Kick Butts Day is a national day of activism to empower youth to stand up, speak out and seize control against Big Tobacco. Kick Butts Day aims to:

  1. Raise awareness of the problem of tobacco use.
  2. Encourage youth to reject the tobacco industry’s deceptive marketing and stay tobacco-free.
  3. Urge elected officials to take action to protect kids from tobacco.

This Kick Butts Day, Eon decided to examine the prevalence of smoking in the United States, the effect on our communities, and to learn more about smoking cessation. Below is a summary of our findings.

  1. Cigarette smoking is the leading preventable cause of morbidity and mortality worldwide, responsible for over 6 million deaths annually (1).
  2. Smokers who quit smoking reduce their risk of developing and dying from tobacco-related diseases such as cancer, heart disease, stroke, lung diseases, diabetes, and chronic obstructive pulmonary disease (COPD), which includes emphysema and chronic bronchitis.
  3. Despite declining smoking rates in the United States, more than 30 million people, or 14.1% of U.S. adults, smoked in 2017 (2).
  4. Annually, one in five U.S. deaths are attributed to cigarette smoking or secondhand smoke exposure (3).
  5. On average, smokers die 10 years earlier than nonsmokers (4).
  6. Economically speaking, smoking costs the United States over $300 billion each year – $170 billion for direct medical care and over $156 billion in lost productivity from premature death and exposure to secondhand smoke (5).
  7. Despite the known risks of smoking, everyday almost 2,000 young adults under the age of 18 smoke their first cigarette (3).

Ironically, big tobacco still spends more than $1 million every hour advertising and promoting cigarettes and smokeless tobacco products (6). Tobacco companies are having to redefine themselves as cigarette smoking has steadily declined and are heavily investing in Modified Risk Tobacco Products (MRTP). In 2016, André Calantzopoulos, CEO of tobacco giant Philip Morris, said he hoped cigarettes would soon be history, a spurious way to say there are no efforts to reduce nicotine addiction and the company is looking to replace cigarette sales with new nicotine alternatives.

Nearly seven in ten (68%) adult smokers want to quit smoking, while more than half of all adult smokers have made some type of quit attempt (7). So why aren’t more smokers successful at quitting? As it turns out, there is much more to it than just quitting.

One of the biggest challenges around smoking cessation is the relatively low rate of sustained success and researchers are just starting to understand the science behind stopping. Tobacco use of any kind can be characterized as a chronic relapsing substance use disorder that is sustained by addiction to nicotine. According to Martin J. Jarvis at the University College of London, “Social, economic, personal, and political influences all play an important part in determining patterns of smoking prevalence and cessation. Although drug effects underpin the behavior, family and wider social influences are often critical in determining who starts smoking, who gives up, and who continues (8).”

Successful interventions begin with identifying nicotine users and appropriate therapies. For providers, the United States Preventive Services Task Force (USPSTF) recommends the “5 A’s Framework”:

  1. Ask every patient about tobacco use
  2. Advise all users to quit
  3. Assess willingness to quit
  4. Assist with attempts to quit
  5. Arrange follow-up

In fact, the Centers for Medicare & Medicaid Services (CMS) now requires all eligible lung cancer screening patients to be offered smoking cessation prior to having a screening exam.

The Centers for Disease Control and Prevention’s Million Hearts offers a Tobacco Cessation Protocol that can be adopted by health systems and providers to use with tobacco dependent patients. The protocol includes a decision tree for intervention and a Quit Plan checklist.  Tobacco Cessation Protocol.

The 5 A’s Framework and identifying nicotine dependent patients has led to an entirely new discipline in healthcare around smoking cessation. As it is, the family doctor who says “you should stop smoking” is not a very successful cessation tool.  What has been found to be successful is a combination of methods and appropriate interventions based upon the user’s willingness to quit. Such methods include:

  • Nicotine replacement therapy (NRT)
  • Medications
  • Counseling and quit plans
  • Quitlines
  • Innovative digital technologies (digital transdermal patch, smart lighters and smart cigarette cases)

Whether you are a physician looking to start a smoking cessation program or a person looking for tools to help a friend stop smoking, this Kick Butts Day join the effort to stand up, speak out, and seize control against big tobacco.



Related Blogs

Incidental findings are common in lung cancer screenings with chest CT. However, reporting of the S-modifier or C-modifier within the Lung-RADs is often inconsistent. Below are some specific guidelines in order to improve reporting consistency and better define potential abnormalities.

Background On The Lung-RADS Reporting System

The American College of Radiology recommends using their Lung-RADS reporting system. When using this system, moderate to severe pulmonary calcifications must be reported as separate data points. The system requires radiologists to describe their findings on a 0–4 scale, along with a description of the lung nodules and their management. There are two additional categories: the “S” modifier, which is used to describe any “clinically significant or potentially significant findings,” and the “C” modifier, which is used if there is a prior history of lung cancer.

Confusion With The S-Modifier

The Lung-RADS reporting system defines the category “S” as occurring when a baseline screening reveals, “Other findings (non-lung cancer).” In this case, the “S,” “May add on to category 0–4.” The system defines category “1S” as occurring when a baseline screening reveals, “No nodules or nodules with calcification with other findings (non-lung cancer).”

The problem and potential confusion with these definitions are that the terminology “non-lung-cancer-related” is subject to interpretation and may not be used consistently.

To better understand this confusion and its potential reporting issues, a retrospective investigation was performed by the Stony Brook University Medical Center, which included 581 individuals who received a baseline low-dose chest CT for lung cancer screening. The study found that initially, “A total of 261 (45%) participants received the Lung-RADS S modifier on baseline CT with 369 incidental findings indicated as potentially clinically significant.” However, after investigation, “an additional 141 incidentalomas of the same types as these 369 findings were described in reports but were not labeled with the S modifier. Therefore, as high as 69% (402 of 581) of participants could have received the S modifier if reporting was uniform.”

How To Report Modifiers In A Radiology Report

Because of the potential confusion mentioned above, it is important to use as specific detail as possible. To improve accuracy and consistency below is an example of how we recommend reporting modifiers in a radiology report.

C Modifier

Prior history of lung cancer; CT exam result modifier C.

Select one:
N – No
Y – Yes
U – Unknown

S Modifier
Other clinically significant or potentially significant abnormalities; CT exam result modifier S.
Select one:
N – No
Y – Yes

If yes, what were the other findings?

Select all that apply:
0 – Aortic aneurysm
1 – Coronary arterial calcification moderate or severe
2 – Pulmonary fibrosis
3 – Mass (check neck, mediastinum, liver, kidneys, other)
4 – Other interstitial lung diseases

Why Reporting Consistency Matters

As screening becomes more widespread, accurate data registries will allow for additional efficiencies and improvements in the screening process. Also, reporting consistency will help fuel the advancement of a wide range of computer analytical tools that will provide information beyond just the early detection of lung cancer. Additionally, tracking other clinically significant findings showed an overall mortality benefit in the National Lung Screening Trial (NLST).

Eon’s Solution for Lung Cancer Screening uses the Lung-RADS guidelines to help lung cancer screening programs determine next steps for all eligible patients. Eon’s Solution for Incidental Pulmonary Nodules (IPN) helps identify, track and manage patients with IPNs based on the Fleischner Society guidelines. Together, Eon can provide an integrated solution for a comprehensive lung program.


Yankelevitz D, Henschke C. Advancing and Sharing The Knowledge Base of CT Screening For Lung Cancer. NCBI Website. Accessed September 16, 2018.

Mehta H, Mohammed TL, Jantz M. Reclassify Lung-RADS Category “S”. Chest Journal Website. Accessed September 16, 2018.

Reiter MJ, Nemesure A, Madu E, Reagan L, Plank A. Frequency and Distribution of Incidental Findings Deemed Appropriate for S Modifier Designation on Low-Dose CT in a Lung Cancer Screening Program. NCBI Website. Accessed September 16, 2018.

Related Blogs

Ground Glass Opacifications (GGOs) can pose a variety of challenges for physicians. Below is a short guide to help ensure proper diagnosis and management.

What are GGOs?

Ground Glass Opacifications are a subset of pulmonary nodules. Unlike solid nodules, GGOs occur with non-uniformity and less density, which can cause a hazy appearance. GGOs may be non-solid (referred to as “pure ground glass”) or part-solid (part of the ground-glass opacity completely obscures the tissue). Part-solid nodules are most strongly associated with lung cancer detected in CT or other imaging modalities.

The risks of GGOs

Knowledge of the causes and effects of GGOs as well as knowledge of patient history are critical in proper diagnosis and management. In malignant part-solid GGO nodules, the solid part histologically represents invasion, whereas the pure GGO areas are considered adenocarcinoma in situ (AIS) – which is the most common cancer manifesting with ground-glass opacity on CT. Because of this, solid transformation of GGO nodules is considered a strong indicator of malignancy. GGO nodules often grow slowly, and if malignant transformation from carcinoma in situ does occur, the process may take years. This means that a longer follow-up time is necessary. Apart from malignant disease, GGO changes can represent lung infections, lung edema with fluid in the interstitium, patchy increased parenchymal perfusion, or interstitial diseases.

The unique challenges of GGOs

In patients with pure GGO nodules, tumor growth can be slow and invasive disease is uncommon. Despite this, resection rates can be high. These unique features pose a challenge for physicians and patients managing GGOs over time. Similar to the management of solid nodules, the goal with GGOs is to identify and cure (usually through resection) all dangerous cancers, and to avoid resection in all benign tumors. With GGOs, the risks of observation with serial imaging are usually lower, but the observation periods may be significantly longer in order to achieve these goals.

Recommended management

Below is a limited summary of the 2017 Fleischner guidelines for GGO and subsolid pulmonary nodules.

Pure GGO Pulmonary Nodules

For pure GGO nodules ≤5 mm in diameter, no routine follow up is suggested. For suspicious pure GGOs ≤5 mm, a CT scan should be performed at 2 and 4 years. For pure GGO nodules >5 mm in diameter, a CT scan should be performed between 6 and 12 months in order to confirm persistence, and then another CT scan should be performed every 2 years until the 5-year mark. After 5 years, the physician and patient can assume benignity and stability and stop following the nodule.

Part Solid (Subsolid) Pulmonary Nodules

A general rule is that GGO cannot truly be defined as part solid until after the nodule is larger than 6 mm diameter. For subsolid nodules less than 6mm, no routine follow up is recommended. A suspicious nodule can be followed with a 2 and 4-year CT scan. For subsolid nodules greater than 6 mm, a CT scan should be performed between 3 and 6 months to confirm persistence. If the overall nodule size does not change and the solid component remains less than 6 mm, an annual CT scan should be performed for 5 years. After 5 years, the physician can assume stability and stop following the nodule.

Multiple Subsolid Nodules or GGO

The category of multiple subsolid nodules includes both pure GGO and part solid GGO. This category can often represent infectious or inflammatory processes. In patients with multiple subsolid nodules smaller than 6 mm, an initial follow up scan is recommended at 3-6 months, with the consideration of follow up at approximately 2 and 4 years to confirm stability depending on the clinical setting. In patients with multiple subsolid nodules with at least one nodule that is 6 mm or larger, management decisions should be based on the most suspicious nodule. If persistence is confirmed on CT scan after 3-6 months, then subsequent CT scans should follow the recommendations from the category of the most suspicious nodule. If multiple nodules are 6 mm or larger, physicians should use the one that is determined to be most suspicious to guide the timing of future scans.

Eon Patient Management Solution for Incidental Pulmonary Nodules (IPN) identifies and recommends next steps for radiologists and other providers based on the Fleischner Society guidelines. Eon also offers white papers on incidental pulmonary nodules, a novel approach to IPNs, and 6 steps for building an IPN program.


Copeland S, Islam E. Management of Ground Glass and Subsolid Pulmonary Nodules: Review. Pulm CCM Website. Accessed September 2, 2018.

Pedersen JH, Saghir Z, Winkler Wille MM, Thomsen LH, Skov BG, Ashraf H. Ground-Glass Opacity Lung Nodules in the Era of Lung Cancer CT Screening: Radiology, Pathology, and Clinical Management. Modern Medicine Network Website. Accessed September 2, 2018.

Related Blogs