Preventing Vision Loss Through Smoking Cessation

Sight is an important indicator of health and quality of life.¹ Age-related macular degeneration (AMD) is a disease that affects the central part of the retina at the back of the eye, which provides vision for daily tasks such as driving, reading, and recognizing faces. AMD is a leading cause of blindness and causes irreversible loss of central vision, especially in older Americans.² Smoking has been found to increase the risk of developing macular degeneration; however, the public’s awareness of this link is limited.³

Recent studies have linked vision loss to trauma, particularly from vehicular accidents^4–6; depression^7–9; other secondary complications^10–13; and nursing home placement.^14,15 Macular degeneration is the second leading cause of legal blindness in the United States and other developed countries and is the leading cause in persons older than 65.^16–19

There is evidence of a consistent association between smoking and AMD. Analysis of data from population-based cohort studies showed that the relative risk of late AMD is 2.4 among current smokers compared with those who never smoked.²⁰ In the Blue Mountains Eye Study, current smokers were not only at greater risk of AMD but also more likely to develop AMD at a substantially earlier age than never or past smokers.²¹ Tobacco smoking has now been accepted by most researchers as an important environmental exposure associated with AMD^16,22,23; however, it is not clear that quitting smoking decreases risk of developing AMD.²⁴ Smoking has been the most consistent factor associated with the prevalence and, to a lesser extent, the incidence of neovascular macular degeneration and geographic atrophy.²⁵ 

In addition, recent studies have confirmed that smokers having a genetic variant increase their risk of AMD by 144-fold.²⁶ Furthermore, not only have studies provided support for a causal relation between smoking and AMD, studies have also shown that environmental exposure to smoke constitutes a serious hazard for AMD in nonsmokers.²⁷ Researchers have estimated that 25% of neovascular macular degeneration and 33% of geographic atrophy could be prevented by not smoking.²⁸ It has also been established that smokers of a pack of cigarettes a day more than double their risk for cataracts and that smoking cessation reduces the risk of cataracts.^29–32

In addition to personal costs associated with visual disability, there are significant economic costs related to rehabilitation, nursing care, and loss of productivity. These significant costs are shared by federal and state entitlement programs.³³ Blinding eye disease is associated with costs to the Medicare program for eye-related medical care. The association between vision loss and higher medical care costs in Medicare beneficiary’s costs are greater for those with progressive vision loss.³⁴ Socioeconomic and lifestyle factors also appear to have a direct relation. Lower socioeconomic levels tended to correlate to poorer health and an increase in nuclear cataract.³⁵

Tobacco is the single greatest cause of disease and premature death in United States today, and is responsible for more than 430 000 deaths each year. Approximately 3000 children and adolescents become regular users of tobacco every day, and the societal costs of tobacco-related death and disease approach $100 billion each year.^36–38 The 2004 Surgeon General’s Report stated that smoking causes harm to nearly every organ of the body, including the eye.²⁸ Reducing illness, disability, and death related to tobacco use is one of the goals of Healthy People 2010, as is reducing blindness and vision impairment.^39,40 Further, tobacco consumption is increasing in low-income countries that already suffer deprivations of basic human needs. The Framework Convention on Tobacco Control attempted to rein in aggressive marketing practices, but its implementation needs to be better monitored. All members of the health care community have a vital role to play in helping smokers quit.

Therefore APHA recommends that—

1. The US Surgeon General add “Smoking can lead to loss of vision and potential blindness” or other similar language to the rotating package warnings on all tobacco products.
2. All national professional health care organizations prompt clinicians to provide information about the link between smoking and eye diseases to their evidence-based intervention counseling.
3. All insurance carriers, including government-funded programs, cover tobacco cessation medications and treatment for its members.
4. Producers of all tobacco cessation materials include information that shows the negative relation between tobacco use and environmental exposure to smoke to an increasing risk of blindness
5. Health education curriculum in public, private, undergraduate, and graduate schools include information regarding the increased risk of blindness associated with tobacco use and exposure to environmental smoke.
6. All professional vision-related associations, organizations, and corporations develop new, or update current, patient education materials, both written and electronic media, based on the new evidence of increased risk of blindness due to macular degeneration from tobacco use and environmental exposure to smoke.
7. National vision-based organizations collaborate on press releases to all major media sources to raise awareness. 
8. Federal, state, and local governmental health agencies publicize the link between vision loss and tobacco use to discourage smoking among all ages.
9. The National Eye Institute develop the most appropriate language linking smoking and eye diseases.
10. The federal government, state governments, municipalities, and industry educate the public as to the dangers of smoking and the development of eye diseases (from previous APHA resolution).
11. Congress enact legislation to require strong warning labels on all tobacco products, including loose tobacco and cigars.
12. The Federal Trade Commission require the US Surgeon General’s warnings on all utilitarian objects that promote tobacco products.
13. The Federal Trade Commission and the US Surgeon General support efforts to monitor the Framework Convention to track tobacco advertising and marketing abroad, especially the specific targeting of children and women in tobacco advertising abroad.
14. All vision care training, including colleges of optometry and ophthalmology residency training programs, add smoking cessation to their curricula.

Definitions

Central geographic atrophy (age-related macular degeneration or AMD) is an advanced form of dry macular degeneration that starts slowly in the parafoveal area and can progress into the foveal area, where severe vision loss will occur. In a 2004 study,28 27% of AMD was attributable to smoking. In addition, this study found that those with bilateral AMD were more likely to be heavy smokers. 

Neovascular or exudative macular degeneration is the least common form of macular degeneration. Commonly known as wet macular degeneration, new blood vessels form in the layer called the retinal pigment epithelium. Wet degeneration advances more rapidly than dry degeneration and tends to lead to more severe vision loss than dry degeneration.