Journal of Public Health Advance Access originally published online on May 11, 2007
Journal of Public Health 2007 29(2):142-146; doi:10.1093/pubmed/fdm019
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‘Smoke gets in your eyes’: a research-informed professional education and advocacy programme
Judith Thornton, Honorary Research Fellow1
Richard Edwards, Senior Lecturer in Epidemiology2
Roger A. Harrison, Research Development Lead, Research Scientist in Public Health3
Peter Elton, Director of Public Health4
Nick Astbury, Consultant Ophthalmologist5
Simon P. Kelly, Consultant Ophthalmologist6,
1 Clinical Epidemiology and Public Health Unit, University of Manchester, Oxford Road, Manchester M13 9PT, UK
2 Department of Public Health, Wellington School of Medicine and Health Sciences, University of Otago, P.O. Box 7343, Wellington South, New Zealand
3 Clinical Epidemiology and Public Health Unit, University of Manchester and Bolton Primary Care Trust, Oxford Road, Manchester M13 9PT, UK
4 Department of Public Health, Bury Primary Care Trust, 21 Silver Street, Bury BL9 0EN, UK
5 Ocular Public Health Committee, Royal College of Ophthalmologists, 17, Cornwall Terrace, London NW1 4QW, UK
6 Eye Unit, Bolton Hospitals NHS Trust, Minerva Road, Bolton BL4 0JR, UK
Address correspondence to Simon P. Kelly, E-mail: simon.kelly{at}rbh.nhs.uk
Smoking is associated with common sight-threatening eye conditions. We suspected that this link was little known and it might be a potent novel health promotional tool. We therefore developed a programme ultimately aiming to reduce the burden of eye disease attributable to smoking. The programme aims were to (1) raise awareness of the link between smoking and eye disease and advocate changes in relevant policies and (2) investigate and promote change in professional practice so that smokers are identified and routinely offered smoking cessation advice/support in eyecare settings. An inter-professional team developed a programme of research and education targeting policy-makers, healthcare professionals, the public and patients. We reviewed evidence about the causal link between smoking and eye disease, researched current awareness of the link, researched current practice of eyecare health professionals, produced health education materials and campaigned for policy changes. The series of projects was completed successfully, achieving media coverage, confirming the causal link between smoking and eye disease and demonstrating low awareness of this association. Healthcare leaders and policy-makers were engaged in our programme resulting in commitment, in principle, from the UK's Chief Medical Officer and the European Commission to consider including warning labels related to blindness on cigarette packets.
Keywords: blindness, eye disease, health promotion, quality improvement, smoking
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Introduction |
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TOP
Introduction
Audit of smoking patternsTobacco smoking is a major risk factor for many chronic diseases1 but the effects of smoking on the eye are not well recognized. Recent epidemiological evidence strongly suggests that smoking is causally linked with age-related macular degeneration (AMD),2,3 cataract4–9 and other eye diseases.10 We suspected that awareness of this link was little known and that it might be a potent novel untapped health promotional tool. The degree to which eyecare health professionals promoted smoking cessation in their practice was also not known, but we suspected it was low. We therefore aimed to explore these hypotheses and develop a programme ultimately aiming to reduce the burden of eye disease attributable to smoking.
We developed a programme of work involving a multidisciplinary team that comprised NHS clinical ophthalmologists and public health academics. The programme was conducted within Bolton Hospitals NHS Trust and the University of Manchester. Links were developed with the Royal College of Ophthalmologists and a local campaigning charity NorthWest Action on Smoking and Health (NWASH).
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Audit of smoking patterns |
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Our interest in the role of smoking in the development of eye disease was stimulated initially by an audit of smoking patterns of AMD outpatients attending Bolton Hospitals NHS Trust. Data from these patients were compared with a local general age-matched population in whom a detailed smoking history had been recorded as part of the Salford Lung Survey. These (unpublished) results confirmed a significantly higher number of smokers and heavy smoking habits in local AMD patients compared with Salford Lung Survey participants.
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Causal association and population impact |
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We undertook a comprehensive literature review of published evidence that linked smoking and eye disease. Using established criteria for causal attribution, we reviewed the available epidemiological evidence on the association between tobacco smoking and AMD and cataract and confirmed a causal relationship.11,12 Using population attributable risk (PAR) methods we estimated the number of UK residents with blindness and visual impairment from AMD related to smoking.13 We estimate that 53 900 residents aged >69 years may have visual impairment because of AMD attributable to smoking and of whom 17 800 are blind. These figures demonstrated the high impact of smoking on eye health and generated considerable media interest. We later revised our estimates of the number of UK cases of AMD causing visual impairment attributable to smoking in the light of new data from the UK.14 The revised estimates are 41350 when cases attributed to exposure among ex-smokers are included and 21800 if these are excluded.15
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Evaluation of smoking cessation practice among eyecare health professionals |
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To evaluate knowledge and practice of healthcare professionals in relation to smoking cessation, we undertook a national survey of all consultant ophthalmologists in the UK who were contacted regarding their attitudes and practice for identifying smokers and giving smoking cessation advice and support.16 Key findings included that only 35% of ophthalmologists asked about smoking habits at new patient visits and 5% at follow up, and only 14% assessed motivation to quit and 22% provided advice and assistance about how to stop smoking to smokers who wished to quit. We also undertook a similar survey of all NorthWest optometrists; only 6.2% routinely take smoking history at new patient community optometric visits and 2.2% during follow up.17 The findings from our surveys suggest there is considerable room for improvement in the identification of smokers and provision of smoking cessation advice by both ophthalmologists and optometrists, and we have been involved in educational activities to assist practitioners to provide smoking cessation advice in ophthalmic and optometric practice. The questions used in our survey of NorthWest optometrists were posed to a seminar of over 100 optometrists in Bristol with similar results (personal communication from Mr M Potts FRCOphth). A survey is ongoing among community pharmacists.
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Evaluation of awareness of risk among patients and the public |
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A survey of 413 patients from Bolton Hospitals NHS Trust found little awareness of the risks of smoking on the eyes but suggested that fear of blindness is as compelling a reason to quit smoking as fear of other smoking-related diseases.18 Only 9.5% of patients believed that smoking was definitely or probably a cause of blindness, compared with 92.2% for lung cancer, 87.6% for heart disease and 70.6% for stroke. About one-half of smokers stated they would definitely or probably quit smoking if they developed early signs of blindness. We then collaborated with a general public survey of over 1000 individuals in the UK in relation to eye disease awareness undertaken by the AMD Alliance by providing key questions regarding smoking and eye health (http://www.amdalliance.org/documents/Position_Paper_European_CampaignOnSmokingAndBlindness.doc). The findings of a lack of awareness among the general public of ocular risks of smoking were similar to the Bolton patient survey. We next conducted a survey, using the same validated survey tool, among 260 teenagers attending youth functions in England to assess teenagers' attitudes to smoking and eye health.19 We found a low awareness in this age group of the ocular hazards of smoking and evidence that such awareness is a novel compelling reason to quit. Although 81% of teenagers were aware of the association of smoking with lung cancer and 27% and 15% with heart disease and stroke, only 5% knew of the association with eye disease. More teenagers (P < 0.01) said they would stop smoking with the early signs of blindness compared with early signs of lung or heart disease.
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Raising awareness of the risk |
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Based on our findings of the lack of knowledge about the risks of smoking and the development of eye disease in diverse groups, we developed a programme of work to raise awareness of the link among healthcare professional, patients and the public.
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Healthcare professionals |
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The evidence demonstrating the causal association between smoking and eye disease11,12 was brought to the attention of the Royal College of Ophthalmologists, the Royal National Institute of the Blind (RNIB) and the AMD Alliance. These organizations have participated in joint publicity campaigns that generated wide media interest.
In an editorial in the British Medical Journal, we described the causal attribution and emphasized the need for greater awareness.13 Through collaboration with the Tobacco Control Resource Centre (TCRC) in Edinburgh, the editorial was made available to medical association journals throughout central and eastern Europe on a copyright-free basis.20 A further collaboration between the TCRC and the BMA's International Committee, and supported by the UK Department for International Development, facilitated dissemination through medical journals in developing countries. The TCRC launched, at our suggestion, an educational multi-media package on smoking cessation for ophthalmologists (http://www.doctorsandtobacco.org/resources.php#143). We contributed to an educational audio package on smoking cessation advice for optometric practice produced for the Directorate of Optometric Continuing Education and Training (http://www.docet.info), which is sent to all UK optometrists. We gave a keynote presentation on smoking and eye health at the annual conference of the British Contact Lens Association (2006) which was attended by a large number of optometrists. An ‘Eyes and Tobacco Study Group’ was set up with local public health colleagues and received NHS Research Funding support. Trainees in both ophthalmology and in public health are encouraged to attend. The Royal College of Ophthalmologists established an Ocular Public Health Committee in response, in part, to our efforts in relation to smoking. The Committee's chairman recently produced a commentary paper on smoking and sight.21
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Patients and the public |
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It is possible that presentation of new health information may have more effects on peoples' actions than reiteration of known warnings. For example, a leaflet advising on holiday skin health precautions was not found to reduce the incidence of sunburn compared with a control group of holiday-makers.22 It is possible that this approach was not successful because the information in the leaflet was already known. Thus in co-operation with NWASH, we developed an information leaflet, ‘Smoking and Blindness’, to highlight the ocular effects of smoking to patients and public. To ensure that it was accessible to the visually impaired, we followed guidelines from the RNIB on optimal print size and colour for the visually impaired. We also had the content reviewed by the Campaign for Clear English (CrystalMark) to ensure clarity for a general audience. Finally, we ‘field-tested’ the draft leaflet on patients attending Low Vision Clinics in Bolton Hospitals before mass production of the leaflet and an appraisal of usability of the final leaflet product for low vision individuals from the RNIB was also arranged. The Professional Standards Committee of the Royal College of Ophthalmologists approved the leaflet. The leaflet has been forwarded to all UK ophthalmologists and optometrists and has also been made available to UK specialist ophthalmic pharmacists. Plans to extend availability to all community pharmacists are ongoing. Demand from high street opticians has also been high. In total, 63 550 leaflets have been sold to date and it is also available for free downloading (www.nwash.co.uk).
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Policy-makers |
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Our research projects demonstrated low awareness of the association between smoking and eye disease among patients,18 ophthalmologists,16 optometrists17 and teenagers.19 We subsequently have drawn the issue to the attention of national and international policy-makers. In July 2005, we made a presentation to the All Party Parliamentary Group at the House of Commons on smoking and eye health (www.collegeoptometrists.org/coo/filemanager/Report_of_meeting_13_July_2005.pdf). This topic has received support from the UK's Chief Medical Officer (Sir Liam Donaldson, correspondence to the Royal College of Ophthalmologists 2006). Furthermore, it is the context of a future Early Day Motion on ‘Smoking and Blindness’ in the House of Parliament (Hansard; EDM 684 of 2005–06). An amendment to this proposed parliamentary motion cites our team for research in this area to date. Efforts to reduce the number of people who smoke and protect society from the harmful effects of active and passive smoking are gathering pace across the European Union (EU). A large-scale public awareness campaign on the link between smoking and blindness is likely to increase the number of people who decide to or seek help to quit and may deter more young people from taking up the habit.
Relevant warnings on tobacco products may further contribute to this objective. We are thus campaigning to have a novel cigarette package warning highlighting this message added to existing UK tobacco product warnings (http://www.packwarnings.nhs/uk/) as planned in Australia. The message ‘Smoking causes blindness’ is suggested. Preliminary data on the impact of television advertisement campaigns on a call to national quitlines in Australia23 and New Zealand24 demonstrate that the link between smoking and blindness acts as a powerful stimulus for smokers to quit. However, as changes to tobacco warnings require action at EU level, we then developed a European campaign with key partners to bring this message to the attention of European decision makers. A joint campaign document has been produced with our partners in the UK the RNIB and AMD Alliance which has now been endorsed by the Comité Permanent des Médecins Européens (CPME) (http://cpme.dyndns.org:591/adopted/CPME_AD_Brd_030905_090_EN.pdf). The campaign aims to alter the agreed warnings on tobacco products within EU member states. We attended a campaigning event with the RNIB and AMD Alliance at the European Parliament (May 2006) to highlight this to Members of the European Parliament and to the media in an event coinciding with World No Tobacco Day, a World Heath Organization initiative. We have succeeded in getting a novel message, ‘It's the smoking not the xxxking’, on to HELP, the EU sponsored smoking cessation campaign website (http://en.help-eu.com/images/mo_edito_img/454_2_0.jpg). In September 2006, a supportive written answer was received from the European Commission in relation as to how the EU might consider such warnings on tobacco products (http://www.europarl.europa.eu/omk/sipade3?L = EN&OBJID = 127259&DETAIL = H-2006-0659&MODE-CRE = NAV).
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Conclusions and future actions |
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We have targeted healthcare professionals, patients, the general public and policy-makers with a novel and compelling promotional message. We have been proactive in seeking government support to our calls and have achieved widespread popular media coverage of our projects. We were short-listed for an NHS Health and Social Care ‘Improving Health and Wellbeing’ award (http://www.healthandsocialcareawards.org).
We have further projects planned and ongoing. A systematic review of smoking and five major eye diseases is underway and will formally assess the quality and results of the epidemiological evidence. The first publication confirmed that smoking contributed to the development and progression of thyroid eye disease.25
Our observations confirm that patients with existing eye diseases or at risk of developing eye disease should be advised to stop smoking, as smoking cessation is likely to slow or stop progression of these three eye diseases and improve the outcome of treatment. Many clinics for patients with diabetes, or cardiac and respiratory problems have incorporated smoking cessation support into their routine services. We have suggested that ophthalmology or optometry services should likewise routinely assess smoking status and offer smoking cessation support for patients with, or at risk of, eye diseases related to smoking. We have also suggested that optometrists might have an extended role in primary smoking prevention, particularly in relation to young people who often present for refraction and or contact lens care as adolescents or young adults just a time when they may be likely to start smoking.17 We plan to work with the RNIB, Royal College of Ophthalmologists and smoking cessation services to promote resource/educational pack for implementing smoking cessation support in eye healthcare settings.
Within the recent provision of photodynamic treatment (PDT) services and the evolving rollout of intra-vitreal medications for neovascular AMD, we believe that the link of AMD with smoking should also be noted by healthcare commissioners when configuring such services. Smoking issues have not been addressed in PDT commissioning which has been a disappointment to us. We were not successful in our suggestion that details of smoking status should be added to the UK's PDT Cohort Study data set, to better understand whether smoking might be a risk factor for recurrence of neovascular AMD after PDT, as it is following argon laser photocoagulation.26
In conclusion, our programme has provided scientific evidence for the causal association between smoking and eye disease and has initiated an important novel health promotional campaign. We are now beginning to identify projects where smoking cessation support can be provided. For example, a pilot project with optometrists in collaboration with the smoking cessation service could look at the feasibility of a system whereby all clients are asked about their smoking status, smokers are given brief intervention and contact details for smoking cessation services. The views of optometrists and clients on this service could be canvassed.
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Competing interests |
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Richard Edwards was a previous chair of NorthWest Action on Smoking and Health. Peter Elton is a council member of NorthWest Action on Smoking and Health.
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Funding |
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Supported by research funds at Bolton Eye Unit, Bolton Hospitals NHS Trust.
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References |
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- Smith W, Mitchell P, Leeder SR. Smoking and age-related maculopathy. The Blue Mountains Eye Study. Arch Ophthalmol (1996) 114:1518–23.[Abstract]
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