leads can look to local qualitative research and findings from other screening programmes when planning how best to engage different communities within their target population. Local screening provision should be designed in close consultation with the communities they intend to serve.

Local smoking cessation services to which people are referred from targeted lung cancer screening will also need to ensure that they are accessible to disadvantaged and marginalised people. This can be done through similar steps as outlined above for screening services.

The NHS has developed new smoking cessation services in local community pharmacy services. Pharmacy teams based within the heart of local communities have always had an important role as one of the first ports of call for people wanting advice or practical support with their health. These services are therefore seen as providing a more accessible service to people who may be unable to access more traditional smoking cessation services. Through the multiple location availability of community pharmacies, people with work or life commitments would be better able to access these services at more appropriate times for them.

Overall impact

The overall impact of a national targeted lung cancer screening programme will be to improve survival rates for lung cancer. This is by targeting screening at those with an elevated risk, with the aim of detecting lung cancer earlier when it is easier to treat. It is estimated that when fully rolled out, the programme has the potential to identify 9,000 cancers earlier each year.

The primary impact of this measure will be the increased access to early healthcare interventions for lung cancer across the targeted population of current and former smokers. This programme will help to improve the health of the eligible population through the early detection and treatment of cancer, causing a reduction in mortality from lung cancer. With effective mitigations in place, the programme could significantly reduce health disparities.

UK NSC recommends that the national targeted lung cancer screening programme should have a smoking cessation service associated with it. This is expected to reduce the number of smokers nationally and therefore reduce the incidence of lung cancer as a result of individuals quitting. As smoking causes a number of different potentially deadly diseases such as cancer, heart attack and stroke, it is expected that the incorporation of smoking cessation services will help reduce morbidity from these conditions as well.

There are risks that certain groups will not be able to access national targeted lung cancer screening due to current known inequality issues. These can be alleviated through a range of methods, including training staff to address concerns, and public awareness campaigns to increase uptake among low uptake groups. However, there remains the risk of certain groups not engaging with the service and therefore the positive impact on inequalities not being as large as it could be.

Addressing the impact on equalities

Current mitigations in screening programmes have been outlined in the evidence above. Mitigations also apply for smoking cessation services, although it will depend on the models chosen as to which will be most appropriate for the targeted lung cancer screening programme.

Mitigations include:

• provision of translated leaflets for those whose first language is not English
• accessible screening clinics for people with disabilities
• provision of fixed screening appointments
• text and or letter reminders for appointments
• targeted communications to groups with lower uptake rates of screening

Monitoring and evaluation

Screening programmes are a Secretary of State delegated function under section 7A of the NHS Act 2006 as amended by the Health and Social Care Act 2012. Quarterly meetings between DHSC and NHS England are used to monitor the delivery of the programme against key performance indicators (KPIs). Work is on-going to develop new KPIs for the national targeted lung cancer screening programme. One of these KPIs will focus on inequalities.

1. Cancer Research UK. Lung Cancer statistics (2023). Viewed online June 2023.   ↩

2. Office of National Statistics. Cancer Survival in England: national estimates for patients followed up to 2017 (2019). Viewed online June 2023.  ↩

3. Office for Health Improvements and Disparities. Smoking profile data (2022). Fingertips data. Viewed online June 2023. ↩ ↩²

4. Cancer Research UK. Survival for lung cancer. 21 Dec 2022. Viewed online June 2023. ↩ ↩²

5. Lewer D, Jayatunga W, Aldridge RW and others. Premature mortality attributable to socioeconomic inequality in England between 2003 and 2018: an observational study. Lancet Public Health. 2020;5(1):e33-e4. ↩ ↩² ↩³

6. Cancer Research UK. Cancer Survival in England, cancers diagnosed 2015 to 2019, followed up to 2020 (2022). Viewed online June 2023. ↩

7. Office for National Statistics. Adult smoking habits in the UK: 2019. Viewed online June 2023. ↩

8. Evans E, Grenda T, Alvarez NH and others (2021). Narrative review of socioeconomic and racial disparities in the treatment of early-stage lung cancer. Journal of Thoracic Disease 13, 58-63. ↩ ↩²

9. Riaz SP, Horton M, Kang J and others (2005). Lung cancer incidence and survival in England: an analysis by socioeconomic deprivation and urbanization. Journal of Thoracic Disease 12,10. ↩

10. Ali N, Lifford KJ, Carter B and others (2015). Barriers to uptake among high-risk individuals declining participation in lung cancer screening: a mixed methods analysis of the UK Lung Cancer Screening (UKLS) Trial. BMJ Open 5, 7. ↩ ↩² ↩³

11. Bauld L, Bell K, McCullough L and others (2010). The effectiveness of NHS smoking cessation services: a systematic review. Journal of Public Health, 32, 1, 71-82. ↩

12. Snowsill T, Yang H, Griffin E and others (2018). Low-dose computed tomography for lung cancer screening in high-risk populations: a systematic review and economic evaluation. Health Technology Assessment, 22, 69. ↩

13. Love-Koh J, Cookson R, Claxton K and others (2020). Estimating Social Variation in the Health Effects of Changes in Health Care Expenditure. Society for Medical Decision Making, 40, 2. ↩ ↩² ↩³ ↩⁴ ↩⁵

14. National Centre for Smoking Cessation and Training (2013). Stop smoking Services and Health Inequalities. Viewed online June 2023. ↩

15. McRonald TFE , Yadegarfar G, Baldwin DR and others (2014). The UK Lung Screen (UKLS): demographic profile of first 88,897 approaches provides recommendations for population screening. Cancer Prevention Research (Philadelphia) 7, 362-71. ↩ ↩² ↩³ ↩⁴ ↩⁵ ↩⁶

16. JK Field JK , Duffy SW, Baldwin DR and others (2016). The UK Lung Cancer Screening Trial: a pilot randomised controlled trial of low-dose computed tomography screening for the early detection of lung cancer. Health Technology Assessment 20, 1-146. ↩ ↩² ↩³

17. Yousaf-Khan , Horeweg N, van der Aalst C and others (2015). Baseline Characteristics and Mortality Outcomes of Control Group Participants and Eligible Non-Responders in the NELSON Lung Cancer Screening Study. Journal of Thoracic Oncology, 10, 747-753. ↩ ↩² ↩³

18. Hirst Y, Stoffel S, Baio G and others (2018). Uptake of the English Bowel (Colorectal) Cancer Screening Programme: an update 5 years after the full roll-out. European Journal of Cancer, 103, 267-73. ↩

19. Public Health England (2021). Population screening: supporting people with a learning disability. ↩ ↩²

20. Lodge K-M (2016). Smoking and People with an Intellectual Disability. ↩ ↩²

21. Selbie D (2018). Progressing a smokefree NHS. UK Health Security Agency blog post, viewed June 2023. ↩

22. Sakellariou D and Rotarou ES (2019). Utilisation of mammography by women with mobility impairment in the UK: secondary analysis of cross-sectional data. BMJ Open, 9, 3. ↩

23. NHS Digital (2022). Statistics on NHS Stop Smoking Services in England - April 2021 to March 2022. ↩ ↩²

24. Public Health England (2021). Severe mental illness (SMI): inequalities in cancer screening uptake report ↩

25. Royal College of Physicians & Royal College of Psychiatrists (2016). Smoking and Mental Health. ↩ ↩²

26. Public Health England (2015). Reducing high smoking rates among patients in mental health units.  ↩

27. Office for National Statistics (2021). Adult smoking habits in the UK: 2021. ↩ ↩² ↩³

28. NHS Digital (2024). Statistics on NHS Stop Smoking Services in England - April 2023 to March 2024 (Q4, Annual). ↩ ↩² ↩³ ↩⁴

29. Allen A M, Oncken C, Hatsukami D (2014). Women and Smoking: The Effect of Gender on the Epidemiology, Health Effects, and Cessation of Smoking. Current Addiction Reports, Volume 1, 53-60. ↩

30. Bolderston A and Ralph S (2016). Improving the health care experiences of lesbian, gay, bisexual and transgender patients. Radiology, 22, 3, 207-211. ↩

31. Office for National Statistics (2024). Cigarette smoking among adults. ↩

32. Action on Smoking and Health (ASH), (2019). Tobacco and Ethnic Minorities. Accessed online in 2024 - no longer available. See 2024 Fact Sheet on Tobacco and Ethnic Minorities. ↩

33. Martins M, Abel G, Ukoumunne O and others (2022). Ethical inequalities in routes to diagnosis of cancer: a population-based UK cohort study. British Journal of Cancer, 127, 869-871. ↩

34. von Wagner C, Baio G, Raine R and others (2011). Inequalities in participation in an organized national colorectal cancer screening programme: results from the first 2.6 million invitations in England. International Journal of Epidemiology, 40, 712-718. ↩

35. Whitaker K L, Krystallidou D, Williams ED and others (2022). Addressing language as a barrier to healthcare access and quality. British Journal of General Practice, 72, 714, 4-5. ↩

36. Office for National Statistics (2022). Gypsies and Travellers in England and Wales: lived experiences. ↩

37. White M, Bush J, Kai J and others (2006). Quitting smoking and experience of smoking cessation interventions among UK Bangladeshi and Pakistani adults: the views of community members and health professionals. Journal of Epidemiology and Community Health, 60(5), 405-411. ↩

38. Smith DR, Behzadnia A, Imawana AR and others (2021). Exposure-lag response of smoking prevalence on lung cancer incidence using distributed lag non-linear model. Scientific Reports 11, article 14478. ↩

39. Buchting FO, Emory KT, Scout and others (2017). Transgender Use of Cigarettes, Cigars and E-Cigarettes in a National Study. National Library of Medicine, 53, 1-7. ↩

40. Nicolle L (2022) Transgender people and healthcare barriers. Pavillion Health Today (online). ↩

41. Grimstad F, Tulimat S and Stowell J (2020). Cancer Screening for Transgender and Gender Diverse Patients. Current Obstetrics and Gynaecology Reports, 9, 146-152. ↩

42. Price CL, Szczepura AK, Gumber AK and others (2010). Comparison of breast and bowel cancer screening uptake patterns in a common cohort of South Asian women in England. BMC Health Services Research 10, 103. ↩

43. Pratt R, Pernat C, Kerandi L and others (2019). “It’s a hard thing to manage when you’re homeless”: the impact of the social environment on smoking cessation for smokers experiencing homelessness. BMC Public Health, 19, 653. ↩

44. O’Moore E. Successfully delivering smokefree prisons across England and Wales. UK Health Security Agency blog. July 2018. ↩

45. Bowden, B (2022). Screening Division Inequities Report 2020-21. Public Health Wales. ↩

46. Libby G, Bray J, Steele RJC and others (2011). Pre-notification increases uptake of colorectal cancer screening in all demographic groups: a randomized controlled trial. Journal of Medical Screening, 18, 24-9. ↩

47. Duffy SW, Myles JP, Maroni R and others (2016). Rapid review of evaluation of interventions to improve participation in cancer screening services. Journal of Medical Screening 17 (24), 127-145. ↩

48. Ghimire B, Maroni R, Vulkan D and others (2019). Evaluation of a health service adopting proactive approach to reduce high risk of lung cancer: The Liverpool Healthy Lung Programme. Lung Cancer Journal 134, 66-71. ↩

49. Dickson J L, Hall, H, Horst C and others (2023). Uptake of invitations to a lung health check offering low-dose CT lung cancer screening among an ethnically and socioeconomically diverse population at risk of lung cancer in the UK (SUMMIT): a prospective, longitudinal cohort study. The Lancet Public Health 8, 2, E130-E140. ↩