Lung cancer in people who have never smoked is increasing. A campaign this month – See Through the Symptoms – aims to raise pharmacists' awareness of symptoms that may need investigation

November is Lung Cancer Awareness Month across the globe. Community pharmacy teams frequently interact with patients who are at increased risk of the disease and can signpost appropriately, for example by promoting smoking cessation services and nicotine replacement therapy.

However, while 72% of lung cancers in the UK are indeed caused by smoking[1], casting the net wider can help to reach symptomatic patients without a smoking history.

Lung cancer rates in this patient cohort are rising[2], but the absence of observable clinical risk factors means they often go undiagnosed until their disease is advanced.[3]

We know that earlier diagnosis improves outcomes, and GPs and community pharmacists alike can take important strides towards achieving that.

I have been involved with a charity campaign called See Through the Symptoms, which is running throughout November alongside Lung Cancer Awareness month.

Targeting primary and community healthcare professionals, including GPs and pharmacists, it highlights the importance of referring symptomatic patients for diagnostic imaging regardless of their age and smoking status.

Look beyond smoking history

Symptoms of lung cancer in never-smokers may be the same as in those who smoke, but could be more likely to be non-specific or atypical. According to the National Institute for Health and Care Excellence (NICE), they include:[4]

  • cough
  • fatigue
  • shortness of breath
  • pain in the chest
  • weight loss
  • appetite loss.

Additional symptoms that might be relevant are:

  • hoarseness
  • pain in the neck, upper back or shoulder
  • persistent or recurrent chest infection
  • blood in sputum
  • persistent enlarged lymph nodes around the collar bone in the neck.

NICE provides clear guidance on referral for diagnostic imaging. Patients aged 40 and over who have two or more unexplained symptoms from its list of six above (one or more if they have ever smoked) should be offered an urgent chest X-ray to be done within two weeks.4

However, research shows that former and never-smokers are less inclined to visit their GP when they have symptoms.[5] Those who do may be more likely to receive false reassurance and, consequently, less likely than smokers to follow up if symptoms don’t improve.

We often find younger people tend to exhibit symptoms that are less obviously respiratory, like upper back and shoulder pain, which are easier to miss or not be recognised as representative of an underlying cancer.

It is crucially important as primary care clinicians that we still consider the possibility of lung cancer in patients who don’t fit the usual mould. GPs should have a lower threshold for performing chest X-rays, including in younger, non-smoking patients with vague symptoms.

Pharmacy teams play a pivotal role too, by encouraging vigilance and advising patients with persistent, unexplained symptoms to see their GP and request a chest X-ray.

Pharmacies driving earlier diagnosis

Non-smoking lung cancer presents a significant healthcare challenge. Nearly half of all lung cancers are diagnosed at stage 4[6], but among never-smokers, delays in diagnosis push this figure up to almost 90%3.

Consequently, non-smoking lung cancer ranks as the eighth most common cancer-related cause of death in the UK, killing around 6,000 people every year.[7]

Campaigns like See Through the Symptoms can help enhance our understanding of this under-recognised disease, as well as highlighting that community pharmacies are a valuable resource when it comes to improving earlier cancer diagnosis.

NHS England has recognised this, having commissioned a local enhanced service pilot to fund direct cancer referrals from pharmacists earlier this year. It is being trialled in areas around the country and is expected to run for at least 12 months.

While many community pharmacies may not be set up for direct referrals, staff on the frontline may see patients with possible red flag symptoms several times before they visit their GP. These encounters represent opportunities to interact with these patients and advise them to get their symptoms checked out.

Making every contact count

There are a few key contact points that provide a good opportunity for raising awareness, such as when patients are waiting for medicines to be dispensed or collecting prescriptions, during medicine use reviews (MURs), or during NHS health checks – although these are only for over-40s.

There are also some groups of patients on whom pharmacy staff should keep a close watch and who may be candidates for a chest X-ray. For example:

  • Patients who are prescribed courses of antibiotics or steroids back-to-back or in quick succession for apparent persistent chest infections.
  • Patients who make repeat purchases of over-the-counter cough, cold and sore throat remedies.
  • Asthmatic patients who request their prescribed inhalers more frequently than usual.
  • Patients who ask advice about ongoing problems with hoarseness or heartburn.
  • Patients seeking pain relief for persistent upper back, neck or shoulder pain.

The advice for patients here should be clear yet avoid unnecessary anxiety: visit your GP and request a chest X-ray to rule out lung cancer.

About the campaign

See Through the Symptoms is run jointly by non-smoking lung cancer charities ALK Positive UK, EGFR Positive UK, and the Ruth Strauss Foundation. It features photographs by renowned British photographer Rankin, whose mother died from lung cancer in 2005.

The series of portrait images show nine patients – eight of whom have never smoked and one, an occasional smoker – all diagnosed with stage 4 lung cancer. For all of them, diagnosis took many months.

Dr Anthony Cunliffe is a GP in London, national lead medical adviser for Macmillan Cancer Support, and GP adviser for the See Through the Symptoms campaign.




[2] Increasing frequency of non-smoking lung cancer: Presentation of patients with early disease to a tertiary institution in the UK - PubMed (

[3] Abbott, J., Beattie, K. & Montague, D. The Role of UK Oncogene-Focussed Patient Groups in Supporting and Educating Patients with Oncogene-Driven NSCLC: Results from a Patient-Devised Survey. Oncol Ther 9, 187–193 (2021).

[4] NICE guideline NG12. Suspected cancer: recognition and referral (updated August 2023)