A game-changer: The smoking cessation prescription

This review synthesises existing evidence regarding the effects of smoking cessation on GU malignancies, emphasising its benefits in reducing cancer recurrence, improving treatment efficacy, and enhancing overall patient quality of life (QoL). Globally, smoking remains a leading cause of preventable illness and mortality, with well-known links to cardiovascular, pulmonary, and oncological diseases. The role of smoking in genitourinary malignancies, particularly bladder and kidney cancers, as well as its impact on prostate cancer (PCa) outcomes, is significant. According to the National Cancer Institute, tobacco use is associated with increased incidence and mortality rates for several types of cancer, including bladder and kidney cancers.

Bladder cancer
Smoking is the predominant risk factor for bladder cancer (BCa), accounting for approximately 50% of cases in men and 35% in women. Tobacco-derived carcinogens, such as aromatic amines and polycyclic aromatic hydrocarbons, are metabolised in the liver and excreted via urine, exposing the bladder’s urothelium to mutagenic compounds. Chronic exposure results in DNA damage and carcinogenesis. Epidemiological studies consistently demonstrate that smokers are at signifi cantly higher risk of developing BCa compared to non-smokers. Smoking cessation has been shown to reduce the risk of developing various tobacco-related malignancies and to improve survival outcomes in cancer patients. Evidence suggests that quitting smoking after a BCa diagnosis signifi cantly decreases the likelihood of recurrence.

Patients who ceased smoking after diagnosis exhibited a lower risk of recurrence compared to those who continued smoking. Meta-analyses have revealed that former smokers have a 40% reduced risk of BCa compared to current smokers, though their risk remains higher than that of never-smokers. Risk reduction becomes particularly pronounced 10–15 years after cessation. Furthermore, smoking cessation has been associated with improved outcomes in patients with non-muscle-invasive bladder cancer (NMIBC), including reduced recurrence and progression rates. Post-diagnosis cessation has also been linked to improved survival in BCa patients.

Kidney cancer
Similarly, smoking is a well-documented risk factor for renal cell carcinoma (RCC). Tobacco carcinogens induce oxidative stress, inflammation, and DNA damage in renal tissue, with risk correlating to smoking intensity. Heavy smokers face significantly higher risks of RCC compared to non-smokers.

Quitting smoking after an RCC diagnosis has been associated with a 50% reduction in mortality risk and a 56% reduction in disease progression risk. Long-term cessation, exceeding two decades, brings former smokers closer to the risk profile of never-smokers. Additionally, smoking cessation enhances treatment outcomes, as smokers generally respond poorly to systemic therapies, including targeted treatments and immune checkpoint inhibitors. By mitigating these adverse effects, cessation improves survival rates.

Prostate cancer
The relationship between smoking and PCa is more complex. While smoking is not a primary risk factor for PCa incidence, it is associated with more aggressive disease, advanced-stage diagnoses, and higher mortality rates. Quitting smoking has been linked to reduced mortality in PCa patients, with former smokers experiencing lower PCa-specific and all-cause mortality compared to current smokers. Risk normalisation occurs approximately 10 years after cessation. The benefi ts are likely mediated through mechanisms such as reduced systemic inflammation, restoration of immune function, and enhanced treatment effi cacy, including improved responses to radiation therapy.

Better outcomes
Patients who cease smoking report better QoL metrics, encompassing both physical health and emotional well-being. The benefi ts associated with smoking cessation can be attributed to several biological mechanisms, including the reduction of carcinogenic exposure, restoration of immune function, reduction of chronic infl ammation, and improved tissue healing and recovery. Quitting smoking reduces exposure to tobacco-related carcinogens that contribute to tumour growth and metastasis. Additionally, cessation improves immune surveillance, decreases infl ammatory markers, and enhances tissue oxygenation, all of which support better outcomes in cancer patients.

Who can help?
Healthcare providers, particularly urologists, play a pivotal role in encouraging smoking cessation among patients diagnosed with GU malignancies. Smoking status should be routinely assessed, and cessation support should be integrated into cancer care pathways. This may include pharmacological interventions such as nicotine replacement therapy or varenicline, as well as behavioural therapies like counselling. Tailored cessation programmes that address individual patient needs, coupled with continuous follow-up support, have proven effective in maintaining cessation efforts.

Conclusion
Smoking cessation markedly reduces the risk and improves outcomes for genitourinary malignancies. While early cessation provides the greatest benefits, quitting smoking even after a cancer diagnosis enhances survival and QoL. Integrating smoking cessation into public health initiatives and oncology care practices is essential for mitigating the impact of GU cancers and improving patient outcomes.

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At EAU25, Prof. Roman Sosnowski will present the lecture “The role of the urologists in guiding patients in lifestyle changes” on Monday 24 March, 10:45 – 12:15, Green Area, Room 4.