8: No. 6, November 2011
Alberto J. Caban-Martinez, MPH, CPH; Evelyn P. Davila, PhD, MPH; Byron L.
Lam, MD; Sander R. Dubovy, MD; Kathryn E. McCollister, PhD; Lora E. Fleming, MD,
PhD; Diane D. Zheng, MS; David J. Lee, PhD
Suggested citation for this article: Caban-Martinez AJ, Davila EP, Lam
BL, Dubovy SR, McCollister KE, Fleming LE, et al. Age-related macular
degeneration and smoking cessation advice by eye care providers: a pilot study.
Prev Chronic Dis 2011;8(6):A147.
Smoking is a modifiable risk factor for age-related macular degeneration
(AMD), the leading cause of irreversible vision loss in the United States. We
conducted a pilot study among eye care providers and AMD patients to assess
smoking cessation preferences and cessation services offered at a large academic
medical center. Most patients who smoke reported never being advised to quit
smoking, although most eye care providers reported that they had advised smokers
to quit. Two-thirds of providers expressed a desire for additional training and
resources to support patient quit attempts, indicating the need for the
integration of smoking cessation opportunities in the clinic setting.
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In the United States, age-related macular degeneration (AMD) is the leading
cause of severe and irreversible vision loss, affecting more than 9.1 million
people. Because of the increasing number of older people in the US population,
this number is expected to increase to 17.8 million by 2050 (1). Treatment
options for “dry” AMD (eg, loss of retinal pigment and photoreceptors in the
central part of the eye) are limited; therefore, addressing the few modifiable
risk factors of AMD such as smoking is important (2). Little is known about the
level of smoking cessation services offered to patients who smoke and who are
being treated for AMD and the smoking cessation preferences of these patients
(2). The purpose of this pilot study was to assess tobacco use and smoking
cessation preferences of AMD patients and level and preference of smoking
cessation services offered by their eye care providers at a large academic
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The institutional review board at the University of Miami approved this pilot
study. In June 2009, we sent clinical faculty, fellows, and residents at the
Bascom Palmer Eye Institute (BPEI) an e-mail message (and 1 follow-up reminder),
extending an invitation to participate in a brief, anonymous Web-based, 16-item
survey (SurveyMonkey, Palo Alto, California). We used a modified question set
obtained from the Association of American Medical Colleges’ national smoking
cessation survey of primary health care providers (3). The survey inquired about
awareness and clinical practice of treating patients who smoke, specific eye
care provider medical training, and provider sociodemographic characteristics.
During the same time, study team interviewers approached AMD patients who
were visiting a BPEI retinal clinic in the patient waiting area to explain study
objectives, assess interest in participating, and obtain verbal consent. Inclusionary participant criteria included having a diagnosis of AMD, being aged
18 years or older, and being fluent in English or Spanish. Interviewers
administered an anonymous, language-sensitive (English or Spanish), 43-item
paper questionnaire developed on the basis of standard tobacco use questions
from the Centers for Disease Control and Prevention’s Behavioral Risk Factor
Surveillance System survey and the Tobacco Use Supplement of the National Cancer
Institute’s Current Population Survey, as well as selected study-specific vision
health and eye disease questions (4,5). No participant incentives were provided.
Analyses were performed using Predictive Analytics Software (SPSS, Inc, Chicago,
Illinois) version 18.0.
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Eye care provider responses
The response rate for the eye care provider questionnaire was 51% (46 of 90).
Forty-six percent of providers were women, 65% were faculty members, 17% were
fellows, and 17% were residents; the most common age group was 30 to 39 years.
Most eye care providers indicated that they seldom or periodically asked about
their patients’ smoking status, assessed their willingness to quit, and advised
them to quit smoking (Table 1).
The proportion of providers who indicated that they always engaged in these
activities ranged from 7% to 28%. Eye care providers were aware that individual
counseling for smoking cessation was available at the institution (94%) but were
less aware that group counseling (7%) and multilingual resources were available
(13%) (Table 2).
Most eye care providers indicated that they would recommend these services if
readily available in the clinic.
When prompted to identify which smoking cessation training or information the
eye care provider would like to use, 46% wanted training on how to select
self-help materials to give their patients and 39% wanted to learn how to
provide social support to their patients as part of their cessation treatment.
Most eye care providers indicated that their medical school education did not
provide adequate training to effectively provide smoking cessation assistance to
their patients (65%).
The response rate for the AMD patient questionnaire was 100% (52 of 52).
Respondents’ age ranged from 52 to 97 years (mean age, 81 y).
Forty-eight respondents were white and 4 were black; 22 reported Hispanic ethnicity. Of
respondents, 19 had a high school diploma or less, and 51 reported some type of
health care insurance coverage. More than half of patients (54%) were not
certain whether smoking causes macular degeneration or severe visual impairment,
and 17% were smokers who, on average, visited an ophthalmologist 5 times per
year. Nearly 90% of smokers reported never being advised to quit by their eye care provider, although two-thirds (n = 6) reported that they were seriously
considering quitting smoking in the next 6 months.
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Epidemiologic evidence strongly suggests a causal relationship between
smoking and the development of AMD (6). We found that a large proportion of AMD
clinic patients were unaware of the link between smoking and eye disease. Eye
care providers were interested in providing more smoking cessation services for
their patients who smoke but generally reported lacking appropriate training,
which indicates that opportunities exist for enhancing eye care and medical
training curricula. Emerging evidence indicates that the risk of tobacco
use–related eye diseases decreases substantially after smoking cessation, as
suggested by the Rotterdam Study and from other scientific review articles
(7-9). Therefore, enhancement of smoking cessation efforts among AMD patients
should be considered an ocular-health priority, although the provision of such
services should be offered to all clinic patients, given the overall deleterious
health effects of continued smoking (10).
The sample size of this pilot study was small; administration of the eye care
provider and patient questionnaires across a more representative sample of
private practice and tertiary eye care clinics may provide additional insight
into factors that influence the awareness and attitudes of patients and eye care
providers in smoking cessation efforts. Finally, eye care provider survey
response rates were slightly lower than those observed in national surveys of
health care providers (11).
In conclusion, this study documented that both clinicians and their patients
with AMD who smoke expressed a desire to facilitate and initiate quit attempts.
Addiction to tobacco is increasingly considered to be a chronic condition often
characterized by repeated attempts to maintain long-term abstinence (1,2).
System-based approaches in which comprehensive smoking cessation services (eg,
telephone quitlines) are embedded in integrated patient-care models have shown
promising results (3), yet such a comprehensive program has yet to be
established and validated in an ocular clinic setting. Development of such a
program in the context of the setting of busy eye care providers will not only
help create awareness of the relationship between smoking and ocular disease
risk but may also reduce the overall burden of tobacco use–associated disease in
this high-risk population.
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Support for this study was provided in part by a National Eye Institute
grant (no. R21-EY019096). None of the study authors have a commercial conflict of
interest to declare. We acknowledge the editorial skills of Mrs Laura McClure
and thank the clinic patients, staff members, and eye care providers that participated and supported this pilot study.
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Corresponding Author: Alberto J. Caban-Martinez, MPH, CPH, Department of
Epidemiology and Public Health, University of Miami, Miller School of Medicine,
Clinical Research Building, Room 1075, 1120 NW 14th St, 10th Fl (R-669), Miami,
FL 33136. Telephone: 305-243-7565. E-mail:
Author Affiliations: Evelyn P. Davila, Kathryn E. McCollister, Lora E.
Fleming, Diane D. Zheng, Department of Epidemiology and Public Health,
University of Miami, Miller School of Medicine, Miami, Florida; Byron L. Lam,
Sander R. Dubovy, Department of Ophthalmology, University of Miami, Miller
School of Medicine, Miami, Florida; David J. Lee, Department of Epidemiology and
Public Health and Department of Ophthalmology, University of Miami, Miller
School of Medicine, Miami, Florida.
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