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Patients must be told of links between smoking and eye disease
The links have been recognized for at least a decade, but ophthalmologists may not be communicating the risks to patients.
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Hugh R. Taylor, AC, MD, participated in some of the earliest research associating cigarette smoking with eye disease while on the faculty at Johns Hopkins University. His epidemiological work continues in his current posts at the Centre for Eye Research Australia at the University of Melbourne.
Prof. Taylor’s research interests include public health issues such as river blindness, trachoma and prevention of blindness, for which he is an international authority. Current studies include genetic and clinical studies on age-related macular degeneration, glaucoma and myopia, and issues relating to aboriginal eye health.
He is the regional chairman for the International Agency for the Prevention of Blindness in the Western Pacific, deputy co-chair of Vision 2020: The Right to Sight Australia, and a managing director of the World Health Organization Collaborating Centre for the Prevention of Blindness. In an interview with Ocular Surgery News, Prof. Taylor described the need for ophthalmologists to communicate to their patients that smoking is related to eye disease.
Ocular Surgery News: Tell us about some of the early epidemiological work that linked smoking and eye disease.
Hugh R. Taylor, AC, MD: The first study we did was a preliminary study to the Chesapeake Bay Waterman Study back in the 1980s. The Waterman Study, which I participated in with Sheila West and others, has become sort of a classic in ophthalmic epidemiology. The initial idea was that we would look at a group of coal miners and a group of watermen. The watermen had a lot of exposure to ultraviolet light, while the coal miners in western Virginia had almost none. One of the things we documented was how much aspirin they took, and another was how much they smoked, just for comparison of the two groups.
We were quite shocked to find, totally unexpectedly, a strong association between smoking and cataract. At first we thought, “This is just a mistake.” So in the later formal Waterman study we included cigarette smoking as a measure, and this hadn’t been included in previous eye studies.
When we analyzed the data, we found there was a strong association between cigarette smoking and nuclear sclerosis — not the other types of cataract — and also an association between smoking and macular degeneration. Within about a year, there were three other studies that also found an association between nuclear sclerosis and cigarette smoking. There was a little study in the United Kingdom, some work from the Beaver Dam study and a couple of epidemiological risk factor studies.
And the subsequent work, particularly the big epidemiologic studies like the Melbourne Visual Impairment Project, which we have done here in Melbourne, the Blue Mountains Eye Study, which Paul Mitchell has done also in Australia, the Beaver Dam Eye Study by Ron and Barbara Klein in Wisconsin, and the Rotterdam Eye Study, which Paulus de Jong has done, all quite clearly and consistently have shown another strong linkage, between cigarette smoking and macular degeneration.
People who smoke have three times the risk of developing macular degeneration, and once they develop it, if they keep smoking they have three times the risk of losing vision from it. And probably up to about a third of all macular degeneration can be attributed to cigarette smoking.
OSN: Would you say that the link between smoking and macular degeneration is assured?
Prof. Taylor: I don’t have any doubt in my mind at all. It has been shown very consistently in a number of different studies in a number of different ways. The same is true for nuclear sclerosis as well.
In both of these conditions, there is a sort of dose response, with people who smoke more having more risk and those who smoke longer having more risk. With stopping smoking, the risk decreases. This has been shown in multiple studies in different populations in different parts of the world. They are quite consistent data.
OSN: Do you think the link between smoking and these eye diseases is well understood by ophthalmologists in general?
Prof. Taylor: No. I do not think it is well understood at all. It’s in the scientific literature. But I am sure that if you took a random poll of ophthalmologists, most of them would not be aware of it.
And I would bet that most ophthalmologists would not make it automatic to ask a patient with macular degeneration or early macular degeneration if they are a cigarette smoker. Because if they are, they really need to counsel them very seriously to stop because otherwise the risk of going blind is increased greatly.
I think this is a very important message to get out.
OSN: What can governments do to increase awareness of the link?
Prof. Taylor: In Australia, the government is being very strong in leading antismoking campaigns and quit-smoking campaigns, with lots of TV ads and things like that. About 4 years ago, we talked the government into making TV commercials highlighting the link between macular degeneration and cigarette smoking. There is a new lot of labeling coming out on the cigarette packs in Australia, and one of the messages will include a warning about the link between smoking and eye disease.
OSN: Smoking is decreasing in industrialized societies and increasing in the developing world. What effect could that have on eye disease and ophthalmology?
Prof. Taylor: There are three large demographic changes happening. The most important is the aging of the world’s population. The number of people over the age of 55 years in the developing countries is going to double in the next 20 years. So there is going to be a huge increase in the number of older people. And with that there is going to be a huge increase in the number of diseases that we see in older people. For ophthalmologists, most of our work is in older people. If you think about macular degeneration, cataract, glaucoma, it’s all in older people. So the volume of that work is going to double in the next 20 years. And it is going to be a huge problem both in the developed countries and the developing countries. That’s the first thing.
The second big change is the explosion in the amount of diabetes. You see this now in the urban areas of India and China, and even in Africa. There are terrible problems with starvation in many parts of Africa still and parts of India too for that matter. But in the cities there is a growing middle class that is relatively affluent, well-fed and inactive. They do not get any exercise, they put on plenty of calories, and they are getting the same sort of obesity that we are seeing in our cities and our populations in Australia, the United States and the rest of the developed world. Rates of diabetes are just going through the roof. They estimate that there will be 80 million people with diabetes in China, for example, in 20 years.
The third area, which you were alluding to in your question, is the cigarette smoking. When you go to countries like China, Vietnam, Indonesia, everyone is smoking. The tobacco companies are diverting their sales and production into those countries. For every pack they don’t sell in Philadelphia or Melbourne, they sell two or three in Beijing or Ho Chi Minh City. So these populations will have an even higher risk of cataract and macular degeneration.
And at the same time these countries are still struggling to set up their cataract surgery programs. They have almost no one who is properly trained or equipped to treat people with glaucoma, do a retinal exam or treat diabetic retinopathy, let alone do a retinal detachment surgery. And they are light-years away from being able to do photodynamic therapy or any treatment for macular degeneration.
OSN: What needs to be done regarding smoking and eye disease?
Prof. Taylor: We need to get the message about the severe impact that cigarette smoking has on vision out to the general public and particularly the smokers. There are some people who will say “I am not going to smoke because of the risk of getting lung cancer,” or “I am not going to smoke because of the risk of getting heart disease or stroke.” But there are other people who will think, “I just can’t imagine losing my vision. I am not going to smoke because of that.”
The more messages and information are put out there, the more likely one or other of those messages is going to help people give up smoking. The other thing is that we, as ophthalmologists, have a particular opportunity with our patients to drive that message home. If you see someone with early macular degeneration and you do not drive the message home to stop smoking, you are almost not treating that patient properly.
The thing is that nicotine is one of the most addictive drugs we know. It takes only 10 cigarettes to addict about a third of the population. The tobacco companies, for 40 years or 50 years, have aimed to get every teenager to smoke at least 10 cigarettes. That way they will pull in that one-third cohort that has addictive tendencies. There is nothing that is more common to be addicted to. We as a society either wittingly or unwittingly still encourage our kids to smoke. That’s a tragedy. The problem is exposing new people to cigarette smoking.
The damage is thought to come from the toxic products that are absorbed by the blood stream. It’s not that “smoke gets in your eyes.” It is the oxidizing effect of the huge variety of chemicals, a direct damaging effect of the blood-borne components of cigarette smoke.
The message we need to get out to ophthalmologists is the need to counsel their patients about cigarette smoking. We as ophthalmologists have not seen that as something important for us to do, other than as a general good thing that any health professional should do.
But specifically we need to address our patients with early macular degeneration. We know the vitamin supplement used in the Age-Related Eye Disease Study reduces the risk in high-risk people by about 20%. But continuing to smoke increases the risk by 300%. That is a huge impact compared to the small effect of anything else we can do.
It is nonsensical to put someone on vitamins to give them a 20% risk reduction but let them keep smoking and give them a 300% increased risk.
For Your Information:References:
- Hugh R. Taylor, AC, MD, a professor and the head of the department of ophthalmology and the managing director of the Centre for Eye Research Australia at the University of Melbourne, can be reached at the Royal Victorian Eye and Ear Hospital, Ophthalmology, 32 Gisborne St., East Melbourne VI 3002 Australia; 61-3-9929-8368; fax: 61-3-9662-3895; e-mail: h.taylor@unimelb.edu.au.
- Mukesh BN, Dimitrov PN, et al. Five-year incidence of age-related maculopathy: The Visual Impairment Project. Ophthalmology. 2004;1176-1182.
- Smith W, Mitchell P, Seeder SR. Smoking and age-related maculopathy. Arch Ophthalmol. 1996;114:1518-1523.
- Taylor HR, West SK, et al. Effect of ultraviolet radiation on cataract formation. N Engl J Med. 1988;319(22):1429-1433.
- Michael Piechocki is an OSN Staff Writer who covers ophthalmology in Europe and the Asia-Pacific region. He also specializes in oculoplastics.