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The best place to start is on the damage smoking causes to vision.
Bill Harvey: 'Everyone is aware, to a varying extent, of the link between smoking and specific eye diseases. One important area is age-related macular degeneration - the commonest cause of sight impairment in the western world. Recent research papers show there is a stronger link between smoking and the more serious forms of AMD, than the link between smoking and lung cancer. This is quite astounding.

'Smoking also affects blood flow, which of course is closely linked to vision, and indirectly it can be linked with several eye diseases, including glaucoma and cataracts.

'Something I find interesting is that in the late 1980s, when I trained, we were encouraged to ask patients if they smoked. This seems to have fallen by the wayside. UK practitioners seem uncomfortable asking, "Do you smoke?" and then, "Are you aware what there is out there to help you?" Yet smoking is 100 per cent recognised as the strongest controllable risk factor for a big number of eye diseases.'

Is it the optometrist's role to discuss smoking and vision with patients? Is this being done?

Richard Llewellyn: 'I do, absolutely. However, I don't talk to everyone about smoking. I do talk to everybody about their general health and medication and I always talk to diabetics and others with specific health issues related to smoking. I am not the least bit reluctant to tell these people, if they are smoking, that they shouldn't be smoking. But it tends to be only those for whom there is a specific, identifiable risk factor.

'What Bill said is right, 30 years ago, on our records cards was a section on smoking. A simple question - "Does this person smoke?" It hasn't been there for years and I don't know why. Yet we have an increasing body of evidence that identifies smoking as being a causative factor in an increasing range of eye problems.'

How do you feel about that, Alison? Do optical professionals have a role to discuss this with their patients?

Alison Gehring: 'I feel different professionals have different roles to play and optometrists are in a unique position as they regularly see their patients. It is important that optometrists provide information about smoking, but they need support and guidance to do so. Additionally, there must be guidance on linking up with other local health professionals.'

Edwin, when you see people in their homes, it is immediately apparent if someone is a smoker or not. Is there a general message for these people?

Edwin Achu: 'Generally, I tend to raise it only for diabetic patients or those suffering a specific eye health issue. But I can see a need to deal with this more, perhaps there is an opportunity to include smoking as a part of eye history and symptoms.'

Len, the smoking ban is already in place in Northern Ireland. What is your experience in discussing the issue with patients?

Len Telford: 'It is not formally within the consultation process. We speak to people about smoking on an ad hoc basis, usually those who are at risk. We often get asked: "What can I do to keep my eyes healthy?"

'I tell people that the same things that cause heart disease can cause eye problems - which they seem to be able to relate to.'

Angela, from a pharmacist's point of view do you have a standard anti-smoking message for everyone or is it just when someone comes in for patches that you have a discussion?

Angela Sekiyama: 'We do both. When we are doing major promotions we proactively approach people and talk to them about smoking. We ask the simple question, "Do you smoke?" Some people might find that a bit offensive, most do not, and for those who say yes, it is an opening for us to continue a conversation.

'I think optometrists have a role in at least establishing whether someone smokes or not and if they do, whether they would like some help to stop. Whether optometrists should actually tell someone to quit - I'm not sure - but they can at least refer them as to where to go for help, so better links with other local health professionals are important.'

Kevin, what is your experience about how and when smoking is mentioned in practice? And whether it should be?

Kevin Lewis: 'As a practitioner, I do not ask every patient whether they smoke, although certainly I would speak to diabetics. Optometrists work in a very competitive environment. We like to hold on to our patients, so we don't really want to upset them. Some people tend to get suspicious when you ask about smoking - they don't particularly like it. That is where the reluctance to ask might come from, practitioners don't want to be seen as just another person who bangs on about smoking. So they don't ask, and they get out of the routine of asking.'

David, you are in an ideal position to get people talking about smoking.

David Cartwright: 'I'll be honest, we don't, as an organisation, tell optometrists to ask. I would suspect the vast majority of optometrists would recognise smoking is a risk factor in ocular diseases - but they don't ask their patients if they smoke. I have looked at many record cards and I have rarely seen smoker written down.

'Should we be getting involved? Absolutely. If we saw somebody who was regularly exposed to lots of UV light, we would undoubtedly tell them to wear UV eye protection. It is strange we consider UV as something we should discuss, but not smoking.

'When we consider diabetic care, all the various professionals - GPs, optometrists - are good at discussing diet and blood sugar control, together they give a cumulative message. The risk factors of smoking are fairly obvious to smokers, and that hasn't stopped them - so I think we need a cumulative message here as well, which optometrists should be part of.'

What are the barriers to practitioners talking to patients about smoking?

Lewis: 'They do not want to upset the patient, and there is also an issue about time. Practitioners probably feel if they spent time discussing smoking and other general health issues they would put themselves under a lot of time pressure. I think they would like more time with patients but they are always aware there is another person right behind them. And certainly the NHS does not pay practitioners for the time it takes to give information and advice.'

Cartwright: 'I think, generally, optometrists don't use their role of looking after the health of the eye. When you consider pre-registration students, they will focus on giving the patient the right prescription and ensuring they have checked the eye looks healthy. I've often heard it said that the student just looks at a patient as a pair of eyes - they don't go into lifestyle. Also, patients go to the optometrist for an eye test, not to be lectured on smoking.'

Harvey: 'I work in a low vision clinic where a lot of people have AMD and a lot of them say, "If only I had known." The other barrier, in my experience, is that I wouldn't feel qualified to give information about where a patient can go to get help in quitting. I don't think I'm unusual in that.'

Cartwright: 'If we start getting that information to optometrists, that could be a start. I suspect education is needed as well. If we took 100 optometrists and asked them, "What exactly is the increased risk factor in AMD?" or "What exactly is the increased risk factor in glaucoma?" they would say, "That's a good question." I suspect the majority wouldn't be as au fait with that information as we would like.'

Harvey: 'Well, the general public has hardly heard of AMD.'

Cartwright: 'The other thing, which is not necessarily an obstacle but perhaps a reason optometrists haven't become involved more, is that there are no smoking cessation agreements, generally, with PCTs like there are with pharmacies. No one says, "Here's £10 if you give every smoker this advice." And there is no product. Pharmacists might be able to give advice and then sell them nicotine patches but that does not exist for optometrists - there is no product and no payment.'

Telford: 'The situation is the same in Northern Ireland - we also don't have any government funding for smoking cessation. Perhaps we should consider though, the patient who comes back in 20 years with AMD and says "Why didn't my optometrist advise me to stop smoking?"

'When someone sees their GP, the GP has to deal with the full scope of conditions throughout their body and advise on lifestyle changes. When they come to see the optometrist, they see you only about their eyes. So if we are aware that there is a strong link between smoking and AMD, not giving that advice could be seen to be negligent. And yet we don't bother to tell them.'

Llewellyn: 'But wouldn't it be such a shame if we ended up practising defensively - defending our own position, rather than looking after the best interests of our patients?

'This discussion is really revolving around what is the role of the optometrist as a primary eye care provider.'

Is it the optometrist's role to get involved in people's lifestyle choices?

Gehring: 'Firstly, it shouldn't necessarily be considered an intrusion or a barrier. It could reinforce a patient loyalty because they feel that you are caring about them.'

Cartwright: 'It adds to the optometrist's healthcare credentials. We are experts in everything to do with the eyes. But all too often we are guilty of just saying, "Well, here's your prescription."'

Lewis: 'We need to give the information. For some people the fear of blindness is a lot worse than the fear of death. It's the fear of being disabled and going through life disabled that people fear. A lot of smokers say, "We have all got to die sometime." But we certainly don't all have to go blind sometime.'

Edwin, you see some of the most vulnerable patients. Should we dabble in their lives or are we just worrying vulnerable patients?

Achu: 'I think it's a key role and I didn't always think that, because I fell into the trap of thinking that smoking causes cancer and heart disease, forgetting the effects it has on the eyes. We have a key role to play in the advice we give patients and telling them about the effects smoking has on the eyes.

'You have to treat each patient as you see them. Some people can take that message, some people can't and if they can't you have to find another way of letting them know.'

Angela, could you talk through the pharmacy schemes available and how you engage people in the idea of smoking cessation?

Sekiyama: 'The scheme we run is linked to Westminster PCT, and of course the PCT has its own scheme as well. It is down to us to find the people to help on to the programme, however sometimes the PCT smoking cessation co-ordinators refer people to us.

'Someone may come in to enquire about the product, or someone might come in with a prescription. In relation to that prescription side, we could just dispense that prescription, and not say anything else. But if we come across someone who is diabetic or who has high blood pressure, then we do ask them, "Do you smoke?" We also have leaflets in store, so if you see someone holding one, that is a cue to ask them, "Do you smoke? Are you thinking about giving up?" And then we can go on to discuss the programme we run.'

So you actively seek out people?

Sekiyama: 'Yes. If someone comes in and we discuss smoking, we tell them how much money the programme will save them. We tell them if they buy it off us, they will probably be spending hundreds of pounds to quit. But then when you tell them by joining the scheme they can get it for the cost of an NHS prescription, £6.85, and they will get consultations with a trained professional - the benefits are obvious.'

Where is the most successful place within the customer journey to bring it up? Is it when they are at the till? When they are picking their prescription up?

Sekiyama: 'Almost all parts. We have trained most of our healthcare consultants in this area. We don't have to do all of it ourselves - we have pre-registration students who are trained to run the scheme as well. Customers are not just taking up all of the pharmacist's time, all of the staff approach customers.'

Telford: 'I think the consulting room is the place to do it. Once you are out and into frame selection and at the till it is too public to put people on the spot.'

What about yourself Edwin? You are dealing with people in their own homes - perhaps with low vision. It's a big issue if they are smoking. Have you got any routes that you can take to speak to them?

Achu: 'Yes, we have actually. We are just in the middle of developing a leaflet which we will send out to patients. Before we see any patient we send out an information pack with details about our company plus appointment time and so on. In that, what we are planning to do is include a leaflet advising about the risks of smoking on a person's general health as well as more specifically to their eye health.'

So you provide a message and let it slowly filter through?

Achu: 'That's right.'

Harvey: 'Several people have said that everyone knows that smoking is bad for you. But I am still convinced that the majority of people do not know about the link between smoking and blindness.'

Gehring: 'Action on Smoking and Health (ASH) North West did a survey about that and it emerged that only 7 per cent of people surveyed knew about the link between smoking and blindness.'

Harvey: 'The AMD Alliance International conducted a study by surveying its members - people with macular degeneration - and they listed things they thought people would have wanted for from their health care services. And at the top of this list - by a mile - was an explanation of what macular degeneration was. So they've got this thing, and no one had ever explained to them what it actually was.

'There is a thirst for information, and this goes back to delivering the message. Patients would see it as a useful thing that they would not shy away from.'

Llewellyn: 'What we are talking about here are people who for some reason are already making that step and are thinking about stopping smoking. Those are perhaps the same groups that I would already talk to, because I have identified risk factors. We must also consider getting information to those who perhaps have not thought about taking that first step. If you can get people to think about quitting, by telling them there is an additional risk that they haven't thought about before, then that is very valuable.'

Gehring: 'One thing we can learn here from health promotion is that there is a step from providing information and raising awareness to actually creating a change in behaviour. And that step is huge. I don't think that changing behaviour is something for optometrists to try and battle. Pharmacies are stepping into that role, but they have health trainers and many different professionals involved.'

Lewis: 'The biggest group, I would have thought, who are at risk of this is the younger generation. We are talking about the 19 or 20-year-old who has just started smoking.

'If you gave the message to them about the risk of damage to vision in terms of "This is your percentage chance of getting AMD", it is quite a strong message to give them. You're not telling them they are going to die, because young people never think they are going to die. But if you tell them they may become disabled in some way, then that message might go some way to stopping them starting smoking or getting them to think about giving up.'

Sekiyama: 'I think the key should be a focus on the preventative. If we do a screening test for diabetes or blood pressure, and if we know AMD is a huge thing, why isn't anything being done to prevent it? If smoking is a major risk factor, then people should be told. If they are told, and they don't want to do anything about it, well that choice is theirs, but you have done your job as a professional.'

Telford: 'The main reason why we don't give this advice is because we often don't have a clue whether they smoke or not. We don't ask the question. But we need to ask it, and we need to record the fact that we have done it, and then revisit it when we see them next. We don't have to ram it down their throat. If we are out in the shop and we have a patient looking at a £300 pair of Alain Mikli frames, we don't look for yellow fingers.'

Cartwright: 'I think we could consider doing more of a treatment plan, similar to those offered by private dentists. On your first visit they will give a complete run down of what is available, presenting it as something to consider in the future.

'Optometrists could do something similar. So you have a first-time buyer aged 15 in front of you, and you say something like: "You have this or that and it is likely you might get slightly more short-sighted as you get older but we will watch that."

'You can imagine taking that further and discuss with them with something like a guide to their future eye health. So put nicely, don't get fat and don't smoke.'

Llewellyn: 'That's an extremely good point. But we are not funded to do any of this. If you put the funding in place for this to happen, you open up all sorts of options in terms of delivering good eye care. We need to look at an eye care plan for people which does not merely identify eye tests every two years, but identifies a range of procedures delivered at different intervals that will provide that patient with the best possible eye care based on family history and other risk factors.'

Who should pay for this advice - the patient, the practitioner, or the PCT?

Llewellyn: 'The only way that we can pay for it is having our patients pay for it themselves. It would be wrong to let this go by without recognising the potential for it to impose an additional workload into the consulting room, and an extra cost. It is a good message but it can't be provided for free.'

Lewis: 'I'm not one to think that the government should be funding everything. There is only a certain amount of money in the pot and so there has to be rationing. But smoking is probably the most high-profile thing we can try and reduce to improve people's health and to save money, long-term, for PCTs. Smoking causes such a wide range of problems and costs so much money, that I think that if PCTs do run these programmes with pharmacists, there is no reason that they can't extend it to optometrists.'

Gehring: 'I don't think there must necessarily be a huge cost involved. ASH has a leaflet which you can download free from its website.'

Llewellyn: 'It is not the cost of providing that material, it's the actual physical time it takes to sit and talk to people. It literally costs me £2 per minute to run a consulting room.'

Sekiyama: 'When you say 'the time it takes to talk', is that talking to the patients about how they can stop smoking, or are you just asking them if they want to give up and then referring them on? Because referring them on should take a minute.'

Llewellyn: 'If you are going to start raising subjects like smoking with them, if it is going to be meaningful and have an effect, it must be part of an effective communication process and that has to be more than, "Take this leaflet, go away and read it." That process has to involve explaining what the issues are, why they are at risk and what the implications are if they continue to smoke. But, of course, it is their choice.'

Moving on to workplace considerations now. Given staff can no longer smoke within five metres the building they work in, are people making provisions for their staff to smoke, or to stop smoking?

Llewellyn: 'We have had a no smoking policy for 20 years and we employ people on that basis and it is not an issue.'

Cartwright: 'We are different because we are a big employer. At head office, smokers can go to bus shelter-type structures, more than five metres away. There are regular drives encouraging people to lead a healthier lifestyle. So there is support to help them give up smoking, which will include some free products like nicotine patches.'

What about when you reach someone's house - as a domiciliary optician your workplace is their home. You can't stop people smoking there.

Achu: 'That's right. It really is down to each practitioner on how to deal with it. We do have guidelines and one of the things we mention in the pre-appointment letters we send out is that the optometrist is going to be coming into the home and that they will go on to see others afterwards. We politely ask them that, if they do smoke, not to do it while the optometrist is there.

'Of course, if someone chooses to smoke while you are there, you can't stop them. I have had situations where I am seeing a woman and her husband is just lighting up cigarettes in the same room while I am there. I can't stop them. I can ask politely would they mind not smoking. But it is their private home and you can't stop them from doing what they want to do.'

Gehring: 'I think the employer should provide a support framework and the skills to health professionals going into the environment to help them deal with it while they are there. I think there should be an overall support framework. That was certainly our response to the Department of Health's consultation on the smoking ban regulations and their implementation.'

Telford: 'We felt we had to develop some kind of protocol for domiciliary optometrists. At nursing homes fairly easy solutions can be found but when we go into people's homes we have to almost conduct a mini-risk analysis for the staff member who goes there. Say the staff member is pregnant, we don't want her going in there and inhaling 50 a day. We are looking at a Welsh model which suggests this one-hour amnesty before a health worker visits. The only problem is tying yourself down to time is sometimes difficult.

'Essentially, it is developing a contract with the patient. We have to bear in mind that we are often going to be dealing with older people who have smoked all their lives and who perhaps have a degree of confusion. Just because they smoke does not mean they should be denied eye care. So our attitude is that the final arbitrator is the member of staff, they have the final decision on whether to do the test or not.'

What measures should practices and optometrists be developing or is this something we should just steer clear of and let the government sort it out?

Cartwright: 'This is something we should be thinking about. Perhaps more in the way of giving more information in practice or simply asking patients whether they smoke. From the College point of view perhaps we should be getting involved in public awareness exercises. These efforts should be tied in with us finding out what help is available for our patients and where they can get it.'

Llewellyn: 'I think the single most important message that I am taking away from today is establishing links with our local anti-smoking campaigns and smoking cessation services.'

Achu: 'Personally, I think it is something I will be addressing with more - if not all - patients. In the domiciliary sector we see a lot of elderly patients who, even if they stop smoking, there is not a lot we can do for them. So the key here is to prevent AMD in the first place. We must reach teenagers before they pick up their first cigarette. The idea of giving out information when they come for their first eye examination at 16 or 17-years-old is actually a very good one.'

Lewis: 'I think that certainly in the consulting process there is room for the simple question, "Do you smoke?" But there are other things that must be considered. It is difficult for us to launch a massive campaign and say, "All our members should discuss smoking and health issues with their patients." However, the average optom out there is really under pressure to see as many patients as possible. They barely get out symptoms and history.'

Llewellyn: 'I think a key part of this is how a practitioner really identifies their role when they are in that consulting room. If they feel they are speaking to patients about their health and it is an important part of what they do, then they will take on the idea of discussing smoking with everyone. It is not a question of asking optometrists to do it, it is a question of making them believe it is an important part of their role.' ●