Smoking, vaping, and the rising burden of ocular conditions: Public health perspective

Dear Editor, The global magnitude of visual impairment has increased significantly over the last few decades; one study reported that nearly 438 million people experienced visual impairment in 2019, representing a more than 90% increase from the estimates in 1990.[1] The results of another meta-analysis reported that 43 million people were blind and 295 million had moderate-to-severe vision loss by the year 2020.[1] It is important to note that the majority of the reported burden is in low- and middle-income nations, which accommodate almost 90% of visually impaired individuals.[1] The objectives of the article are to identify the impact of smoking and vaping on ocular conditions and propose public health measures and recommendations to minimize these identified impacts. Smoking tends to affect the eye health in multiple ways through oxidative stress by increasing the production of free radicals which expedites oxidative damage to ocular tissues, like lens and retina.[2] Further, the toxins present in cigarette smoke can cause narrowing and damage to blood vessels, which reduces oxygen and nutrient supply to the eyes, thereby affecting overall health of eyes.[2] In addition, due to the continuous exposure to smoke, irritation of ocular surface is triggered leading to redness and dryness in eyes.[2] The findings of a systematic review revealed that current smokers generally have 12 times higher risk of developing age-related macular degeneration, four times higher risk of developing cataract, and three times greater risk of developing primary open-angle glaucoma, compared to nonsmokers.[2] Tobacco smoke can irritate the ocular surface and significantly enhance the risk and severity of dry eye syndrome.[2] The available literature provides evidence about the role of smoking in proptosis and optic nerve damage in Graves’ disease, uveitis, and cystoid macular edema.[2] Vaping has been associated with the development of various ocular morbidities, and this is predominantly because of the harmful chemicals (viz. nicotine, propylene glycol, flavoring agents, carbonyl compounds, trace metals, etc.) that are released as aerosols.[3,4] E-cigarette users are at remarkable risk of developing dry eye disease, as free radicals and aldehydes released in vapor results in instability of the tear film, interfere with tear volume, and increase the chances of corneal staining.[3] In addition, second-hand and first-hand exposure to aerosols results in irritation of the ocular surface, and patients present with redness, tearing, and burning sensation.[3] The findings of a recently conducted study demonstrated the role of flavored liquids in inducing oxidative stress and inflammation of retinal pigment epithelial cells.[4] Nicotine present in these devices results in vasoconstriction in ocular vessels and can trigger nystagmus or abnormal eye movements.[4] Acknowledging the rising burden of visual impairment and the role of smoking and vaping in the causation of different ophthalmic morbidities, there is an urgent need to implement targeted interventions to reduce the adverse consequences.[2–5] The primary intervention is to counsel the patients for smoking cessation in each visit, as this can significantly improve quit rates and minimize ocular risk.[4] This can be coupled with offering nicotine replacement therapy to ensure successful cessation. It is advised to conduct fundus examination of smokers to facilitate early detection of cataract, vascular changes, and age-related macular degeneration.[2] In continuation, youth can be educated to quit smoking or vaping using social media platforms, wherein the focus is on the wide range of ocular morbidities attributed to these hazardous practices.[5] Another option would be to introduce these topics as a part of the school curriculum to make students aware of the harmful consequences and discourage them from initiation. There is a definite need to strictly impose existing legal provisions and bans to discourage youths from initiating smoking or vaping.[2] The effectiveness of these interventions can be significantly improved by providing telephonic or mobile-app support to cessation attempts and reducing smoking-induced ocular morbidities. Finally, there is a clear need to conduct longitudinal studies to ascertain the ocular consequences of vaping to fill the existing literature gaps.[3,4] However, the best outcome will depend on the adoption of an integrated approach, wherein experts from concerned sectors join hands to reduce the impact of smoking on ocular health.[1,2,5] In conclusion, smoking and vaping have been associated with a spectrum of ocular morbidities. The need of the hour is to create the awareness about these ocular conditions and encourage people to quit these hazardous practices to minimize the burden of smoking/vaping-induced eye problems. Data availability statement The literature pertaining to the article can be made available at request by contacting Saurabh RamBihariLal Shrivastava at [email protected] on reasonable request. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.