Are you helping patients stub out smoking?

Smoking can lead to lung cancer and heart disease—but blindness? Americans aren't as quick to make that connection, indicating a crucial dialogue for the nation's primary eye care providers.

More than half a century has passed since the landmark 1964 Surgeon General's report detailing smoking and health, yet tobacco use is still the leading cause of preventable disease and death in the U.S. with cigarettes the most commonly used tobacco product. Although public awareness of serious smoking-related complications has grown steadily over the years, there remains a gulf in understanding regarding smoking's effects on eye health.

In fact, as few as 9.5% of U.S. smokers believed that smoking could cause blindness. A 2011 Optometry study concluded it's not only an American problem; 9.7% of British and 13% of Canadian smokers fell in the same category. However, contrast that with Australia where a full 47% of smokers know the harm. So, what gives?  

It wasn't until the past dozen years that smoking-related eye conditions drew attention in the Surgeon General's report, and only within the past three years that the report outlined a causal relationship between smoking and the leading cause of blindness and central vision loss in the U.S., age-related macular degeneration (AMD).  

Although AMD is one of the more serious eye conditions aggravated by smoking, it's not the only one as other conditions include Graves ophthalmology, diabetic retinopathy, dry eye and contact-lens related keratitis all affected.  

But what explains Australia's outlier? It wasn't information about tarred lungs that hastened calls to Australia's National Tobacco Campaign cessation hotline, "Quitline," but the relatively new evidence in 1998 that smoking could cause blindness. This blazoned TV ads and was later underscored when Australia began wrapping cigarette cartons in graphic warning labels. Other countries haven't taken such sweeping efforts to stress eye health in their public campaigns.  

However, that's changing as the World Health Organization attempts to promote tobacco control efforts by stressing the health, economic and developmental tolls in a worldwide awareness campaign that comes to a head every May 31. Called World No Tobacco Day, this health observance, in part, underscores the importance health care practitioners play in smoking cessation. It also represents an opportunity for optometry.  

Smoking and eye health  

Initiating the smoking conversation is about more than simply checking a box in the patient's EHR, it's a way of delivering an effective, resonating message that benefits the patient's overall health. But steering the dialogue from "do you smoke?" to "here's how to quit," is an entirely different matter—one which not all doctors are comfortable addressing.  

A 2014 Optometry & Vision Science study among Canadian optometrists found:

• 98% believed that cigarette smoke was a risk factor for AMD
• 55% assessed patients' smoking status during their initial visit
• 33% assessed patients' interest in quitting
• 7% discussed tobacco use prevention with teens

Perhaps most telling from the survey: about 9 in 10 doctors were interested in continuing education (CE) in this area that included strategies for discussing tobacco cessation and prevention. Marlee Spafford, O.D., Ph.D., University of Waterloo School of Optometry associate dean and study co-author, says evidence suggests that doctors may not be sure how to take the next step in tobacco cessation conversations.  

"While Canadian optometrists and optometry students have knowledge regarding tobacco-induced eye disease and ask their patients questions about their tobacco use, there are limited [cessation] conversations initiated with patients," Dr. Spafford notes.  

Her findings suggest doctors may benefit from additional training while in school, as well as optometry's inclusion in tobacco cessation guidelines and the proliferation of relevant optometry-related handouts.

"While my work focused on the Canadian landscape, I think that these points would resonate beyond Canada," she says. "It's something optometry should be talking more about."  

Beyond optometry's role?  

Not everyone is of one opinion on that matter, however. Although Medicare has incentivized and encouraged practices to report on tobacco counseling and cessation, some doctors still don't see it within their role. So, too, patients can be sensitive to the topic.  

Doug Totten, O.D., AOA Ethics and Values Committee chair, quotes the AOA Standards of Professional Conduct when it comes to the question of role: Optometrists have a duty to respect the right of their patients to be active participants in decisions affecting their health care. This duty should be reinforced and supported through patient education and effective communication.  

"I agree that optometrists do have a role in counselling patients to encourage habits and behaviors that can promote better health," Dr. Totten says. "Optometrists can advise a patient that smoking can be detrimental to ocular health. Smoking cessation can reduce the risk of some eye diseases and it is our obligation to educate patients about these facts."  

The AOA's second evidence-based clinical practice guideline, Comprehensive Adult Eye and Vision Examination, affirms this, stating that eye doctors should ask about, document and inform patients about their smoking habits and the benefits to eyes, vision and overall health through smoking cessation.  

"Optometrists should talk to patients about smoking cessation just as a patient's primary care physician and dentist are also giving the same advice," Dr. Totten says.