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 Table of contents

1. Promoting health: a smoking cessation case study...................................................................................... 1

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Document 1 of 1

Promoting health: a smoking cessation case study

Author: Keane, Maeve; Coverdale, Gill

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Abstract: This article describes the health promotion activity that took place between a nursing student and a
male patient to address his expressed wish to stop smoking. Health promotion is defined and the social
influences that affect health are identified. Health promotion and smoking cessation are then discussed within
the context of national and local policy.

Full text: Headnote

Abstract
This article describes the health promotion activity that took place between a nursing student and a male patient
to address his expressed wish to stop smoking. Health promotion is defined and the social influences that affect
health are identified. Health promotion and smoking cessation are then discussed within the context of national
and local policy.
Keywords
Health promotion, policy, smoking cessation, vascular surgery
These keywords are based on subject headings from the British Nursing Index.
GOVERNMENT POLICIES encourage nurses to use every available opportunity to promote patients' health and
wellbeing (Department of Health (DH) 2004, 2010a). All nurses have a role to play in promoting patient health
and wellbeing, regardless of the care setting: it is a key standard in The Code (Nursing and Midwifery Council
(NMC) 2008a) and in Standards for Proficiency for Pre-Registration Nursing Education (NMC 2008b).
According to the Ottowa Charter, health promotion is the process of enabling individuals and communities to
increase control over the determinants of health, thereby improving their overall health (World Health
Organization (WHO) 1986). Health promotion is often used as an umbrella term for all activities intended to
prevent disease, improve health and enhance wellbeing (Naidoo and Wills 2004).
Nurses have a distinct and unique relationship with patients and their families that inspires trust. It is therefore
important that nurses use all opportunities to promote the health of patients and support the process of
behaviour change in those who are at risk of poor health outcomes. The most effective way of improving a
patient's health is to involve him or her in any plans or decision making, thereby empowering the person.
Empowerment involves the possession of skills or competencies that enable individuals to exert control over
their lives, address factors that enhance or inhibit their environment, and increase their self-belief and self-worth
(Tones 1993). Because some patients react negatively to being advised to change their behaviour (Rollnick et
al 1992), it is important to empower them to make the decision to change. An empowered participatory
approach allows patients to articulate the issues that are important to them.
This article discusses the applicability of four health promotion models for a 70-year-old male recovering from
vascular surgery in an acute hospital in the north of England. The Taxonomy of Need (Bradshaw 1972), Health
Belief Model (Becker 1974), Cycle of Change Model (Prochaska and Diclemente 1983) and Health Action
Model, first developed by Tones and Tilford in 1994 and then enhanced by Tones and Green in 2004, were
used to provide a theoretical framework for practice.
The models depict a clear representation of the wide ranging influences on health-related behaviour, such as
the environment, lifestyle, beliefs, values, motivation and pressure on individuals to conform. The models
provide a useful framework for students when developing skills and competence in health promotion. These
models share similarities but also have subtle differences, which makes them more suitable in certain contexts
or settings.

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Case study
Jack is a 70-year-old retired male who lives with his wife in a council house in the north of England. He has
peripheral arterial occlusive disease, arterial hypertension and has smoked one packet of 20 cigarettes a day
for 40 years. Jack was admitted to hospital and underwent a successful femoropopliteal bypass (elective
vascular surgery) to reverse the effects of critical limb ischaemia.
Critical limb ischaemia is a continuation of peripheral arterial occlusive disease caused by atherosclerosis
(Cosmi et al 2001, Murray 2001). It is an acute event that is defined clinically by the presence of more than two
weeks' ischaemic pain at rest, and leg ulcers or gangrene attributable to arterial occlusive disease (Al-Khaffaf
and Dorgan 2005).
Atherosclerosis is a disease of the arteries in which the flow of blood is blocked by fatty deposits (Cosmi et al
2001). Cigarette smoking causes atheroma formation, accelerates the effects of atherosclerosis and enhances
the effects of other risk factors such as diet, hyperlipidaemia and hypertension (Murray 2001). The location of
the artery affected by these pathological events will determine the nature of the disease (Murray 2001).
In Jack's case the lower limb arteries were affected, which is why he experienced lower limb ischaemia. Jack
expressed a wish to give up smoking four days after surgery and asked nursing staff for advice and information
on available support.
Government policy and health promotion
Transnational, national and local policy influences the health promotion strategies undertaken by healthcare
professionals (Piper 2009). The Ottawa Charter (WHO 1986) provided a framework for healthcare practitioners
to empower patients to take control of their health. The four commitments outlined in the Bangkok Charter
(WHO 2005) were to make the promotion of health:
* Central to the global development agenda.
* A core responsibility for all national governments.
* A key focus of communities and civil society.
* A requirement for good corporate practice.
Healthcare policy in the UK - for example, High Quality Care for All (DH 2008) and the Essence of Care 2010
(DH 2010b) - includes a commitment to health promotion by highlighting the importance of empowering patients
to take control of their own health care. The NHS has a responsibility to promote good health as well as treating
illness, and is committed to providing a locally led, patient-centered and clinically driven health service (DH
2008).
Health promotion models
There is no single accepted definition of health promotion (Laverack 2007). The definition that theorists use is
largely dictated by the theoretical model they adhere to (Tones and Green 2004, Laverack 2007). Broadly, there
are five different approaches to health promotion, with medical, behaviour change, educational, social change
and empowerment models (Naidoo and Wills 2004). The medical approach is mainly preventive, characterised
by preventing ill health and premature death. The behaviour change approach encourages individuals to adopt
healthy behaviours. The educational approach provides knowledge and information to the public so they can
make informed decisions about their health choices and behaviours. The social change model acknowledges
the importance of the socioeconomic environment and attempts to address this using a top-down approach.
Finally, the empowerment model aims to enable people to gain control over their own lives (Naidoo and Wills
2004). WHO (2005) defines health promotion as 'the process of enabling people to increase control over their
health and its determinants, and thereby improve their health'. This aligns itself with the empowerment model of
health promotion. Because the WHO (2005) definition is generally accepted as the primary goal of health
promotion (Laverack 2007), this article discusses the empowerment health promotion model.
Smoking cessation strategies
The National Institute for Health and Clinical Excellence (NICE) (2006) recommends that the duty of every

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nurse should be to encourage patients to stop smoking. Rigotti et al (2007) suggested that a hospital admission
presents an opportunity for healthcare professionals to introduce the possibility of smoking cessation to patients
because of the combined effect of restrictions on smoking in hospital and the patient's perceived vulnerability,
making them more likely to accept help. Sharp et al (2008) suggested that hospital admission can be viewed as
a teachable moment, requiring nurses to be active in health promotion by engaging patients in smoking
cessation strategies.
Health promotion strategies should take into account the social determinants of health (Tones and Green 2004).
Smoking rates are highest in lower socioeconomic groups and adults from the most disadvantaged groups are
less likely than those from more advantaged groups to stop smoking (DH 2010c). Jack is categorised as being
in social class V (Table 1), and therefore is at increased risk of smoking (DH 2010c) and of developing
atherosclerosis and vascular disease (Hands et al 2007). This is illustrated by the class gradient in mortality
from cardiovascular disease (Connolly and Nag 2004). However, higher rates of smoking are not the sole cause
of the increased incidence of vascular disease in lower socioeconomic classes. Stress, genetics, diabetes, poor
diet, infection and environmental factors are also implicated in the development of atherosclerosis (Connolly
and Nag 2004, Marieb 2008).
The DH (2010c) recognises that 'smoking kills half of all long-term users and is the biggest single cause of
inequalities in death rates between rich and poor in the UK'. Smoking cessation has been a major focus of
healthcare policy, and in 2004 a commitment was made to reduce smoking prevalence in adults to 21% or less
by 2010 by making smoking in public places illegal (DH 2004). Smoking rates in adults in England have fallen
from 28% to 21% and smoking rates for manual workers have fallen from 31% to 29% between 1998 and 2008
(DH 2010c).
England and Wales became smoke-free in public places on July 1 2007. This had a significant effect on local
NHS smoking cessation services, which noted a 20% increase in demand for their services in the year following
the ban (DH 2008). However, smoking cessation rates remain lower in lower socio-economic groups (NICE
2008). In recognition of this, NICE (2008) recommends that smoking cessation services target manual working
groups, pregnant women and difficult-to-reach communities.
Local health promotion initiatives
The document High Quality Care for All (DH 2008) directly affected local healthcare policy as it dictated that
primary care trusts must commission comprehensive wellbeing and prevention services aimed at their
population's needs. For this to take place, a joint strategic needs assessment must be undertaken (DH 2008).
Reducing smoking rates was one of the health promotion goals, along with addressing childhood obesity,
teenage pregnancy and improving mental and sexual health, outlined in High Quality Care for All (DH 2008).
In the area where Jack lives, 30% of the population smokes (Tomintz et al 2008). The local joint strategic needs
health assessment found a clear link between smoking and deprivation, with the highest rates of smokers (46%)
being found in the most deprived areas of the city (NHS Leeds 2009). In line with national policy, local health
strategies have been focusing on reducing smoking rates in routine and manual occupation groups to 26% by
2010 (DH 2010c) by increasing the capacity of smoking cessation support and developing new services in a
range of settings, such as community healthcare, hospitals and workplaces (NHS Leeds 2009).
It has been suggested that smoking cessation support services are ineffective in promoting the health of
marginalised groups who are disengaged from the community because of their social class (Boyle et al 2006).
This is intensified by a chronic mistrust of national institutions among people from these communities (Boyle et
al 2006). To address this, a local initiative employs health trainers recruited from the local community to support
people making lifestyle changes (NHS Leeds 2009). Jack expressed a wish to meet his local health trainer
when he was discharged from hospital.
Theoretical models of health promotion
Health promotion models provide a useful way of conceptualising health promotion, analysing existing practice

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and planning and charting interventions (Naidoo and Wills 2004). The following theories underpinned the work
carried out with Jack to promote and support his smoking cessation.
Taxonomy ofneed
The first stage of health promotion is to assess what the patient needs to become healthier (Naidoo and Wills
2004). Bradshaw (1972) outlined four different types of health and social need:
* Comparative needs - groups who are in need because they do not have access to adequate services and
resources.
* Normative needs - those defined by experts, but may not be objective facts.
* Felt needs - those defined by the patient.
* Expressed needs - arise from felt needs, but are expressed in words or how patients use a service.
Jack expressed his need to give up smoking by saying: 'I have to give up smoking nurse. I don't want to end up
losing my legs.' According to Asadri-Lari et al (2003), Bradshaw's (1972) model aims to provide a practical
definition of need for healthcare workers but fails to take into account the dichotomy between services needed
and services available.
Although Jack expressed a need to stop smoking, his ability to access smoking cessation services will depend
on availability in his area and liaison between hospital and primary healthcare services. The nursing student
liaised with the medical team at the hospital to get a prescription for nicotine replacement therapy. She also
sourced information on Jack's local smoking cessation service and health trainer to ensure that he would be
supported on discharge.
Health belief model
The health belief model suggests that people's ability to change is influenced by its feasibility and a cost-benefit
analysis (Becker 1974). This includes the person's beliefs about his or her susceptibility to illness or injury, the
severity of the illness and the efficacy of the action (Naidoo and Wills 2004). In accordance with standard
smoking cessation practice, a motivational interview was conducted during Jack's hospital stay to establish his
beliefs about smoking cessation. A motivational interview is a directive patient-centered method of counselling,
designed to help people explore motivations for behaviour change in an attempt to resolve any ambivalence
towards smoking cessation (Lai et al 2010).
Jack expressed a desire to give up smoking because he feared his legs would need to be amputated, which can
be analysed as expressing a belief that the benefits of smoking cessation outweigh the costs. He said he felt
vulnerable and susceptible to the worst outcome of the disease, making him much more willing to address the
problem and determined to change. Understanding Jack's motivations and beliefs about smoking helped
healthcare staff plan how to assist him best with smoking cessation. The health belief model has been criticised
for lacking structure and guidance on predicting specific behaviours (Norman and Conner 1996). However,
Nejad et al (2005) argued that the lack of structure makes the model more effective in predicting a variety of
behaviours, including smoking cessation.
Cycle of change model
Historically, behaviour change was equivalent to taking action and patients were assessed as having changed
when they had quit smoking (Naidoo and Wills 2004). The cycle of change model explains change as a process
that involves progression through a series of changes: pre-contemplation, contemplation, preparation, action,
maintenance and termination (Prochaska 2004). Relapse is also included as a part of the process. It is helpful
for healthcare staff and patients to see behaviour change as a cycle and not to view relapse as a failure, but as
part of the process (Naidoo and Wills 2004). It is important for healthcare professionals to recognise which
stage patients are at so that resources can be targeted effectively (Prochaska 2004).
Jack was considered to be at the preparation stage because he had expressed a wish to give up smoking. Jack
required extra support at this stage to change his behaviour. Patients should be involved in the planning of any
change as research has shown that patients are more likely to stop smoking if they are involved in the change

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process (Naidoo and Wills 2004). Although this model provides a useful tool for evaluating where the patient is
on the cycle of change, it does not provide a strategy for promoting change in health status (Tones and Green
2004). The Health Action Model was used to bridge the gap between evaluating the patient's stage of change
and strategies for action.
Health action model
The health action model is derived from the empowerment theory of health promotion (Tones and Green 2004).
It attempts to provide a framework for the major variables influencing health choice and action, which are the
patient's beliefs and attitudes, motives for changing health behaviours and social and environmental pressures.
This model consists of two components. The first component is the individual's behavioural intention, which
comprises an interaction between three separate areas: cognitive, normative and affective systems; what the
patient thinks and has knowledge of; and what the norm is for him or her and his or her peer group. The
decision to act is influenced by a cluster of beliefs, motives and social pressures (Tones and Green 2004).
Jack's decision to give up smoking may therefore be influenced by his belief that giving up smoking will be
beneficial to his health, the motivation not to have his leg amputated as a result of worsening critical limb
ischemia and the social pressure of his family and friends persuading him to give up smoking.
The second component relates to the contributory factors that determine whether or not an intention is
implemented in practice (Tones and Green 2004). This is intended as a strategy to provide post-decisional
support. The health action model (Tones and Green 2004) conceives the development of self-concept and self-
esteem as essential factors in an individual's motivation to change a health-related behaviour. As an
empowerment model of health promotion it suggests that health promotion should promote empowerment of
individuals and communities and assist removal of barriers to the attainment of good health (Tones and Green
2004). This includes supporting people to develop knowledge, social interaction, psychomotor skills and
creating a supportive environment (Tones and Green 2004).
According to this model, an effective health promotion strategy may be difficult to achieve on an acute surgical
ward. With this in mind, the nursing student liaised with Jack's GP and local smoking cessation services to
ensure he would be supported adequately in the community and ensure his success in quitting smoking. Jack
suggested that a barrier to him giving up smoking was that his wife also smoked, therefore smoking cessation
advice was also given to her.
In keeping with the health action model, it has been possible to increase Jack's knowledge and understanding
of the effects of smoking on vascular disease by giving him up-to-date advice and information via health
education literature. However, whether health education could bring about behaviour change through
information or persuasion alone has been contested (Naidoo and Wills 2004). Tones and Green (2004)
advocated using health education in conjunction with empowerment and patient choice.
It is widely accepted that cigarette smoking is a manifestation of nicotine addiction (The Leeds Initiative 2006). It
is therefore important that any health promotion activity associated with smoking cessation addresses this
addiction. This fits in with the concept of creating a supportive environment, which is part of the health action
model (Tones and Green 2004). The nursing student liaised with the medical team to ensure Jack was
prescribed medication to support him to manage his addiction. He was offered a choice of nicotine replacement
therapy or varenicline, a nicotinic receptor partial agonist that reduces the cravings and the pleasurable effects
of nicotine (British National Formulary 2011). However, after receiving information on both options, Jack
decided to use nicotine replacement therapy in the form of patches. According to the empowerment model, it is
important to give patients choices (Tones and Green 2004).
Evaluation
Although Jack's hospital admission provided the opportunity to offer smoking cessation advice, it is difficult to
evaluate the effectiveness of this health promotion activity. Government policy considers a patient to have quit
smoking if he or she has not smoked for four weeks (DH 2010b). On an acute surgical ward with a high turnover

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of patients this is difficult to assess. However, in the cycle of change model, behaviour change is viewed as a
process that involves progression through a series of changes (Prochaska 2004).
In this case study the patient's expressed need was listened to and Jack was supported through the initial stage
of the cycle of change model (Prochaska and DiClemente 1983) using health education, multidisciplinary
working, nicotine replacement therapy and referral to the appropriate agencies that would support and empower
Jack to change his behaviour. On discharge, the patient felt positive about giving up smoking.
Conclusion
This article has demonstrated how a patient's health needs can be addressed and met using an empowerment
model of health promotion. National policy has made smoking cessation a health priority, which has improved
the resources available, especially for those in economically deprived areas. It has not been possible to carry
out an evaluation of the effect of this health promotion activity. However, as change is an ongoing process this
activity has attempted to support and assist the patient in his preparation to stop smoking
Sidebar
Keane M, Coverdale G (2011) Promoting health: a smoking cessation case study. Nursing Standard. 26, 4, 35-
40. Date of acceptance: June 21 2011.
Review
All articles are subject to external double-blind peer review and checked for plagiarism using automated
software.
Online
Guidelines on writing for publication are available at www.nursing-standard.co.uk. For related articles visit the
archive and search using the keywords above.
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AuthorAffiliation
Authors
Maeve Keane
Nursing student, University of Leeds.
Gill Coverdale
Lecturer in public health and primary care, University of Leeds.
Correspondence to: g.e.coverdale@leeds.ac.uk

MeSH: Aged, England, Health Policy, Health Promotion -- organization & administration, Humans, Male,
Models, Theoretical, Smoking Cessation -- psychology, Health Promotion -- methods (major), Smoking
Cessation -- methods (major), Vascular Surgical Procedures -- rehabilitation (major)

Publication title: Nursing Standard

Volume: 26

Issue: 4

Pages: 35-40

Number of pages: 6

Publication year: 2011

Publication date: Sep 28-Oct 4, 2011

Year: 2011

Section: Art & science

Publisher: RCNi

Place of publication: Harrow-on-the-Hill

Country of publication: United Kingdom

Publication subject: Medical Sciences--Nurses And Nursing

ISSN: 00296570

CODEN: NSTAEU

Source type: Scholarly Journals

Language of publication: English

Document type: General Information, Journal Article

Accession number: 22013830

ProQuest document ID: 896272551

Document URL: http://search.proquest.com/docview/896272551?accountid=170128

Copyright: Copyright RCN Publishing Company Sep 28-Oct 4, 2011

Last updated: 2015-09-12

Database: ProQuest Public Health

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