Bladder cancer and smoking.
Part 4:
efficacy of health promotion
Abstract
This is the last of a four-part series on bladder cancer and smoking.
Part 1 presented an overview of bladder cancer and the role of
smoking in its development (Anderson and Naish, 2008a), part 2
discussed diagnosis and management of bladder cancer (Anderson
and Naish, 2008b) and part 3 examined perceptions and beliefs related
to smoking and health (Anderson and Naish, 2008c). Part 4 examines
evidence for the efficacy of health promotional measures in helping
people to stop smoking. It aims to provide an insight into whether
health education and health promotion increase awareness of the
impact of smoking on health and wellbeing, and whether a persons
subsequent behaviour changes enough for them to stop smoking.
Finally, it discusses the role of the healthcare professional in helping
people to achieve this objective.
Key words: Bladder cancer n Definitions of health n Health education
n Health promotion n Smoking
efore addressing health promotion and health
B education, it is necessary to define what we mean
by health; we will therefore examine a number
of definitions that aim to establish what health
means. We have tried to incorporate health education and
health promotion into smoking cessation strategies, which
also address a number of issues such as cost implications,
resources and the wider impact of government strategies
to implement smoking bans and the aim of such bans.
Healthcare professionals need to take every opportunity to
promote health and provide health education in patients
who present with bladder cancer, but their primary aim
should be to prevent people starting to smoke, which in turn
will reduce the incidence of bladder cancer.
Defining health
If healthcare professionals are to promote health as a vital
asset, they should first establish the meaning of health. Health
is a crucial concept, but one that is difficult to define as
peoples perceptions and beliefs have a significant bearing on
how they conceptualize it. According to Sadler (2002), health
Beverley Anderson is Macmillan Uro-Oncology Nurse Specialist and
Wendy Naish is Nurse Consultant Urology, Epsom and St Helier
University Hospitals NHS Trust, St Helier Hospital, Surrey
Accepted for publication: September 2008
1340
Beverley Anderson, Wendy Naish
means different things to different people, and what they
understand by the term will often differ at various stages of
their life. Many authors have attempted to define health; one
of the most renowned definitions is that of the World Health
Organization (WHO, 1958):
Health is a state of complete physical, mental
and social well-being, and not merely the
absence of disease and infirmity.
While this definition acknowledged health to be more
than non-disease, it was criticized for proposing an ideal
that would be increasingly difficult to achieve. Subsequently,
WHO proposed a more holistic definition, which
acknowledged the social, personal and physical attributes of
health (WHO, 1986). In 1987, Pender provided an excellent
overview of health, which relates to the individual, the family
and the community:
Health is the actualization of inherent and
acquired human potential through goal-directed
behavior, competent self-care, and satisfying
relationships with others while adjustments are
made as needed to maintain structural integrity
and harmony with relevant environments.
In contrast to WHO, Penders definition proposes criteria
for evaluating health in which health is seen as a way of
preserving the status quo, involving a dynamic process of
change as the individual strives to achieve physical, mental
and social fulfilment, i.e. a state of wellbeing (Royle and
Walsh, 1993).
These definitions clearly embrace health, depicting it as
a precious resource that should be valued and nurtured. In
reality, however, many people abuse their health, and sadly do
not appreciate its true worth until it becomes threatened by
illness or disease, as in smoking.
Health promotion
Health promotion has been described as a multifaceted
process that encompasses the overlapping fields of health,
education, disease prevention, health politics and disease
management (Tannahill, 1984; French, 1990). Early
definitions of health promotion were related to changing
lifestyle behaviours that could be damaging to health,
or to changing behaviour so as to maximize health and
functioning (Royle and Walsh, 1993).
A central part of health promotion is prevention. Indeed,
numerous reports and policy documents have emphasized
the need to prevent people smoking in order to prevent
British Journal of Nursing, 2008, Vol 17, No 21

diseases linked with smoking (Cutler, 1999). Prevention
can be broken down into three specific levels: primary,
secondary and tertiary.
Primary: At this level, activities are geared towards decreasing
the probability of illness (i.e. avoiding the disease and
protecting against illness). They include risk avoidance and
risk reduction. Primary prevention is clearly applicable to
some cancers where the cause is known (Charlton, 1994).
It clearly applies in the case of bladder cancer, as there
is significant evidence of a correlation between cigarette
smoking and development of the disease (Pashos, et al,
2002; Senegupta et al, 2004; Dearing, 2005).
Secondary: This level relates to activities for early diagnosis
and early intervention to reduce the duration and severity
of illness.
Tertiary: This level focuses on rehabilitation and coping with
disability or chronic disease (Royle and Walsh, 1993).
Central to targeting health promotion at these levels is an
emphasis on changing peoples behaviour to improve their
health (WHO, 1984; Sadler, 2002). In relation to smoking,
this might be at a primary level, i.e. smoking cessation, or at
a tertiary level through educational work. Implementation
of the NHS Cancer Plan (Department of Health [DH],
2000) has raised public and professional awareness of health
promotion and cancer care. The Plan specifically targets
cancer prevention. This is largely through investment in
smoking cessation campaigns and encouraging people to
eat more fruit and vegetables, reinforcing the view of health
promotion as having a primarily preventive function in
relation to cancer care (Allsop, 1990; Mant, 1992).
Health education
Health education has been described by Tones (1990) as:
Any planned activity which promotes learning
about illness or health so that there is some
relatively permanent change in a persons
knowledge and ideas.
The process is viewed as the strongest single predictor
of health-promoting behaviour (McCleary-Jones, 1996)
and has been highlighted as an essential part of nursing
care by several authors (Latter, 1993; Royle and Walsh,
1993; Wilson-Barnett and Macleod-Clark, 1993). French
(1990) sees health education as not only ensuring that
health information is available to every individual (patient
education), but also involving education of the policy
makers in society, thus placing health firmly on their
agenda. Emphasis is placed on information being given
in a format that enhances the individuals understanding
and consequently enables him/her to adopt behaviour that
promotes a healthier lifestyle (Campbell, 1999).
Smoking cessation strategies
Bladder cancer is a common disease, and smoking has
been identified as the main predisposing factor in its
development. It is possible to alter the course of the disease,
but preventive efforts must focus on avoidance or cessation
of cigarette smoking and on public education about known
environmental risk factors (Pashos et al, 2002; Cancer
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URO-ONCOLOGY NURSING
Box 1. The benefits of smoking cessation
Improved quality and quantity of life for those stopping smoking
Improved quality and quantity of life for those living with smokers, through
a reduction in the harm from passive smoking
Lower healthcare expenditure on treatment of smoking-induced disease
Less workplace absenteeism due to smoking-related disease
Less harm from passive smoking in public places
Reduction in costs related to cleaning up after smokers
Research UK, 2007). In the UK, smoking cessation has
progressed extensively since publication of the Government
White Paper Smoking Kills (DH, 1998). This strategy
has remained firmly on the Governments agenda as an
initiative designed to provide significant health benefits, as
outlined in Box 1.
However, despite the significant benefits afforded by
smoking cessation, ex-smokers accounts of quitting suggest
that the difficulty in quitting is underestimated, and that
even those who are highly motivated to stop smoking find
quitting to be a difficult, if not impossible endeavour (Parry
et al, 2001). It is estimated that about 4 million smokers
a year attempt to quit, but only 36% of these succeed
(Fiore et al, 2000; National Institute for Health and Clinical
Excellence [NICE], 2002).
Nevertheless, some success has been reported. Evidence
suggests that once smokers have acknowledged the risks
of smoking to their health and have weighed the cost
of these against the benefits of stopping, this is usually a
strong enough incentive to kick-start positive action in
extinguishing the habit (Cancer Research, 2007). Success
is also more likely if the individual is motivated, gives up
immediately, goes cold-turkey, has both family and social
support and has made several previous attempts at stopping
(Royle and Walsh, 1993).
The role of educational measures
Smoking bans
Currently, more than a quarter of the people in Britain
smoke, so smoking is clearly a major public issue. The
Government fully recognizes peoples right to choose to
smoke, and while their intention is not to infringe upon
that right, they have a responsibility to highlight the
incurred risks of smoking on peoples health and to initiate
action to secure improvements in lifestyle.
Previous actions were aimed primarily at reducing
preventable deaths, diseases and disabilities, but were also seen
to play a part in reducing healthcare costs, increasing work
productivity and making communities more appealing for
companies to be located in (Smoke Kills: A White Paper on
Tobacco, 1998). There is substantial evidence to demonstrate
the causal relationship between exposure to environmental
tobacco smoke and its health effects on individuals. As a
result, pressure has been brought to bear on employers to
establish restrictive smoking regulations in the workplace.
This strategy has been viewed as a particularly cost-effective
public health measure as it has been shown to lower the
1341
 prevalence of smoking employees, specifically among female
employees (Brenner and Mielck, 1999), and in helping active
smokers to substantially reduce their daily consumption
(Mikanowicz, et al, 1999). Conversely, a significant increase
has been noted in the number of children who commenced
smoking, further reinforcing the need for new government
action (Smoke Kills: A White Paper on Tobacco, 1998).
Action came about in the form of smoking bans,
although previous attempts at enforcing smoking bans
in the UK had been harshly criticized because of the
Governments laxity in enforcing the bans and seemingly
continuing to profit from tax on tobacco products.
Nevertheless, in 2005, bans were subsequently enforced
in Scotland, Wales and Northern Ireland, with further
enforcements within NHS establishments in December
2005. More recently, England followed suit with the no
smoking in public places legislation. Since the 1 July
2007, smoking is prohibited in virtually all enclosed
public places and workplaces in England, and failure to
comply with this law is an offence (NICE, 2007).
Understandably, bans may seem drastic. Many will
question their imposition, possibly viewing them as an
infringement of their freedom of choice (their right to
continue smoking). It is sometimes argued that smoking in
adults is a personal lifestyle choice without victims, hence a
common argument opposing government prohibitions on
public smoking is that they violate the rights of individuals
(Smoke Kills: A White Paper on Tobacco, 1998). On the
other hand, bans could be constructive as there is always
the danger that one persons freedom of choice could
adversely affect anothers health, as in the case of passive
smoking (Royle and Walsh, 1993).
If we accept the findings of medical research, which
proposes that passive smoking is harmful to ones health
(Smoke Kills: A White Paper on Tobacco, 1998), then we
should also accept that the individuals right to smoke
could be countered by anothers lifestyle right to breathe
smokeless air (Royle and Walsh, 1993). It seems justifiable,
therefore, to enforce stringent measures whereby people are
manipulated, coerced, or even forced by legislation, to live
healthier lifestyles (Sadler, 2002).
The role of the nurse as health promoter
Although the role of the nurse as health promoter has been
acknowledged since Florence Nightingales era (Cutler,
1999), for a long time health promotion in the UK was seen
as a role for health visitors, with the emphasis very much
on child health (Royle and Walsh, 1993). Over the years,
the concept of health promotion has evolved to become
the responsibility of all healthcare professionals, both
within healthcare establishments and in the community
(DH, 1989, 1992; NHS Management Executive, 1993), but
the main responsibility remains with nurses to be actively
involved in promoting the health of their clients (Norton,
1998; Sadler, 2002).
Within their area of practice, the authors perceive their
role as health promoter/educator to be an integral part of
the care they provide. With regard to smoking, nurses are
well positioned in all areas of practice to promote a tobacco-
1342
free lifestyle. Providing smokers with educational advice and
outlining the effects of smoking on their health and the benefits
of stopping, in both the short and long term, are seen as a vital
part of encouraging them to stop. This is particularly true of
hospitalized patients (Wallace-Bell, 2003). There is evidence to
suggest that hospital smokers who receive inpatient advice and
follow-up for one month are more likely not to be smoking
after 6 months than patients who receive standard care, which
is: being asked about smoking at every opportunity, being
advised to stop smoking in a personalised and appropriate
manner, having their motivation to change assessed and have
follow-ups arranged if possible (Wallace-Bell, 2003).
The patients rights also have to be considered. Evidence
dictates that in the provision of health advice, healthcare
professionals have a responsibility to respect the individuals
right to choose, in this case their right to continue smoking
despite identifiable risks to their health (Sadler, 2002). As
pointed out by Royle and Walsh (1993), it is difficult, and
even stressful, to change patterns that have been part of
ones life for a long time. Hence, when nurses ask patients
to follow directions they must be sensitive to the impact
that these will have on their lives (Royle and Walsh, 1993).
This is an important factor and one that must be kept at the
forefront of health education.
Factors affecting smoking cessation strategies
There is clear evidence that smoking cessation interventions
are effective (Parrott and Godfrey, 2004); however, as
illustrated below, there are factors that will either impinge on
or promote its success.
Cost implications
The cost of smoking in terms of peoples health is high. Such
costs can include the effects on the individual as well as those
borne by the wider community (Royal College of Physicians
of London, 2007). One of the main costs of tobacco smoking
is the health burden it creates. In the UK, treatment of
illness and disease caused by smoking is estimated to cost the
NHS up to 1.7 billion every year in terms of GP visits,
prescriptions, treatments and operations (DH, 1998; Action
on Smoking and Health (ASH), 1999; Parrott and Godfrey,
2004). In addition, a further 17 million is spent on anti-
smoking education and campaigns.
Other cost implications include:
Loss of quality and quantity of life.
The harmful effects of passive smoke exposure in non-
smokers (a high value could be placed on any premature
loss of life or passive smoking related illnesses).
The cost imposed by smokers on the wider community,
through, for example, the use of scarce health service
resources or by lower productivity in the workplace.
The cost of health service resources in treating various
smoking-related diseases.
Estimated difference in healthcare costs of smokers
compared with non-smokers.
Health resources
There have been many estimates of the economic cost of
smoking in terms of health resources (Parrott and Godfrey,
British Journal of Nursing, 2008, Vol 17, No 21

2004). Significant costs are attributed to treatments for
bladder cancer. These include surgical intervention, e.g.
transurethral resection of bladder tumour (TURBT),
and intravesical instillation of cytotoxic drugs such as
epirubicin and mitomycin (chemotherapy) or Bacillus
Calmette-Gurin (BCG) (immunotherapy). Intravesical
BCG is by far the most widely used treatment, with the
most effective outcomes.
However, although treatment is highly effective, the
delivery of health care in todays economic climate
is determined not only by quality but also by cost-
effectiveness. Currently, the cost of each BCG treatment,
depending on the manufacturer, is in the region of 7080
plus VAT. As treatment is usually given in cycles for up to
3 years, caregivers see this as a costly intervention. Cost
is further highlighted by debate about the efficacy of
treatment if patients continue to smoke. Within our local
trusts, urologists have voiced strong concerns, and many
believe that treatment should be withheld if patients are
unable to stop smoking. This is clearly an emotive topic
which raises both ethical and moral considerations and
highlights the importance of educational measures.
Smoking cessation programmes
In 2002, NICE estimated the cost-effectiveness of smoking
cessation programmes using cessation products, such as
nicotine replacement therapy (NRT) and bupropion, an
antidepressant that was found to have smoking cessation
properties (Brassard, 2007). The means by which the
provision is financed is a crucial determinant of the
effectiveness of smoking cessation products. Evidence shows
that smokers are more likely to take up smoking cessation
interventions if they are provided by their insurance scheme
or health service than if they have to pay for it themselves.
In the UK, NHS provision can reduce costs through bulk
buying and discounts from pharmaceutical manufacturers.
Employers are not obliged to help employees to stop
smoking; however, if they do help them, they could reduce
their risk of non-compliance with the law and achieve
significant improvements in peoples health (NICE, 2007),
and in the long term reduce the number of sick days that
cost organizations a great deal of money. Following the
recent smoking ban in public places in July 2007, as an
incentive to quit smoking, NHS employees in the authors
local hospital were offered the option of obtaining
smoking cessation aids from their pharmacy department
at a reduced cost.
Conclusion
Cancer is acknowledged to be a major killer in modern day
society, and despite advances in our knowledge of cancer and
its causes, prevention remains a significant challenge within
health care (Cutler, 1999). While prevention of bladder
cancer has been an uphill struggle, there have been significant
improvements in management of the disease, specifically
diagnosis and treatments.
Smoking is an addictive behaviour, and as with all
addictions the habit is hard to break. To some extent, success
relies on convincing people to take responsibility for their
British Journal of Nursing, 2008, Vol 17, No 21
URO-ONCOLOGY NURSING
health and, in so doing, encouraging them to adopt healthier
lifestyles. Evidence has shown that health promotion and
health education are effective strategies in achieving this
objective, in combination with support from nurses, who
have a pivotal role in the process.
Nurses must accept that they have a responsibility to
support patients in their efforts to stop smoking, but they also
must accept that pressure on time and increasing workload
will affect their ability to deliver this effectively. However,
since the evidence demonstrates that giving up smoking
leads to improvements in a persons overall wellbeing and
prevents further deterioration in their health (Wallace-
Bell, 2003), nurses further acknowledge their obligation to
support patients in their attempts to stop smoking regardless
of these pressures. (Cantrell, 1992).
Finally, we must accept that changing a persons lifetime
behaviour is highly dependent on the individuals willingness
to participate in this initiative, hence their compliance is
imperative. It is recognized that inhaled nicotine is strongly
addictive (NICE, 2002), and healthcare professionals should
be aware that, despite health education, many individuals will
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KEY POINTS
n In terms of peoples health, the cost of smoking is high. Such costs include
the effects on the individual as well as those borne by the wider community.
n The healthcare professionals role is pivotal in educating people on the
actions they can take to stop smoking.
n Health education is viewed as the strongest single predictor of health-
promoting behaviour.
n Smoking cessation provides significant benefits, but quitting is often a difficult,
if not impossible, endeavour.
1344
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