Prevention involves correct information, but also shocking images that induce people to stop smoking.
Cigarette smoking has harmful effects on the entire organism and the eye is certainly no exception. The eye district that suffers the most damage is certainly the retina, in fact there is solid scientific evidence that smoking can promote the onset of Age-Related Macular Degeneration (AMD) and also the progression from the initial forms to proliferative neovascular forms, which can seriously impair visual capacity.
AMD is a complex retinal disease, the onset of which is linked to a multiplicity of genetic, environmental and lifestyle-related aetiological factors. Among the latter, cigarette smoking certainly has the most important impact, through a damage induction mechanism mediated partly by direct oxidation, depletion of antioxidant substances and then by complement activation and microvascular alterations. Clinically, these processes manifest themselves in the typical features of atrophic AMD: degeneration of the retinal pigment epithelium, formation of extracellular deposits such as drusen and thickening of Bruch's membrane. Subsequent steps of retinal damage, such as angiogenesis and choroidal neovascularisation, promote the transition to the more advanced stages of AMD.
Even the onset of cataract can be influenced by the effects of smoking. Scientific studies show that the intensity and cumulative effect of smoking increase the risk of cataracts; in fact, in smokers of more than 15 cigarettes per day, the risk of cataracts is 42% higher than in smokers who have never smoked.
Quitting smoking reduces the risk of cataracts over time, but still lasts for decades, certainly for more than 20 years and the longer the more intense and prolonged the smoking practice.
Smoking also increases the risks of dry eye and progression of the diabetic retinopathy.
Prevention and social responsibility
Discouraging the prevalence of cigarette smoking is a public health priority, which is pursued through clinical approachessuch as nicotine replacement and pharmacotherapy, and behavioural approachesranging from counselling to fiscal interventions (such as increasing excise duties).
Anti-smoking policies can have an important impact on populations as a whole, e.g. the discouraging effect that the increasing cost of a single packet or smoking bans in many public settings (schools, cinemas, bars, restaurants) can have.
Among the anti-smoking policy measures, special attention should be paid to the warnings on cigarette packets and, in particular with regard to vision, the phrase 'Smoking increases the risk of blindness'.
In Italy, since March 2018, cigarette manufacturers have been required to print this and other deterrent phrases on the packet, often in combination with deliberately striking images, implementing an April 2014 EU directive.
Why put shock images on packages
The question remains to what extent these warnings and especially the related images are effective and do not simply constitute a minor annoyance for smokers.
In this regard, a study by the American University of North Caroline showed that with the addition of pictures 40% of smokers stated that they had tried to quit during the course of the study, compared to 34% who had received packages with only text warnings. Furthermore, 5.7% of those who had received packets with the pictures quit for at least one week before the end of the study compared to 3.8% who had received only the pictures.
We need to understand at this point why shocking illustrations are a more powerful stimulus to quit smoking than dissuasive phrases. A very recent study published in the Annals of Behavioral Medicine showed that these images provoke a kind of aversive reaction and keep the accompanying message vivid in smokers' minds. In contrast to the predictions of many theories of health behaviour, warnings have been seen to exert very little influence through changes in beliefs and attitudes and even no influence through a change in risk perception.
One limitation of the conclusions reached in this study is that the smokers enrolled all had a strong motivation to quit, which may be absent in other long-term smokers.
Finally, it is difficult to predict whether the images may have the same impact over a long period of time or whether, with the onset of a kind of habituation, they may no longer play an important role in driving people to stop smoking.
Bibliographic references
Myers CE, Klein BE, Gangnon R, et al. Cigarette smoking and the natural history of age-related macular degeneration: the Beaver Dam Eye Study. Ophthalmology. 2014 Oct;121(10):1949-55.
Woodell A, Rohrer B. A mechanistic review of cigarette smoke and age-related macular degeneration. Adv Exp Med Biol. 2014;801:301-7.
Brewer NT, Hall MG, Noar SM, et al. Effect of Pictorial Cigarette Pack Warnings on Changes in Smoking Behavior A Randomized Clinical Trial. JAMA Intern Med. 2016 Jul 1;176(7):905-12.
Brewer NT, Parada H Jr, Hall MG, et al. Understanding Why Pictorial Cigarette Pack Warnings Increase Quit Attempts. Ann Behav Med. 2018 May 29. doi: 10.1093/abm/kay032.
Dr. Carmelo Chines
Direttore responsabile
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