Smoking is a major risk factor for a number of ocular diseases. It is a direct risk factor for cataract, age-related macular degeneration and vascular diseases causing sight loss through damage to blood flow in the eye and brain. Indirectly, it influences the rate of diabetic disease and vascular perfusion in those at risk of glaucoma. It is a major contributor to ocular surface disease, such as tear dysfunction and surface inflammation, and in contact lens wearers has been found to have an association with microbial keratitis.

Smoking is a modifiable risk factor, unlike age, gender, ethnicity and so on. Something can be done to take it out of the equation. Furthermore, good evidence exists for a decreased risk influence as time goes on after ceasing smoking.

So, surely it is important for all categories of eye care professions to discover if their patient is aware of the eye health risks of their habit and, once made aware, of measures that may help them to give up.

Alternatively, is smoking a lifestyle choice by risk takers who know full well the implications of their habit but would rather live a life of their own chosen quality and not think about the future? Indeed, might not the repeated nag of health professionals have a negative impact on such people and only serve to flatter their rebellious streak or, worse, discourage them from future involvement with the system?

Dr Rohit Narayan recently wrote a review paper of what is currently known of the health impact of e-cigarettes (Optician 21.06.19), and this served as a follow-up to his paper on smoking and eye health from last year (Optician 11.05.18). These articles are the main source material for this month’s interactive CET exercise where you will be asked to consider your involvement in asking patients about smoking habits, offering advice and finding out about cessation resources. The exercise is to be found online as usual, along with useful references and links to the two articles. Here are a few key points to consider first.

Smoking and AMD

Some key points to remember regarding the influence of smoking upon what is the commonest cause of visual impairment in the UK.

  • Smoking is a major modifiable risk factor and is associated with AMD.
  • Smoking increases the risk of AMD two to four-fold.
  • Pack-years smoked better reflects the amount of exposure.
  • Cigarette smoke is comprised of a gas and tar phase containing chemicals with a high concentration of free radicals.
  • Cigarette smoke induces ‘pro-inflammatory’ changes in the retinal pigment epithelium, along with oxidative damage.
  • Risk of AMD remains present up to 20 years after cessation of smoking.
  • Passive smoking carries risk of AMD.
  • Public awareness of the link between smoking and ocular health is lacking.
  • Eye care providers have a duty of care to inform patients of the long-term ocular risk of smoking and AMD.
  • Electronic cigarettes are considered ‘safer’ than conventional cigarettes, although more research is needed.
  • Smoking cessation with a discussion of dietary modification is recommended.
  • AREDS and AREDS II formulations only indicated in intermediate/ late stage AMD.
  • AREDS formula (beta carotene) carries increased risk of lung cancer in smokers.
  • AREDS II: lutein+zeaxanthin a better substitute for beta carotene.

Smoking and Ocular Surface

Both conventional smoking and vaping exposes the ocular surface to a wide range of chemicals, some of which cause irritation and can exacerbate an already compromised tear film. There is also some association between smoking and keratitis in contact lens wearers. This may, in part at least, be related to compliance and hygiene issues in regular smokers.

The Role of the ECP

Public awareness of the link between smoking and ocular health is lacking. The role of eye care professionals is therefore a critical role in educating the public and encouraging smokers to quit. Awareness of the risk of blindness from smoking is low among teenagers, but fear of blindness may be more likely to motivate teenagers to stop smoking than fear of lung or heart disease.

A survey into patient’s perceptions and experience of an eye examination revealed they expected their eye care professional to examine their eye health, ask them about their smoking and diet habits, and indicated feeling comfortable discussing these topics with their primary eye care provider. These findings suggest that brief momentary interventions relating to tobacco use and diet are likely to be acceptable to deliver in both ophthalmology and optometry settings.

The College of Optometrists has raised smoking awareness through its ‘Lifestyles and Eyes’, ‘Cataracts’ and ‘Macular Degeneration’ leaflets. This, coupled with guidelines for other primary care providers, can be adapted into an optometric setting. Some focus on connecting a patient with a specific cessation support service, while other approaches rely on the provider to personally support patient cessation. Studies in UK optometric settings have demonstrated the feasibility of delivering brief smoking cessations with good success, and ECPs should be encouraged to find out what cessation supports are available in their community.

A variety of training programmes exist for all levels of healthcare professionals. Of particular interest is the National Centre for Smoking Cessation and Training (NCSCT) which offers a ‘Very Brief Advice’ module aimed at clinicians who provide smoking cessation and support as a small part of their wider role. These web-based programmes include video simulations of discussing smoking and its cessation in a variety of patient scenarios. See table 1.

Stopping smoking is tough. Smokers know they should stop, yet often they do not know how, or that support is available. There are many factors influencing a patient’s ability to quit, and although offering VBA can be influential, it may not result in a quit attempt at that time, however, that should not prevent the clinician presenting it at subsequent visits.

With the proper training and resources, it is certain that the optometric community can and will play a greater role in addressing tobacco-use cessation among patients. Many community pharmacists are knowledgeable and can offer advice over the counter. Strategies such as VBA, used as part of our everyday routine, can influence a patient’s potential success in quitting.

Interactive Exercise

This exercise is designed to encourage discussion between all categories of registrant as each group might be expected to deal with the challenges either within or outside the consulting room. While, for the optometrist and contact lens optician, there may be direct clinical implications, all three registrant categories can play a useful part (and indeed are encouraged to under the GOC Standards of Practice) in informing the patient of the implications of lifestyle choices. Obviously, each would be expected to answer according to their particular professional responsibility.

Before you attempt the exercise, there are six multiple choice questions which assess an overall understanding of paediatric assessment. To ensure successful completion, the relevant source material is available here and here. 

Remember:

•There is no one single answer for your discussion, but what is needed is a reflection of your discussion (which must be for a minimum of ten minutes please) that is sufficient evidence of the various points having been covered.

• Read the source material available  

• Complete six multiple choice questions to confirm you have grasped the main concepts

• Read the case scenario about which you are to confer with a registered colleague (for at least ten minutes please)

• The exercise is designed for both optometrist and dispensing optician so please ensure your discussion is relevant to your own role and responsibility

• Confirm with us the name and GOC registration number of the colleague with whom you have discussed the case and also write some short notes on the outcome of your discussion

• At the end of the month’s active period we will confirm that your discussion outcome meets the requirement for an interactive point

• Look out for a published discussion based on all responses in a future issue of Optician.