We have read with interest the letter entitled “Promotion of anti-smoking strategies as the most effective and efficient way to reduce lung cancer (and other diseases)”,1 replying to our recently published article.2 We would like to comment on the discrepancies perceived by the authors of this letter in our study.

The provisional nature of the NELSON trial results and the female cohort size, already discussed in our work, do not limit the possibility of applying the criteria used in the NELSON trial to our study sample to carry out a basically descriptive analysis identifying women who are at high risk of developing lung cancer. We believe that using the inclusion criteria of the 2 major trials that have demonstrated benefit in reducing lung cancer mortality (NLST and NELSON) provides 2 plausible, albeit preliminary, sets of results, differentiated by the sensitivity of these criteria.

We agree that the evidence seems to indicate that the use of risk prediction models3 may be more effective than simplified criteria for identifying high-risk individuals. However, population cancer screening programs recommended in the European Union (EU) (colorectal, breast, and cervical) tend to employ strategies that are much closer to the use of simplified criteria, probably because they are easier to implement. We also agree with the authors when they say that the implementation of lung cancer screening programs is a highly controversial and polemic topic,4,5 but we believe that our observations are appropriate in this context of uncertainty. Clearly, if the NLST and NELSON trials had shown a net lack of effectiveness for low-dose computed tomography, our conclusions would not make sense.

Finally, the authors claim that we should have underlined the opportunity cost of screening compared to smoking cessation treatments, as well as placing more emphasis on tobacco control strategies. We are surprised by this comment, given that the introduction of our article mentions the cost of lung cancer screening compared to smoking cessation interventions.5 Furthermore, in our conclusion we argue that “smoking cessation should be promoted within breast cancer screening programs, taking advantage of the situation as a teachable moment…” As authors of this study, we maintain that support for the implementation of comprehensive tobacco control policies must continue.6

In short, there is a broad consensus on the higher effectiveness and efficiency of smoking cessation compared to lung cancer screening, a consensus to which we subscribe. However, we are not indifferent to other positions proposed in the EU,4 nor to addressing complex questions, such as what to offer to high-risk former smokers. In this regard, we believe that the work of a researcher, particularly in public health, is most relevant when it is one step ahead of political decision-making.