Ophthalmology provides a unique perspective on many aspects of health; the eye is a window to many vascular, inflammatory, genetic, and environmental conditions. The vision specialist often carries the burden of managing the end-organ effects of systemic disease such as diabetes, rheumatoid arthritis, and hypertension. With diabetes in particular, ophthalmologists are acutely aware of the need for prevention and cost-effective screening. However, there is an epidemic of blindness that has enveloped much of the world, and eye physicians are standing silently by. This epidemic is the vision loss attributable to tobacco smoking.

The association of smoking with ocular disease is well described.1 Most practicing ophthalmologists can readily recall patients with smoking related diseases. The strong association of tobacco abuse with Grave’s ophthalmopathy, uveitis, and age-related macular degeneration are readily apparent to the astute clinician. Tobacco smoking is also associated with dysfunctional tear syndrome, cataracts, and likely contributes directly to the development of diabetes mellitus.2

A survey of patients found that fear of blindness was a prime concern,3 and it is established that the negative health consequences of smoking are an important contributor to smoking cessation.4 In fact, the fear of loss of vision was second only to lung cancer as a potential motivating factor for those considering quitting smoking. Given this overwhelming evidence that suggests that fear of blindness could be an important tool in promoting smoking cessation among patients, it is given surprisingly little attention in the ophthalmic community.5

In 2014 the United States Department of Health and Human Services published a report commemorating the 50th anniversary of the landmark 1964 report that brought the association of smoking and disease to the forefront. Dr. Boris D. Lushniak, M.D., M.P.H., the acting surgeon general, stated:

“It is my sincere hope that 50 years from now we won’t need another Surgeon General’s report on smoking and health, because tobacco-related disease and death will be a thing of the past. Working together, we can make that vision a reality.”6

Ophthalmologists, as physicians, should also be working together to promote smoking cessation. Similar to many other evidence-based interventions that are poorly adopted in daily practice, this aspect of patient health has not received adequate attention. We have a unique opportunity, and obligation, to intervene in this preventable contributor to blindness. The benefits to our patients could be tremendous, and it is rare that we have such a powerful therapeutic option that only carries the cost of changing our practice patterns.

It is likely that lack of training and awareness is a barrier to implementing this paradigm; if the ophthalmologist could simply prescribe “smoking cessation”, uptake would likely be swift. However, there are guidelines for brief clinical interventions with smokers. The U.S. Public Health Service has developed the “5 A” mnemonic for patient encounters7:

• • ASK - about tobacco use at every encounter.
• • ADVISE - to quit tobacco use in a clear manner.
• • ASSESS - willingness to quit.
• • ASSIST - in quitting.
• • ARRANGE - follow-up to monitor progress.

The first 3 steps are readily adaptable to the ophthalmologists’ practice, and require very little time. The smoking status of each patient should already be a standard part of the patient history. For current smokers, a simple statement alerting them to the potential adverse effects of smoking on their vision may motivate them to consider cessation. For those patients who report a willingness to quit, referral should be made to a primary care provider for the final two steps, which may include behavioral skills counseling, pharmacotherapy, and group support. Many smokers require multiple attempts at cessation, but the sooner we encourage them to begin that journey the sooner we begin fighting the ignored epidemic of blindness.