In August 2011, the National Lung Screening Trial (NLST) investigators published their results: screening with low-dose computed tomography (LDCT) reduces mortality from lung cancer among heavy smokers.1 For some, these results were evidence enough to begin LDCT screening programs. Others2 more closely examined the total evidence about thevalueof lung cancer screening, that is, the extent towhich the benefits justify the harms and costs.3 One of the important analyses in this effort used NLST data to assess cost-effectiveness.4 This analysis found that screening heavy smokers has an incremental costeffectiveness ratio (ICER) of $81 000 per quality-adjusted life-year (QALY), with a wide 95% CI ($52 000-$186 000) and marked variation among subgroups. For example, a subgroup analysis showed that the ICER for people with a history of heavy smoking (at least 30 pack-years) who were currently smoking was $43 000 per QALY; for those who had previously stopped smoking, the ICER was $615 000 per QALY. This analysis involved 2 critical assumptions about the psychological effects of screening on heavy smokers: that the cascade of screening leads to few psychological harms and that screening has no effect on smoking behavior. The qualitative study by Zeliadt et al5 in this issue of JAMA Internal Medicine should prompt us to revisit these 2 assumptions. Althoughmany acknowledge the potential psychological effects of lung cancer screening,6 we have little useful evidence to help determine the frequency and burden of the potential psychological harms of lung cancer screening. The critical question that needs to be answered is what are the shortand longer-termpsychological effects of offering LDCT screening as a proven program to heavy smokers, compared withnot offering screening? Studies that compare screenedvs nonscreened groups within randomized clinical trials do not address this question because participation in the trial itself has psychological effects and participants usually differ from community nonparticipants in important ways. Studies that compare false-positivewithnegative screening results donot help us answer the critical question. Studies that do not use sensitive condition-specificmeasurement instruments areunlikely to detect the types of psychological effects thatmay result from screening. This issue iswhere thequalitative analysis byZeliadt et al5 is helpful. The investigators use a more sensitive qualitative approach to gain a richer understandingof the associationbetween screening and heavy smokers’ sense of their health. It Related article page 1530 Lung Cancer Screening in Smokers and theMotivation to Quit Smoking Original Investigation Research