February 2015
Volume 56, Issue 2
Perspective  |   February 2015
Smoking Causes Blindness: Time for Eye Care Professionals to Join the Fight Against Tobacco
Author Affiliations & Notes
  • Tahgrid Asfar
    Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, Florida, United States
  • Byron L. Lam
    Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, Florida, United States
  • David J. Lee
    Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, Florida, United States
    Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, Florida, United States
  • Correspondence: Taghrid Asfar, Department of Public Health Sciences, Miami Miller School of Medicine, Clinical Research Building, 1120 NW 14th Street, Room #931, Miami, FL 33136, USA; tasfar@med.miami.edu
Investigative Ophthalmology & Visual Science February 2015, Vol.56, 1120-1121. doi:10.1167/iovs.15-16479
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      Tahgrid Asfar, Byron L. Lam, David J. Lee; Smoking Causes Blindness: Time for Eye Care Professionals to Join the Fight Against Tobacco. Invest. Ophthalmol. Vis. Sci. 2015;56(2):1120-1121. doi: 10.1167/iovs.15-16479.

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      © ARVO (1962-2015); The Authors (2016-present)

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Sight is an important indicator of health and quality of life. Approximately, 3.4 million Americans 40 years of age and older are visually impaired or blind. Evidence suggests that smoking increases the risk of the most common sight-threatening conditions of eye disease. Half a century after the release of the 1964 landmark Surgeon General's report on smoking and health, tobacco smoking continues to be the leading public health problem in the United States, and nearly half a million adults annually die prematurely from smoking-related diseases. On the historic occasion of the 50th anniversary of the 1964 report, the 2014 Surgeon General's report is devoted to smoking and health. This report provides new evidence about the link between cigarette smoking and eye disease, which signifies a new role for eye-care professionals in tobacco control on two levels. First, on a clinical level, eye care professionals should integrate smoking cessation treatment in the standard care of patients' management in eye-care settings in order to motivate and help smoking patients in quitting smoking. Second, on a political level, eye care providers can serve as powerful public advocates against tobacco use, thereby significantly enhancing public awareness about the link between smoking and eye disease.

While epidemiologic investigations into smoking as a risk factor for eye disease began in earnest in the 1970s, the first inclusion of smoking-associated eye conditions in Surgeon General's report on smoking and health did not occur until 2004.1 This report confirmed the causal relationship between smoking and developing cataract. Although visual impairment due to cataract can be treated surgically, the enormous number of cataract surgeries places heavy demands on the US healthcare system. In the latest 2014 Surgeon General report, new evidence about the causal relationship between cigarette smoking and AMD was confirmed.1 Age-related macular degeneration is a leading cause of blindness and causes irreversible loss of central vision. Beyond this, other conditions such as Graves' ophthalmopathy, diabetic retinopathy, dry-eye syndrome, and contact lens–related keratitis are other possible smoking-related ocular morbidities.2 Because strong evidence now exists indicating that smoking is a major risk factor for common sight-threatening conditions, the 2014 report calls on all ophthalmologists, optometrists, and other eye-heath care providers to assess and address the smoking status of their patients. 
Fear of blindness was found to be just as compelling a motivation for smoking cessation as fear of lung cancer, heart disease, and stroke.3 Acknowledging this fear as part of a teachable moment can serve as a powerful motivation for eye patients to quit smoking. Therefore, eye care professionals have a unique opportunity to play a key role in motivating their patients to quit smoking. Evidence indicates that brief advice from healthcare providers on smoking cessation based on the 5 A's model (Ask about smoking, Advise them to quit, Assess willingness to quit, Assist with quitting, and Arrange for follow-up) increases the odds of quitting by 30%.1 Many diabetes, cardiac, and respiratory clinics now incorporate smoking cessation support into their services, and the benefits of ophthalmology services that follow those examples are enormous and clear. 
At present, only one study about smoking cessation practices among eye care providers in the United States has been reported.4 Conducted in 2002, the results showed that 71% of ophthalmologists and 38% of optometrists ask patients about tobacco use. Among these doctors, only 30% of ophthalmologists and 16% of optometrists regularly advise patients to quit smoking.4 Because of this limited information, new studies to investigate and promote changes in eye care professionals practices related to smoking cessation are highly needed. 
The same study reported several challenges involved in implementing smoking-cessation services in eye-care settings. The main challenges were a lack of time and training in smoking cessation for eye care providers.4 Steps to reduce these barriers should be prioritized in light of new evidence about the serious consequences of smoking on vision. These can include developing and testing brief smoking cessation approaches that can be incorporated into busy eye-clinic settings, providing training in smoking cessation counseling, as well as providing resources and materials needed to help eye care practitioners effectively support their patients in quitting smoking. In addition, incorporating smoking cessation training in the ophthalmology curriculums has the potential to build doctors' competency in addressing their patients' smoking behavior. Finally, more research is needed to develop, implement, and evaluate systems-level strategies to maximize tobacco control in eye-care clinical settings. 
Because primary smoking prevention is perhaps even more important than treatment, eye care professionals are also encouraged to advocate against tobacco use. Unfortunately, despite the strong evidence about the link between smoking and blindness, there is a lack of awareness of this link among the public. A recent study investigating awareness of blindness as a smoking-related condition in the United States indicated that 76% of the population believed that there is no association between smoking and blindness, 14% were unsure, and only 9% believed that there is an association.5 Evidence suggests that smokers are more motivated to quit smoking if they believe that their disease is related to smoking.6 Therefore, increasing public awareness about the link between smoking and eye disease could significantly impact smoking behavior and consequently reduce loss of vision in the United States. 
A potential way to increase public awareness of the risk of smoking on eye diseases is to add graphic health warning labels about smoking-related eye conditions on cigarettes packets. A global survey about public awareness of the risk of smoking on the eye found that among the 14 countries surveyed, Australia had the highest level of awareness (77%) of blindness as a smoking-related disease.5 This was due to its antismoking campaigns that was launched in 2006 and included a ‘Smoking Causes Blindness' graphic warning on cigarette packs. A more recent antismoking campaign launched by the State Health Department of New York in 2009 used TV, radio, and internet to increase the public awareness about smoking and eye diseases (in the public domain, http://www.health.ny.gov/press/releases/2009/2009-12-30_tobacco_ads.htm). As a result of this campaign, total calls made to the state tobacco quit line increased significantly during the campaign period (from 3.9%–9.0%). However, it decreased after the campaign ended (from 9.0%–4.5%). Therefore, launching a long-term, sustained national mass media campaign in the United States to increase the public awareness about the link between smoking and eye disease is an important next step. 
In addition, a study among youth in United Kingdom found that fear of blindness was a stronger motivating factor in quitting smoking than fear of lung cancer, heart diseases, and deafness.7 Therefore, integrating the message of “Smoking Causes Blindness” in upcoming mass media campaigns and health education in the future may effectively reduce smoking uptake among youth as well. 
Tobacco use is an important modifiable risk factor for several serious eye conditions that can lead to blindness. As with other specialties that encounter most of tobacco use morbidities and mortalities (e.g., cardiologists, respiratory specialists), eye care practitioners are encouraged to take a key role in both motivating and helping their patients to become tobacco-free, and raising public awareness about the link between smoking and blindness. 
Supported by grants from the Centers for Disease Control and Prevention (CDC) U58DP002652 (Atlanta, GA, USA). 
Disclosure: T. Asfar, None; B.L. Lam, None; D.J. Lee, None 
Services USDoHH. Surgeon General's Reports 2014. Available at: http://www.surgeongeneral.gov/initiatives/tobacco/. Accessed September 22, 2014.
Galor A Lee DJ. Effects of smoking on ocular health. Curr Opin Ophthalmol. 2011; 22: 477.
Bidwell G Sahu A Edwards R Harrison R Thornton J Kelly S. Perceptions of blindness related to smoking: a hospital-based cross-sectional study. Eye. 2005; 19: 945–948.
Gordon J Andrews J Lichtenstein E Severson H Akers L Williams C. Ophthalmologists' and optometrists' attitudes and behaviours regarding tobacco cessation intervention. Tob Control. 2002; 11: 84–85.
Kennedy RD Spafford MM Schultz AS Iley MD Zawada V. Smoking cessation referrals in optometric practice: a Canadian pilot study. Optom Vis Sci. 2011; 88: 766–771.
McCaul KD Hockemeyer JR Johnson RJ Zetocha K Quinlan K Glasgow RE. Motivation to quit using cigarettes: a review. Addict Behav. 2006; 31: 42–56.
Moradi P Thornton J Edwards R Harrison RA Washington SJ Kelly SP. Teenagers' perceptions of blindness related to smoking: a novel message to a vulnerable group. Br J Ophthalmol. 2007; 91: 605–607.

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