Preventing Vision Loss Through Smoking Cessation

  • Date: Nov 06 2007
  • Policy Number: 20071

Key Words: Eye Care Disorders, Tobacco, Smoking, Cigarettes, Vision Care

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 accidents4–6; depression7–9; other secondary complications10–13; 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 AMD16,22,23; 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.


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.


  1. Swanson MW, McGwin G. Visual impairment and functional status from the 1995 National Health Interview Survey on Disability. Ophthalmic Epidemiol. 2004;11:227–239.
  2. Klein R, Wand Q, Klein BEK, Moss SE, Mauer SM. The relationship of age-related maculopathy, cataract, and glaucoma to visual acuity. Invest Ophthalmol Vis Sci. 1995; 36:182–191.
  3. Bintz D. Eye See Tobacco Free Program targets new contact lens wearers on dangers of tobacco use. Rural Roads. 2006;4:10–17.
  4. Owsley C, McGwin G Jr, Ball K. Vision impairment, eye disease, and injurious motor vehicle crashes in the elderly. Ophthalmic Epidemiol. 1998;5:101–113. 
  5. Owsley C, Stalvey BT, Wells J, et al. Visual risk factors for crash involvement in older drivers with cataract, Arch Ophthalmol. 2001;119:881–887. 
  6. Szlyk JP, Mahler CL, Seiple W, et al. Driving performance of glaucoma patients correlates with peripheral visual field loss. J Glaucoma. 2005;14:145–150.
  7. Brody BL, Gamst AC, Williams RA, et al. Depression, visual acuity, comorbidity, and disability associated with age-related macular degeneration. Ophthalmology. 2001;108:1893–1900.
  8. Horowitz A, Reinhardt JP, and Kennedy JG. Major and subthreshold depression among older adults seeking vision rehabilitation services. Am J Geriatr Psychiatry. 2005;13:180–187. 
  9. Rovner BW, Casten RJ, Tasman WS. Effect of depression on vision function in age-related macular degeneration. Arch Ophthalmol. 2002;120:1041–1044. 
  10. Coleman AL, Stone K, Ewing SK, et al. Higher risk of multiple falls among elderly women who lose visual acuity. Ophthalmology. 2004;111:857–862. 
  11. Glynn, RJ, Seddon JM, Krug JH Jr, et al. Falls in elderly patients with glaucoma. Arch Ophthalmol. 1991;109:205–210. 
  12. Ivers RQ, Cumming RG, Mitchell P, et al. Visual risk factors for hip fracture in older people. J Am Geriatr Soc. 2003;51:356–363. 
  13. Lin MY, Gutierrez PR, Stone KL, et al. Vision impairment and combined vision and hearing impairment predict cognitive and functional decline in older women. J Am Geriatr Soc. 2004;52:1996–2002. 
  14. Klein BE, Moss SE, Klein R, et al. Associations of visual function with physical outcomes and limitations 5 years later in an older population. The Beaver Dam Eye Study. Ophthalmology. 2003;110:644–650. 
  15. Wang JJ, Mitchell P, Cumming RG, Smith W. Visual impairment and nursing home placement in older Australians: the Blue Mountains Eye Study. Ophthalmic Epidemiol. 2003;10:3–13.
  16. Klein R, Klein BE, Linton KL. Prevalence of age-related maculopathy. The Beaver Dam Study. Ophthalmology. 1992;99:933–943.
  17. Buch H, Vinding T, Nielsen NC. Prevalence and causes of visual impairment according to World Health Organization and United States criteria in an aged, urban Scandinavian population: the Copenhagen City Eye Study. Ophthalmology. 2001;108:2346–2357.
  18. Klaver CC, Wolfs RC, Vingerling JR, et al. Age-specific prevalence and causes of blindness and visual impairment in an older population: the Rotterdam Study. Arch Ophthalmol. 1998;116:653–658.
  19. Hawkins BS, Klein R, West SK. Epidemiology of age-related macular degeneration. Molecular Vision. 1999;5:26.
  20. de Jong PT. Age-Related Macular Degeneration. N Engl J Med. 2006;355:1474–1485.
  21. The Blue Mountains Eye Study. Smoking and the 5-year incidence of age-related maculopathy. Arch Ophthalmol. 2002;120:1357–1363.
  22. Klaver CC, Assink JJ, Vingerling JR, et al. Smoking is also associated with age-related macular degeneration in persons aged 85 years and older: The Rotterdam Study [letter]. Arch Ophthalmol. 1997;115:945.
  23. Delcourt C, Diaz JL, Ponton-Sanchez A, Papoz L. Smoking and age-related macular degeneration. The POLA Study. Pathologies Ocularies Liees a l’Age. Arch Ophthalmol. 1998; 116:1031–1035.
  24. Klein R. Klein BE, Tomany SC, Moss SE. Ten-year incidence of age-related maculopathy and smoking and drinking: The Beaver Dam Eye study. Am J Epidemiol. 2002;156:589–598.
  25. Klein R, Peto T, Bird A, Vannewkirk MR. The epidemiology of age-related macular degeneration. Am J Ophthalmol. 2004;137:486–495.
  26. DeAngelis MM, Ji F, Kim IK, et al. Cigarette Smoking, CFH, APOE, ELOVL4, and Risk of Neovascular Age-Related Macular Degeneration. Arch Ophthalmol. 2007;125:49–54. 
  27. Khan JC, Thurlby DA, Shahid H, et al. Smoking and age related macular degeneration: the number of pack years of cigarette smoking is a major determinant of risk for both geographic atrophy and choroidal neovascularisation. Br J Ophthalmol. 2006;90:75–80.
  28. The Health Consequences of Smoking: a Report of the Surgeon General. Atlanta, GA: Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2004. 
  29. Kelly SP, Thornian J, Edwards R, et al. Smoking and cataract: review of causal association. J Cataract Refract Surg. 2005;31:2395–2404.
  30. Christen WG, Glynn RJ, Ajani UA, et al. Smoking cessation and risk of age-related cataract in men. JAMA. 2000;284:713–716.
  31. Hiller R, Sperduto, RD, Podgor MJ, et al. Cigarette smoking and the risk of development of lens opacities. Arch Ophthalmol. 1997;115:1113–1118.
  32. Fiore MC, Bailey WC, Cohen SJ, et al. Treating Tobacco Use and Dependence. Quick Reference Guide for Clinicians. Rockville, MD: US Department of Health and Human Services, Public Health Service; 2000.
  33. Chiang YP, Bassi LJ, Javitt JC. Federal budgetary costs of blindness. Milbank Q. 1992;70:319–340. 
  34. Javitt J, Zhou Z, Willke RJ. Association between vision loss and higher medical care costs in Medicare beneficiaries costs are greater for those with progressive vision loss
  35. Ophthalmology. 2007;114:238–245.
  36. Chakravarthy, U, Augood C, Bentham G, et al. Cigarette smoking and age-related macular degeneration in the EUREYE study. Ophthalmology. 2007;114:1157–1163
  37. US Federal Trade Commission (FTC). Cigarette Report for 2003. Washington DC: US Federal Trade Commission; 2005.
  38. Klein, BE, Klein R, Lee K, Meuer S. Socioeconomic and lifestyle factors and the 10-year incidence of age related cataract. Am J Ophthalmol. 2003;136:506–512.
  39. Moradi, P, Thornton J, Edwards R, Harrison RA, Washington SJ, Kelly SP. Teenagers’ perceptions of blindness related to smoking: a novel message to a vulnerable group. Br J Ophthalmol. 2007;91:605–607.
  40. Tan JL, Mitchell P, Kifley A, Flood V, Smith W, Wang JJ. Smoking and the long-term incidence of age-related macular degeneration. The Blue Mountains Eye Study. Arch Ophthalmol. 2007;125:10889–10895.
  41. US Department of Health and Human Services. Healthy People 2010 (Conference Edition, two volumes). Washington, DC: US Department of Health and Human Services; 2000.