Transfer Alert

This paper was transferred from another journal. As a result, its full editorial history (including decision letters, peer reviews and author responses) may not be present.

PONE-D-24-38765Self-blaming as a Barrier to Lung Cancer Screening and Smoking Cessation Programs in Italy: A Qualitative Study

PLOS ONE

Dear Dr. Ghirotto,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

I have examined the paper myself and was able to secure the services of 2 expert reviewers. As you can see, they largely agree on the strengths of the paper and I concur. Reviewer 2 has provided an extensive list of useful suggestions, including a set of points that need to be referenced with which I strongly concur (e.g., Globocan will provide the most current incidence and prevalence figures for Italy etc). My suggestions are as follows:

1. Please address each of the reviewers’ points in turn. I will add some further comments on some of these below, as well as comments of my own.
2. The abstract is definitely too long. The limit for PlosOne is 300 words and you are at about 430. This needs to be trimmed and certainly can be trimmed.
3. Please go through and address the paragraph structure of the manuscript. Avoid any single sentence paragraphs. These must be integrated with the paragraphs below or above, as appropriate, or inserted elsewhere.
4. As you can probably tell by my name, I too can see the mixed English/Italian idiom. I strongly suggest you remove this entirely. In general, second language (L2) speakers have difficulty in comprehending idioms and so these should be avoided altogether in scientific and scholarly papers. That is, I would also suggest you remove “the straw the broke the camel’s back”.
5. The sample size needs to be introduced carefully because it also points back to a process that is very important in qualitative research that has not been addressed in your manuscript, that of saturation. The reviewers ask why you chose 15 people. In general, in interview studies such as yours, the researchers would commence gathering interview data and only stop once each it was evident that no new material was forthcoming. This is called the point of saturation. It could occur after 5 or 25 or more interviews. It is difficult to reconcile how you would specify 15 people before you began interviewing and then have a sense of saturation. It is OK if you needed to, for pragmatic reasons, limit the number of interviews. But you need to explain that clearly and also to discuss what approaches you took to assess saturation in the circumstances.
6. For the TA, you should present a table with all the themes and an illustrative quote for each. This is in addition to the material in the body and will greatly help readers navigate your model.
7. Further, I think that the Discussion section misses the opportunity to relate cultural factors to psychological perceptions of screening, cancer, and lung cancer. In my current position in Hong Kong, I have been exposed to some distinctly Chinese perspectives on cancer that has contrasted with results of my previous work with lung cancer patients in Australia. Similarly, you might consider what aspects of the Italian sample and their interpretations can be drawn out. Much of the scholarship in this area is dominated by the Anglophone world and it is important to give voice to true cultural factors. For example, the potential for Italian fatalism seemed to be evident in some of the quotes I saw.
8. As for the references to the Youtube video and other public health activities based on this study, these should be removed from the manuscript. They are certainly laudable, but it is up to the organization to promote these and to derive impact from this research. This does not belong in the Strengths and Limitations section, nor in any other part of the paper.
9. Finally, you need to apply a qualitative assessment framework such as COREQ and incorporate it into the MS, most likely as an Appendix. This is very important for readers to be able to contextualise your work.

Please submit your revised manuscript by Jan 12 2025 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

• A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
• A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
• An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Stefano Occhipinti

Academic Editor

PLOS ONE

Journal Requirements:

When submitting your revision, we need you to address these additional requirements.

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at 

https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and 

https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf

2. Thank you for stating the following financial disclosure: 

 This study contributed, without receiving funding, to the Italian Ministry of Health Pilot project “Progetto Pilota di un programma di screening per il tumore polmonare integrato con la cessazione del fumo: percorsi, selezione dei soggetti e protocolli diagnostici, in vista di una valutazione HTA”. The study was partially funded by Emilia Romagna Regional Health Authority DGR n° 1800/2020.

The research project “Analisi dei meccanismi d’azione psico-comportamentali con cui la proposta di adesione alla TAC spirale agisce sulle abitudini tabagiche e sulla disassuefazione al fumo” has been supported by a ‘5x1000’ national grant from the Italian League against Cancer (LILT-Rome).

This study was partially supported by the Italian Ministry of Health – Ricerca Corrente Annual Program 2025.  

Please state what role the funders took in the study.  If the funders had no role, please state: ""The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript."" 

If this statement is not correct you must amend it as needed. 

Please include this amended Role of Funder statement in your cover letter; we will change the online submission form on your behalf.

3. Thank you for stating the following in the Acknowledgments Section of your manuscript: 

This study contributed, without receiving funding, to the Italian Ministry of Health Pilot project

“Progetto Pilota di un programma di screening per il tumore polmonare integrato con la cessazione

del fumo: percorsi, selezione dei soggetti e protocolli diagnostici, in vista di una valutazione HTA”.

The study was partially funded by Emilia Romagna Regional Health Authority DGR n° 1800/2020.

The research project “Analisi dei meccanismi d’azione psico-comportamentali con cui la proposta

di adesione alla TAC spirale agisce sulle abitudini tabagiche e sulla disassuefazione al fumo” has

been supported by a ‘5x1000’ national grant from the Italian League against Cancer (LILT-Rome).

This study was partially supported by the Italian Ministry of Health – Ricerca Corrente Annual

Program 2025.

We note that you have provided funding information that is not currently declared in your Funding Statement. However, funding information should not appear in the Acknowledgments section or other areas of your manuscript. We will only publish funding information present in the Funding Statement section of the online submission form. 

Please remove any funding-related text from the manuscript and let us know how you would like to update your Funding Statement. Currently, your Funding Statement reads as follows: 

 This study contributed, without receiving funding, to the Italian Ministry of Health Pilot project “Progetto Pilota di un programma di screening per il tumore polmonare integrato con la cessazione del fumo: percorsi, selezione dei soggetti e protocolli diagnostici, in vista di una valutazione HTA”. The study was partially funded by Emilia Romagna Regional Health Authority DGR n° 1800/2020.

The research project “Analisi dei meccanismi d’azione psico-comportamentali con cui la proposta di adesione alla TAC spirale agisce sulle abitudini tabagiche e sulla disassuefazione al fumo” has been supported by a ‘5x1000’ national grant from the Italian League against Cancer (LILT-Rome).

This study was partially supported by the Italian Ministry of Health – Ricerca Corrente Annual Program 2025.

Please include your amended statements within your cover letter; we will change the online submission form on your behalf.

4. In the online submission form, you indicated that The data that support the findings of this study are available on request from the corresponding author, LG. 

All PLOS journals now require all data underlying the findings described in their manuscript to be freely available to other researchers, either 1. In a public repository, 2. Within the manuscript itself, or 3. Uploaded as supplementary information.

This policy applies to all data except where public deposition would breach compliance with the protocol approved by your research ethics board. If your data cannot be made publicly available for ethical or legal reasons (e.g., public availability would compromise patient privacy), please explain your reasons on resubmission and your exemption request will be escalated for approval. 

5.  Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

********** 

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: N/A

********** 

3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: No

Reviewer #2: No

********** 

4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

********** 

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Overall, the authors present a rigorous qualitative study that explores the perspectives of stakeholders involved in LCS and individuals eligible for the smoking cessation program. They seem to recommend implementing timely smoking cessation programs alongside LCS initiatives, with an emphasis on effective communication methods to help reduce potential self-blame among participants. Please see my feedback for minor revisions below.

Suggested minor revisions:

Introduction

Authors wrote “The results of previously published qualitative studies indicate the need to consider the specific needs of individuals who decide to embark on a smoking cessation journey [16,22–24,29], given the uniqueness of the target population”. Could you elaborate on this statement and give examples of those specific needs and link these findings to the aim and justification of your study?

Methods

Authors wrote “Through purposive sampling [30], we included: a) current and former cigarette users who participated in the ITALUNG study, and b) cigarette users aged 50-70 with a smoking history of ≥15 pack-years who were offered smoking cessation interventions and were theoretically eligible for future screening.” If data is available, please include details on when the smoking cessation interventions were offered to the participants (how many years ago?, how long has it been since the participants have been involved in these programs (ITALUNG, smoking cessation?)

Authors wrote “Semi-structured interviews comprised a series of open-ended questions for discussing the following:

- Experience of participating in the trial.

- Perception of risk.”

Please specify what risk is being referred to here (e.g., participants’ own perception towards their risk towards lung cancer? Or risk of participating in the trial?)

Results

For the tables, please include notes for abbreviations used (e.g., What is Ex?).

Discussion

How do the findings contribute to the broader field of smoking-related lung cancer stigma beyond the existing knowledge on the association between smoking and self-blame? It would also be helpful to highlight any unique findings from your study compared to previous research in this area, such as culturally specific observations or unique insights from conducting this study in Italy compared to studies in other contexts.

Minor typos:

Introduction – 2nd paragraph: After the first “random screening trial” is mentioned, please bracket RST for future abbreviations.

Reviewer #2: This is a solid qualitative study about Italians´ perception of both lung cancer screenings and smoking cessation interventions. I think authors did a great job in conducting the study and presenting their results. The rationale and the need for the research is also well-explored, as the author discussed the possible implementation of lung cancer screening as an intervention program in Italy.

That being said, I only have few minor suggestions that I think could further enhance the overall quality of the paper. Some of these are a bit more substantial, while most are actually just minor typos.

More substantial:

1) It is generally recommended to avoid excessively short paragraphs, especially those with just a single sentence. The authors tend to use many full stops, even when they are still discussing the same topic. I suggest reviewing the text with this in mind.

2) The abstract is very detailed, but quite lengthy. I am not updated about the journal´s policy about the maximum length of the abstract, but I will suggest to revise the result and conclusion sections to shorten them up.

3) At the same time, please mention the analysis technique you employed (RTA) in the abstract.

4) There are some points throughout the manuscript when I expected to find a citation, but none is provided. Following, I will report the sentences that in my opinion should be appropriately addressed to a reliable quote: I strongly suggest authors to add them up.

a. Lung Cancer (LC) is the first cancer cause of death in Europe.

b. Smoking is the most decisive risk factor and has the most considerable attributable fraction in most countries.

c. In recent decades, there has been a noticeable reduction in age-adjusted incidence rates of lung cancer.

d. Early diagnosis has the potential to lower disease fatality rates, although attempts in the 1970s were largely unsuccessful.

e. RTA was 9 adopted because of its flexibility and potential to provide rich and complex understandings

5) Page 7. Authors state they aimed at recruiting 15 participants from the trial, but there is absolutely no rationale mentioned behind this choice. This problem is mirrored with focus groups. Please provided an explanation for your sample size choices within the text, with proper references.

6) Related to prior point, please also add information about how the composition of each focus group was determined and why.

7) At page 13, just before the first sub-paragraph about the emerged themes (Depreciation and fatalism toward the risk of smoking) there is a text paragraph which is meant to anticipate the results (starting with “A prevailing sense of optimism…” until the end). I think this might be bad positioned here, as it basically synthetizes the upcoming results. I would consider deleting it or moving it in the discussion section.

8) Page 11: “Six participants were proposed with the program but did not accept it”. Do you have any information about their reasons? Or their demographics? This should be addressed in the limitation as a self-selecting bias.

9) Page 24, the first paragraph of strength and limitations (from “This qualitative analysis has proven to be a powerful tool for communication…” till the last YouTube link). I am not convinced this is the right place to mention the use of this research findings for dissemination. In my understanding, this is the place where you should discuss about the strength more related to the study design and implication for future research and scientifically-oriented interventions. Maybe you could mention this information – including the YouTube video – in a footnote?

Minor suggestions/typos:

1) Page 5, “Qualitative research delves into participants' narratives to provide insights into those elements, which are invaluable for designing interventions that resonate with patients' real-world experiences”. This sentence sounds odd. It is unclear what “those elements” is referred to. Please rephrase to improve clarity.

2) Page 6, there is a space missing between “Emilia-Romagna” and the citation 15.

3) Page 6, “The central research question was: What are the perspectives of individuals eligible for LDCT screening on the interplay between the two interventions (screening and smoking cessation program)?”. I would suggest to add “kind of” or “type of” before “interventions”. This expression is used also in other places of the manuscripts but in my opinion sounds odd.

4) Page 7, “The investigator explained the research's type and purpose”. I suggest to revise the use of the word “type” here. Maybe “design” or “methodology” would work better.

5) For consistency, please revise the use of periods in the excepts from participants´ words. I suggest avoiding the period at the end of quoted sentences (i.e., within quotation marks), and using it directly at the end after the parentheses indicating the participant information (e.g., FGM01 or 01).

6) Pages 7-8. I would suggest to use semi-column instead of periods in the bulleted lists.

7) Page 17 “the last straw that definitively overflowed the vase”. I think that an international audience would not understand this, as it appears to be a mix between a literal translation of the Italian idiom “la goccia che fa traboccare il vaso” and its respective in English, “the straw that broke the camel's back”. If I am wright, I would suggest author to just choose one of the two and use it in full!

8) Page 8. You mention that the “interviews and FGMs were immediately verbatim transcribed”, but if I am right you have never mentioned before that these were audio and/or video recorded. If this is the case, please add more information about this in the text.

9) ACKNOWLEDGMENTS, first line: “This study contributed, without receiving funding, to..”. I would suggest to rephrase it making clear that no founds have been received specifically from that project, as than other funding are listed.

10) While presenting the sample, the number of males and females in bracket is sometimes written in numbers and in other cases in letters. Please be consistent (I would choose numbers, but I am not sure about the journal policies if there are any).

11) Page 11, “The interview’s mean is 27’51’’ (range: 18’50’’-52’51’’)”. I think authors used “´” instead of commas. Please revise.

12) Page 10, “(in-house prot. n. 2020/0013503 del 03/02/2020)”. “Del” is still in Italian, I think.

13) Page 10, “It was explained to the participants, who were assured they could discontinue participation without consequences”. It is unclear what that “it” is referred to. Please revise or just leave the main sentence “Participants were assured they could discontinue participation without consequences”.

14) Page 10, “Study population”. I think that “Study sample” or “Participants” would be a more appropriate title, as you are here presenting those who participated in the study and not the inclusion or exclusion criteria solely.

********** 

6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #2: Yes: Marcella Bianchi

**********

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

Self-blaming as a Barrier to Lung Cancer Screening and Smoking Cessation Programs in Italy: A Qualitative Study

PONE-D-24-38765R1

Dear Dr. Ghirotto,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

An invoice will be generated when your article is formally accepted. Please note, if your institution has a publishing partnership with PLOS and your article meets the relevant criteria, all or part of your publication costs will be covered. Please make sure your user information is up-to-date by logging into Editorial Manager at Editorial Manager® and clicking the ‘Update My Information' link at the top of the page. If you have any questions relating to publication charges, please contact our Author Billing department directly at authorbilling@plos.org.

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Enkeleint A. Mechili

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #2: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: N/A

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: No

Reviewer #2: No

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: The authors have addressed my comments well and I am particularly pleased to see the paper's valuable cultural contributions. I appreciate the work you have put into enhancing its quality. Thank you for your thoughtful revisions.

Reviewer #2: The authors have successfully incorporated the requested revisions throughout the manuscript, which, in my opinion, significantly improved its already high overall quality.

Here are my very last suggestions, which are, of course, optional:

• Regarding “ex” cigarette users, I would suggest using the word “former” rather than “earlier,” as it sounds more appropriate to me (but English is not my mother tongue, so please take this with a grain of salt).

• I apologize for not catching the meaning of the ´´ symbols to indicate minutes earlier. However, even in the current form, you could consider making it even more explicit what you are referring to (e.g., “On average, the interviews lasted approximately 27 minutes (ranging from 18 to 52 minutes)”).

• Thank you for adding a proper description of the sample composition and its rationale. I am accustomed to referring to the concept of data saturation when defining sample sizes. While I do believe that the new version of the manuscript makes it sufficiently clear how choices were made, mentioning the arbitrary choice of recruiting 15 participants still seems somewhat strange to me. However, I particularly appreciate the reflection on the material unavailability of the former ITALUNG participants, which, in my opinion, helps justify the decision to set a relatively low minimum number (instead of a precise number of 15). Nevertheless, I also think the current version contains all the information necessary for readers to form their own opinions on the matter and interpret the results with appropriate caution. Of course, the overall merits of the manuscript are still sufficient to recommend its publication. Therefore, I would defer to the editor’s expertise for the final decision on this specific issue.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #2: Yes: Marcella Bianchi

**********