It is now widely accepted that lung cancer screening through low dose computed tomography (LDCT) results in fewer diagnoses at a late stage, and decreased lung cancer mortality. Whilst reducing deaths from lung cancer is an essential prerequisite, this must be balanced against the considerable economic costs accumulated in screening. Multiple health economic models have shown substantial variation in cost per Quality Adjusted Life Year (QALY), partly driven by the healthcare costs in the country concerned and partly by other modifiable programme components. Recent modelling using UK costs and a targeted approach suggest that most scenarios are within the willingness to pay threshold for the UK. However, identifying the most clinically and cost effective programme is a priority to minimize the total financial impact. Programme components that influence cost effectiveness include the method of selection of the eligible population, the participation rate, the interval between rounds of screening, the method of pulmonary nodule management, and the approach to clinical work up. Future research will clarify if a personalized approach to screening, using baseline and subsequent risk to define screening intervals is more cost effective. The burden of LDCT screening on the medical infrastructure and workforce has to be quantified and carefully managed during implementation.