October 2018


Research highlight
How should ophthalmologists address smoking risks with patients?

by Vanessa Caceres EyeWorld Contributing Writer

Smoking related dry eyes

A patient with visually significant cataract
Source (all): Ravi Patel, MD


Eye physicians can have a crucial role in the battle against tobacco use

Everyone has heard the message that smoking is bad for them, but that message doesn’t necessarily stop everyone from quitting.
Although you may assume that primary care providers are warning patients about tobacco dangers, ophthalmologists can play a crucial role in spreading the message about smoking’s health effects, said Afif El-Hasan, MD, volunteer spokesperson, American Lung Association, and pediatrician, Kaiser Permanente, San Juan Capistrano, California.
In fact, he thinks that warnings from eye doctors may be even more effective because of the simple but powerful message that smoking can cause someone to lose vision.
“It’s wonderful to have a frank discussion about this with patients,” Dr. El-Hasan said.

Who’s still smoking?

The percentage of U.S. adults who smoke has declined by more than 50% since 1964, which is when the U.S. Surgeon General first warned of tobacco’s health dangers, according to the National Cancer Institute’s Cancer Trends Progress Report. However, the decline in smoking has slowed since 1991.
Ophthalmologists have a general sense that patients are smoking less, although it is also dependent on geographic location. Plus, there are new potential dangers to consider.
“My impression is that fewer people smoke, but the younger generation is vaping,” said Andrew Adelson, MD, Eye Physicians of Washington, Washington, D.C., and board member, Prevention of Blindness Society of Metropolitan Washington.
Alan Mendelsohn, MD, Eye Surgeons & Consultants, Hollywood, Florida, has a unique perspective based on where he practices. “South Florida has a larger number of smokers per 1,000 inhabitants than the national average because there is a noticeable increased prevalence of smokers among those who have immigrated from Central America, South America, Cuba, and Puerto Rico and now reside in South Florida. This is a consistent topic in my office with any patient, from teenagers up,” he said.
The growing prevalence of marijuana smoking also comes up in these conversations, said Andreas Lauer, MD, professor of ophthalmology, Oregon Health & Science University, Portland, although that’s a topic worthy of its own debate.

Broaching the topic

With smoking still an issue for about 16% of the U.S. population, and more in some states, how can ophthalmologists broach the topic of smoking’s ill effects?
You could use the electronic medical record (EMR) as a starting point. “It’s required to ask about smoking history and is an automatic question in our EMR system,” said Maria Scott, MD, medical director, Chesapeake Eye Care and Laser Center, and LASIK surgeon, TLC Laser Eye Centers, Annapolis, Maryland. “That gives us a good opportunity to talk about the detriments of smoking.”
Another approach is to bring it up when treating problems that could be smoking-related. “As a corneal specialist, I see many patients coming in for treatment of dry eye and cataracts,” said Ravi Patel, MD, Eye Associates of Central Texas, Round Rock. “These are easy transition points to raise the topic with the patient. When patients come in frustrated with their vision or the discomfort from their dry eyes, it’s a great time to explain how smoking accelerates vision loss from cataracts and limits my ability to improve their dry eyes,” Dr. Patel said. Many patients may have heard about smoking’s association with cancer and cardiovascular disease but not cataracts, AMD, and dry eye, Dr. Patel said. Dr. Patel finds it powerful to show patients a photo of their retina, cataract, or ocular surface to help them fully understand smoking damage.
Similarly, Dr. Lauer will discuss smoking when he sees patients with age-related macular degeneration (AMD) or diabetic eye disease who also smoke.
Smokers can have more severe diabetic retinopathy, more severe and prolonged thyroid eye disease complications, and possibly increased progression of optic nerve deterioration with open angle glaucoma, Dr. Mendelsohn said.
All of this correlates with Dr. El-Hasan’s point that ophthalmologists may play a larger role in the smoking discussion than they assume.
Dr. Mendelsohn is passionate about discussing smoking with patients and said that he and his staff bring it up with all patients, from the early teen years up. “My staff and I think that about 50% of our smokers eventually stop smoking due to consistent reminders about the health-related dangers,” he said. He also has observed that almost all of the smoking patients do not know about the ocular risks. “The ocular side effects seem to be what makes them stop. This new piece of information seems to be a game changer,” he said.
Here’s yet another reason to discuss smoking: “Ophthalmologists should talk about smoking not just because smoking affects the eye and visual system, but because we are caring physicians first, before we are eye doctors,” said Benjamin Ticho, MD, associate professor, University of Illinois Eye & Ear Infirmary, The Eye Specialists Center, Chicago. “Smokers who’d like to be healthier need encouragement and consideration, not condemnation and criticism.”


When patients say that they want to quit, there are several recommendations that ophthalmologists can make. A first move is to refer them back to the primary care provider for additional help, said Dr. Scott, who will also send a letter to that provider. “If they don’t wish to quit, I say that they are adults and it’s their choice, but it’s my responsibility to tell them the associated risks,” she said.
Dr. El-Hasan said the American Lung Association’s Freedom From Smoking program (Freedomfromsmoking.org) is often used to help those who want to quit. With the program and anti-smoking aids such as nicotine patches and gums, those committed to quitting usually can reach their goal in a month. “It can be a painful month,” Dr. El-Hasan said.
Dr. Mendelsohn advocates a gradual approach instead of cold turkey; the Freedom From Smoking program also does not recommend cold turkey, Dr. El-Hasan said. “My suggestion is to reduce the number of cigarettes by 50% within a 3-month period then slowly wean themselves totally within 6 months,” Dr. Mendelsohn said. He and his staff check in on progress and support them along the way. “When those patients report having stopped smoking, my staff and I clap and shower the patient and family members with praise. Positive reinforcement works, as does regular reminders,” he said.
Seeking social support from health providers, family, and support groups can also be important, Dr. Ticho said.
Ultimately, the patient must want to quit, Dr. Lauer said. This can be a frustrating part of the smoking discussion. He estimates that among his anti-smoking talks, only one in 30 to 50 patients will come back and say they quit. “The odds are stacked against you, but it’s still worth it” to discuss the topic, he said.

Addressing e-cigarettes

Ophthalmologists are still grappling with what to advise patients regarding e-cigarettes.
“The rise of e-cigarettes complicates this conversation because there is no long-term study that can isolate its health impact,” Dr. Patel said. “This is particularly concerning, given its rise of use in younger individuals.”
When patients ask him about e-cigarettes, he tells them that the products have not had long-term studies and that they carry more risk than not smoking at all. “If you’re a nonsmoker, it’s best to avoid them altogether,” he said.
Although most of his patients are older and likely not using e-cigarettes, Dr. Lauer wonders if asking about e-cigarette use on intake forms or via the EMR could help spur a discussion about these questionable devices.
If patients say they use e-cigarettes to help quit cigarette smoking, you could share results from a study that found U.S. adult smokers who did not use electronic nicotine delivery systems quit smoking twice as often as those who used those devices, and 90% who both smoked and used e-cigarettes were still smoking a year later.1 Other studies have reported mixed results about the potential role of e-cigarettes in helping smokers to quit.2

Benefits of not smoking

Ultimately, ophthalmologists should know that their anti-smoking discussions may help save vision.
“I think many patients are unaware of how smoking can impact their eyes, and raising awareness of the damage caused by cigarettes and secondhand smoke can be important in preventing blindness,” Dr. Adelson said.
You can also put a positive spin on your anti-smoking message by letting patients know how their health improves after they stop smoking, Dr. El-Hasan said. For instance, after 12 hours of not smoking, the carbon dioxide level in the blood drops to normal. After 2 to 3 weeks, the risk for a heart attack decreases. After 1 year of not smoking, the risk of coronary artery disease lowers to half of that of a smoker. At 15 years, the coronary artery disease risk is the same as a nonsmoker, Dr. El-Hasan said. 


1. Weaver SR, et al. Are electronic nicotine delivery systems helping cigarette smokers quit? Evidence from a prospective cohort study of U.S. adult smokers, 2015–2016. PLoS One. 2018;13:e0198047. 
2. McKay B. Few who vape stop smoking, study finds. Wall Street Journal. July 10, 2018.

Editors’ note: The physicians have no financial interests related to their comments.

Contact information

: nfarano@youreyes.org
El-Hasan: Afif.H.El-Hasan@kp.org
Lauer: lauera@ohsu.edu
Mendelsohn: admendelsohn@gmail.com 
Patel: rapatel5462@gmail.com
Scott: 410-571-8733
Ticho: bticho@mac.com

How should ophthalmologists address smoking risks with patients? How should ophthalmologists address smoking risks with patients?
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