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Talk to patients about smoking’s negative effects
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Most people understand the negative effects smoking can have on the heart and lungs, but when it comes to the eyes, many patients are blind to the sight-changing consequences of the highly addictive habit.
“The optometrist should advise patients that smoking is bad for their eyes, as well as bad for their general health, and should assist them with getting access to smoking cessation services,” said Simon P. Kelly, FRCSEd, FRCOphth, FEBO, a consultant ophthalmic surgeon at Bolton Eye Unit in England. Dr. Kelly and his colleagues have conducted several recent studies on the subject and have made it their mission to create a public relations campaign to get the word out.
“We have evidence that most people don’t know that smoking is associated with blindness and macular degeneration,” Dr. Kelly told Primary Care Optometry News in an interview. “When people are provided with this information, they’re sufficiently shocked, and it becomes a compelling reason to quit.”
Dr. Kelly said he and his colleagues surveyed hundreds of optometrists to ask whether they counseled patients to quit smoking. The results were discouraging.
“Very few optometrists who responded to the survey said that they do anything about smoking advice in relation to their patients,” he said. “Some optometrists may say that it’s not their job, it’s not their duty to do this. However, nearly every health care professional, doctor, nurse or therapist does have a duty to help people improve their health.”
Dr. Kelly said he feels that optometrists in the United States may be taking a similar road.
Damaging vision
Smoking tobacco has been proven to have a causal and acceleratory link to both age-related macular degeneration and cataracts, the two leading causes of blindness. Retinal ischemia, anterior ischemic optic neuropathy and thyroid eye disease are three other ocular disorders linked to the habit. A study in Survey of Ophthalmology said Graves’ disease patients with eye involvement who smoke also may be at risk for vision loss.
Image: © Commonwealth of Australia |
Randall Thomas, OD, MPH, FAAO, a PCON Editorial Board member who practices in Concord, N.C., referred to an article on pars planitis, or intermediate uveitis. “In that study, just over 50% of people with pars planitis were smokers,” he told PCON. “That was the first link of smoking to uveitis.
“Beyond that, we do know that smoking has a negative influence on the entire cardiovascular system, and there are diseases of the eye such as diabetic retinopathy, anterior ischemic optic neuropathy and other general vascular conditions for which smoking may play a decretory role,” he continued
Dr. Thomas added that smoking also is another independent risk factor for corneal complications in contact lens wearers.
J. James Thimons, OD, another PCON Editorial Board member and director of Ophthalmic Consultants of Conneticut, said the chemicals in tobacco smoke have a negative effect on the ocular surface, and a link may someday be found to glaucoma, as well.
“There is no question in my mind that nicotinic acid and, maybe more importantly, the role of smoke itself can increase ocular surface dysfunction,” Dr. Thimons told PCON in an interview. “The other connection, albeit less clear, is the one that is related to glaucoma. It has been suggested.
“Nobody has found a link yet, but given the fact that nicotinic acid produces vasoactive events relative to the retina as well toxicity, the thought has been that the same vasoactive event affects the patient in glaucoma.”
Smoking also causes significant lipid layer changes, resulting in dry eye, according to a 2003 prospective study presented at an American Society of Cataract and Refractive Surgery annual meeting.
Counsel patients
The risks of smoking have been established. How then do practitioners go about counseling patients to quit?
“Research has shown that a strong message from the person’s doctor is the most important factor in successful quitting,” Nicky R. Holdeman OD, MD, associate dean for clinical education at the University of Houston College of Optometry, told PCON. “A few words from someone a patient likes and respects can go a long way. Patients also would look at their optometrists favorably in that they’re not just concentrating on the eyes, but being a little more involved and concerned about their overall health.”
Dr. Thimons agreed. “I am 100% behind the idea that the ophthalmic clinician, the community-based eye care practitioner, has a responsibility to identify patients who are at risk and to recommend — at whatever level they are comfortable with — behavior modification.”
Taking the time to counsel patients to quit is important, Dr. Thomas said.
“I explain to them that [smoking] is the single most damaging thing you can do to your body, and then I sincerely, encourage them to try to stop.”
Cessation devices
Telling a patient they need to quit is the first step; recommending a cessation regimen is the next, the doctors agreed.
Dr. Thomas writes “Chantix” (varenicline, Pfizer) on the back of his business card and gives it to his patients. He then tells them to talk to their primary care provider about getting a prescription for the drug.
“I try to give them hope,” he said. “It sets the stage for the primary care physician and the patient to have a meaningful conversation about stopping.”
Dr. Holdeman said he will correspond with the patient’s primary care physician if he encounters a patient who smokes who is developing AMD – but he also encourages the patient to stop
“If you look at what constitutes a successful program, that’s really the first step – face-to-face advice and suggestions regarding smoking cessation and then being there for reinforcement,” he said. “Know where the patient may get some self-help materials, be aware of community programs and know what drug therapies are available.”
Dr. Thimons shows patients their fundus photos, as well as recommends a smoking cessation clinic run by his local hospital. “Quite frankly, in my experience, without that more formal recommendation, not a whole lot gets done,” he said. “I also tell them that I am going to write a letter to their physician letting them know what we found today so there’s a second person in the game.”
Efforts in the U.K., Australia
For their part, the researchers in the United Kingdom have adopted the slogan, “Smoking causes blindness” for their public health campaign.
“The ocular information may be a novel health promotional tool to raise the public awareness,” Dr. Kelly said. “We would like to see an advertising campaign highlighting this, and we’d like to see this message on cigarette packages.”
So far, along with the Royal National Institute of Blind people, they have taken the message to the European Union in Brussels. The paper titled “Towards a smoke-free Europe” – with the message that the EU recognizes that smoking causes macular degeneration and that public awareness needs to be raised – passed in the European Parliament, which means individual countries now could put such warnings on tobacco products if they wished once this has been developed further by the European Commission. Australia adopted a similar measure, and those warning labels began appearing in 2006.
Efforts in the U.S.
Joel London, MPH, CHES, spokesman for the CDC’s Office on Smoking and Health, acknowledged that the effects of smoking on the eye were not addressed in the last Surgeon General’s message on the topic, which was published in 2006.
Another report is starting to make the rounds and now is under the purview of the senior scientific editor there, he said. “Folks here at the CDC are aware of the latest literature,” Mr. London said, adding that “it is being considered for inclusion” in the next Surgeon General’s report.
For more information:
- Simon P. Kelly, FRCSEd, FRCOphth, FEBO, can be reached at +(44) 01204 390694; fax: +(44) 1204 390554; Web site: www.dr-kelly.eyemd.org.
- Randall Thomas, OD, MPH, FAAO, can be reached at 6017 Havencrest Court, Concord, NC 28027; fax: (704) 792-1647; e-mail: thomasepec@carolina.rr.com.
- J. James Thimons, OD, can be reached at Ophthalmic Consultants of Connecticut, 75 Kings Highway Cutoff, Fairfield, CT 06430; (203) 257-7336; fax: (203) 330-4958; e-mail: jthimons@sbcglobal.net.
- Nicky R. Holdeman OD, MD, can be reached at 505 J. Davis Armistead Bldg., Houston, TX 77204-2020; (713) 743-1886; fax: (713) 743-0965; e-mail: nrholdeman@uh.edu.
- Joel London can be reached at the Centers for Disease Control and Prevention, 4770 Buford Highway, N.E., Mailstop K-50, Atlanta, GA 30341; (770) 488-5493.
References
- U.S. Department of Health and Human Services. The Health Consequences of Smoking: A Report of the Surgeon General. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2004. Available from: http://www.cdc.gov/tobacco/data_statistics/sgr/sgr_2004/index.htm.
- Solberg Y, Rosner M, Belkin M. The association between cigarette smoking and ocular diseases. Surv Ophthalmol. 1998;42(6):535-547.
- Altinors D, Akça S, Akova Y, et al. Smoking associated with damage to the lipid layer of the ocular surface.
- Am J Ophthalmol. 2006;141(6):1016.
- Seddon JM, George S, Rosner B. Cigarette smoking, fish consumption, omega-3 fatty acid intake, and associations with age-related macular degeneration. Arch Ophthalmol. 2006;124:995-1001.
- Klein R, Knudtson M, Cruickshanks K, Klein B. The Beaver Dam Eye Study. Further observations on the association between smoking and the long-term incidence and progression of age-related macular degeneration. Arch Ophthalmol. 2008;126(1):115-121.
- The American Cancer Society offers smoking cessation classes. Call (800) ACS-2345 or visit www.cancer.org.