- Email: [email protected]
Practice Patterns Among Eye Care Providers at US Teaching Hospitals With Regard to Assessing and Educating Patients About Smoking
Accepted Manuscript Practice Patterns Among Eye Care Providers at US Teaching Hospitals with Regards to Assessing and Educating Patients About Smoking Zachary C. Landis, Ramunas Rolius, Ingrid U. Scott PII:
S0002-9394(17)30225-8
DOI:
10.1016/j.ajo.2017.05.023
Reference:
AJOPHT 10153
To appear in:
American Journal of Ophthalmology
Received Date: 25 July 2016 Revised Date:
24 May 2017
Accepted Date: 25 May 2017
Please cite this article as: Landis ZC, Rolius R, Scott IU, Practice Patterns Among Eye Care Providers at US Teaching Hospitals with Regards to Assessing and Educating Patients About Smoking, American Journal of Ophthalmology (2017), doi: 10.1016/j.ajo.2017.05.023. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Abstract
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Purpose To investigate practice patterns of eye care providers at academic medical centers in the United States (US) with regards to assessing patients’ smoking status and exposure, educating patients regarding ocular risks of smoking, and counseling patients about smoking cessation. Design Cross-sectional survey.
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Methods An anonymous survey including multiple choice and Likert-style questions was constructed on http://www.surveymonkey.com and emailed to the coordinators of all 113 US ophthalmology residency programs, with a request to forward to all faculty, fellows, residents, and optometrists at their institution. Main outcome measures include proportion of eye care providers who assess patients’ smoking status, educate patients regarding ocular risks of smoking, and discuss with patients smoking cessation options. Results Of the 292 respondents, 229 (78%) “always” or “periodically” ask patients about their smoking status, 251 (86%) “seldom” or “never” ask patients about second-hand smoke exposure, 245 (84%) “always” or “periodically” educate patients about ocular diseases associated with smoking, 142 (49%) “seldom” or “never” ask patients who smoke about their willingness to quit smoking, and 249 (85%) “seldom” or “never” discuss potential methods to assist with smoking cessation.
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Conclusions Most eye care providers assess patients’ smoking status and educate patients regarding ocular risks of smoking. However, approximately half do not ask, or seldom ask, about patients’ willingness to quit smoking, and most do not discuss smoking cessation options.
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Practice Patterns Among Eye Care Providers at US Teaching Hospitals with Regards to Assessing and Educating Patients About Smoking
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Short Title: Practice Patterns Regarding Educating Patients About Smoking
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Zachary C. Landis,1 Ramunas Rolius,1 Ingrid U. Scott1,2
1
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Penn State Eye Center, Department of Ophthalmology, Penn State College of
Medicine, Hershey, PA 17033, USA 2
Department of Public Health Sciences, Penn State College of Medicine,
Correspondence to:
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Hershey, PA 17033, USA
Ingrid U. Scott, MD, MPH
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Department of Ophthalmology
Penn State College of Medicine
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500 University Dr, HU19
Hershey, PA 17033-0850 Phone: (717) 531-8783 Fax: (717) 531-5475
Email: [email protected]
1
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Introduction
Smoking is a significant modifiable risk factor for various ocular diseases. The relationship between smoking and age-related macular degeneration (AMD)
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has been well documented in numerous epidemiologic studies.1-3 A recent metaanalysis of five case-control studies and five cross-sectional studies found
smoking to be the strongest and most consistent modifiable risk factor for late
SC
AMD.2 In addition, the relationship between smoking and cataract has been well established, most consistently with the development of nuclear cataract.3,4 A
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weaker association has been demonstrated between smoking and open-angle glaucoma.3 While the current literature does not demonstrate an association between smoking and diabetic retinopathy, several studies have documented the detrimental systemic health effects of smoking in patients with diabetes
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mellitus.3,5
Despite the proven associations between smoking and several ocular and systemic diseases of public health importance, there has been little investigation
EP
into the role eye care providers play in educating patients about the health risks of smoking and encouraging smoking cessation. In a recent pilot study performed
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at a single center in the United States (US), a survey was distributed to all faculty, fellows, and residents at an academic medical center.6 Forty-six of the 90 eye care providers (51%) responded. Of the 46 respondents, 40 (87%) periodically/seldom or never asked about patients’ smoking status, 43 (93%) periodically/seldom or never assessed patient willingness to quit smoking, and 33 (72%) periodically/seldom or never advised patients to quit smoking.6
2
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To our knowledge, there is only one study in the literature that investigated, on a broader level, the role eye care providers in the United States play in educating patients about the health risks of smoking and encouraging
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smoking cessation, and that study was performed over a decade ago.7 In that
study, a survey was distributed to licensed ophthalmologists and optometrists in four western states of the United States (no resident or fellowship-level eye care
SC
providers were included); 30% of ophthalmologists and 16% of optometrists
reported that they regularly advise patients to quit smoking.7 According to a more
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recent study conducted in the United Kingdom and consisting predominantly of optometrists, about one-third of eye care providers assess smoking status and counsel patients about smoking cessation.8
It has been reported that fear of blindness is greater than fear of other
TE D
diseases related to smoking, such as lung cancer and heart disease.9,10 Nearly half of the United States population in a large survey rank losing vision as the worst health condition that could happen to them.11 However, only approximately
EP
33% to 50% of the population is aware that smoking is a risk factor for eye disease that can lead to blindness.9,11 The role of public health approaches
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specifically targeting smoking prevention and cessation through graphic health warning labels (GHWL) was reported to be effective specifically in younger populations, but more recent cross-sectional studies have demonstrated that repeated exposure to GHWL may decrease their effectiveness.10,12 As public health approaches through GHWL may be losing traction in certain populations, more weight may be placed on the individual patient-provider interaction. To our
3
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knowledge, there is minimal evidence specifically on the role of eye care provider-patient interactions in preventing smoking and aiding in smoking cessation.
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The current study aims to investigate practice patterns of eye care
providers and providers-in-training at academic medical centers in the US with
regards to assessing patients’ smoking status and exposure, educating patients
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smoking cessation methods and resources.
SC
regarding ocular risks of smoking, and providing information to patients about
Methods
The study protocol was approved by the Institutional Review Board of the Penn State College of Medicine. An email containing a description of the study,
TE D
an invitation to participate, and the survey link was sent to the coordinator of each ophthalmology residency program accredited by the Accreditation Council for Graduate Medical Education (ACGME), with a request to forward the email to
EP
all ophthalmologists, optometrists, fellows, and residents at their institution. Demographic information, including age, gender, race, current level of
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training (resident, fellow, or attending), and years since completion of residency/fellowship training (if applicable), was collected, followed by a 13question survey consisting of multiple choice and Likert-style questions (Table 1). Participants were asked to select among four response options (always, periodically, seldom, never). Weekly reminders were emailed for 4 consecutive weeks. Additional follow-up was performed through phone calls to all of the
4
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residency program coordinators to confirm that the survey had been distributed. In addition, in order to determine the response rate while maintaining anonymity, the program coordinator was requested to provide the number of faculty, fellows,
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and residents to whom the survey was distributed; however, in some cases the residency program coordinator did not provide this information.
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Results
The survey was emailed to the program coordinator of each of the 113
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ACGME-accredited ophthalmology residency programs in the US. Forty-six program coordinators confirmed that the survey was distributed to all eye care providers at their institutions and provided an exact number of eye care providers to whom it was distributed (n=1374). Seven program coordinators confirmed that
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their program was not participating in the study. Seventy program coordinators provided no response. Two hundred ninety-two eye care providers responded to the survey. Thus, although the actual response rate is unknown, the highest
21.25%.
EP
possible response rate, based on the confirmed number of surveys distributed, is
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Fifty-one percent of the respondents were male. Seventy-five percent of
the respondents identified themselves as Caucasian, 18% as Asian, 2% as Black/African-American, and the remainder as other or from multiple races. Two hundred sixty-nine (92%) of the respondents were trained as, or in training as, ophthalmologists, while the other 23 (8%) were trained as optometrists.
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Of the ophthalmology respondents, 148 (55%) were faculty members, 19 (7%) were fellows, and 102 (38%) were residents. Of the faculty respondents, 113 (76%) had completed fellowship training, and 33 (22%) had not (2 did not
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respond to the question). Ninety-six (33%) respondents believe they had not received adequate smoking counseling training during residency, 125 (43%) believe they had received adequate smoking counseling training during
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residency, and 71 (24%) were unsure. Despite receiving responses from
ophthalmologists in all of the subspecialties, the number of responses within
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each subspecialty was too small to analyze for potential differences among subspecialists.
All responses among the 292 providers to the thirteen questions are displayed in Table 1. Of the 292 respondents, 101 (35%) “always” ask patients
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about their smoking status, 179 (61%) “never” ask patients about second-hand smoke exposure, 97 (33%) “always” educate patients about ocular diseases associated with smoking, and 40 (14%) “always” ask patients who smoke about
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their willingness to quit smoking.
A breakdown of responses by provider type are displayed in Table 2.
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Sixty-two (42%) ophthalmology faculty “always” ask about smoking status, 27 (18%) “always” assess willingness to quit smoking, and 61 (41%) “always” advise smoking cessation. Twenty (20%) ophthalmology residents “always” ask about smoking status, 9 (9%) “always” assess willingness to quit, and 31 (30%) “always” advise smoking cessation. Eighty-five (32%) ophthalmologists (at all levels) “always” ask about smoking status, 37 (14%) “always” assess willingness
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to quit smoking, and 98 (36%) “always” advise smoking cessation. Sixteen (70%) optometrists “always” ask patients about smoking status, 3 (13%) “always” assess willingness to quit smoking, and 9 (39%) “always” advise smoking
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cessation.
Discussion
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The current study represents the first national survey of practice patterns among eye care providers and providers-in-training at teaching hospitals in the
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US with regards to assessing patients’ smoking status and exposure, educating patients regarding ocular and systemic risks of smoking, and providing patients with information about smoking cessation. In the current study, a minority of eye care providers consistently ask patients about their smoking habits and advise
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their smoking patients to stop smoking. Further, the majority of eye care providers do not ask patients about second-hand smoke exposure, do not consistently ask patients who smoke about their willingness to quit smoking, and
EP
do not discuss with patients potential methods to assist with smoking cessation. One major limitation for eye care providers with regards to facilitating
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smoking cessation among their patients is time. However, as the link between smoking and various eye and general health diseases is well-established in the literature, smoking cessation is an important part of optimizing ocular and systemic health. One time-efficient intervention that even very busy clinicians can perform is providing smokers with an educational brochure containing information regarding the ocular and general health risks of smoking and smoking cessation
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methods and resources which are available (including contact information for providers who administer/provide smoking cessation methods). In the current study, ophthalmology faculty members were twice as likely
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as ophthalmology residents to ask patients about smoking status (42% vs. 20%), and to assess patient willingness to quit smoking (18% vs. 9%). Faculty
members were also more likely than residents to advise smoking cessation (41%
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vs. 30%). This may be due, at least in part, to residents’ perceiving their role as supportive, rather than primary, and one focused on learning ophthalmologic
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concepts and technical skills and providing strictly ophthalmologic care. However, given the strong association between smoking and ocular disease, it is important for all eye care providers to be aware of the role they can play in encouraging smoking cessation among patients.
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Compared to ophthalmologists (42%) and ophthalmologists-in-training (20%), a higher proportion of optometrists (70%) ask patients about smoking status, yet a similar proportion in each group of eye care providers assesses
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patient willingness to quit smoking and advise smoking cessation. Optometrists may take a more comprehensive, rather than subspecialized, approach to eye
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care than ophthalmologists at teaching hospitals (most of whom are subspecialists) and, therefore, may be more likely to routinely ask about smoking. However, only slightly more than half of optometrists advise patients who smoke to quit smoking, which highlights the need for eye care providers to recognize the importance of not only screening for smoking, but educating patients regarding the importance of smoking cessation.
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The majority of eye care providers never assesses second-hand smoke exposure. Passive exposure to tobacco smoke has been demonstrated to not only have similar risks to active smoking in systemic disease, but also to have
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negative effects on ocular health. Several studies have documented the
relationship between passive smoke exposure and hypermetropia in children, as well as ocular surface epithelial damage in contact lens wearers.13,14 Overall,
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however, there are relatively few studies that look specifically at passive tobacco smoke exposure and ocular disease, indicating the need for further
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investigation.15,16
Study limitations include the relatively small number of responses, the inability to calculate a definite response rate, and the inability to compare practice patterns across ophthalmologic subspecialty providers. The reported response
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rate of 21.25% is based on confirmed data from 46 ophthalmology programs across the United States. Due to the lack of information from 70 programs, 21.25% is the highest possible response rate and the actual response rate is
EP
unknown. Additional limitations include the limited Likert-style response choices and the potential ambiguity of the response options. Despite our survey tool
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being based on a modified version of the only published survey on this topic, several of the questions may have been ambiguous to the respondents.6 For example, for such survey items as “educate patients about ocular diseases associated with smoking” and “educate patients about systemic diseases associated with smoking”, it is unknown whether the eye care providers responded to such questions as applied to only their smoking patients or as
9
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applied to all of their patients (smokers and nonsmokers). In addition, the answer choice “periodically” may be interpreted by respondents differently; “periodically” could be interpreted as more or less often than seldom, although the four choices
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were listed in order of what was perceived to be least frequent (“never”) to most frequent (“always”). In order to address this study limitation, “seldom” and
“periodically” were grouped together as a single column in Table 1. Finally, all
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comparisons are descriptive; given the relatively small group sample sizes (e.g. only 19 respondents were fellows), no statistical tests were performed to
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investigate whether group differences were statistically significant. Smoking is a well-known modifiable risk factor for various ocular diseases, including AMD and cataract. While most eye care providers assess patients’ smoking status and educate patients about the adverse effects of smoking on
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ocular diseases, most do not provide information regarding methods and resources to help patients quit smoking. This disconnect represents an opportunity for eye care providers to have a greater impact on not only patients’
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ocular health, but also patients’ systemic health. Ophthalmologists-in-training less frequently address smoking with their
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patients than do ophthalmology faculty. Ophthalmologists and optometrists at teaching hospitals also differ in their practice patterns. As the significance of smoking as a risk factor for numerous ocular and systemic diseases is well established, it is important to investigate further the role of eye care providers in facilitating smoking prevention and smoking cessation.
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Acknowledgements/Disclosure
annual meeting, May 3-7, 2015, Denver, Colorado.
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Presented in part at the Association for Research in Vision and Ophthalmology
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The authors have no financial or proprietary interest in the information presented.
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References 1
Klein R. Overview of progress in the epidemiology of age-related macular
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degeneration. Ophthalmic Epidemiology. 2007;14(4):184-7.
2
Chakravarthy U, Wong TY, Fletcher A, et al. Clinical risk factors for age-related
macular degeneration: a systematic review and meta-analysis. BMC
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Ophthalmology. 2010;10:31.
3
Ophthalmol. 2007;144(6):961-9.
4
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Klein BEK, Klein R. Lifestyle exposures and eye disease in adults. Am J
Klein BE, Klein R, Linton KL, Franke T. Cigarette smoking and lens opacities:
5
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the Beaver Dam Eye Study. Am J Prev Med. 1993;9(1):27-30.
Klein R, Moss SE, Klein BE, DeMets DL. Relation of ocular and systemic factors
6
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to survival in diabetes. Arch Intern Med. 1989;149(2):266-72.
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Caban-Martinez AJ, Davila EP, Lam BL, et al. Age-related macular
degeneration and smoking cessation advice by eye care providers: a pilot study. Preventing Chronic Disease. 2011;8(6):1-4.
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7
Gordon JS, Andrews JA, Lichtenstein E, et al. Ophthalmologists’ and
optometrists’ attitudes and behaviours regarding tobacco cessation intervention.
8
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Tobacco Control. 2002;11(1):84-85.
Lawrenson JG, Evans JR. Advice about diet and smoking for people with or at
risk of age-related macular degeneration: a cross-sectional survey of eye care
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professionals in the UK. BMC Public Health. 2013;13:564.
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Ng DH, Roxburgh ST, Sanjay S, Au Eong KG. Awareness of smoking risks and
attitudes towards graphic health warning labels on cigarette packs: a crosscultural study of two populations in Singapore and Scotland. Eye (Lond).
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2010;24(5)864-8.
Moradi P, Thornton J, Edwards R, Harrison RA, Washington SJ, Kelly SP.
Teenagers' perceptions of blindness related to smoking: a novel message to a
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vulnerable group. Br J Ophthalmol. 2007;91(5):605–7.
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Scott AW, Bressler NM, Ffolkes S, Wittenborn JS, Jorkasky J. Public attitudes
about eye and vision health. JAMA Ophthalmol. 2016;134(10):1111-8.
12
Ratneswaran C, Chisnall B, Li M, et al. Desensitisation to cigarette package
graphic health warnings: a cohort comparison between London and Singapore. BMJ Open. 2016;6(10):e012693.
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13
El-Shazly. Passive smoking exposure might be associated with hypermetropia.
Ophthalmic Physiol Opt. 2012;32(4):304-307.
14
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Ward SK, Dogru M, Wakamatsu T, et al. Passive cigarette smoke exposure
and soft contact lens wear. Optom Vis Sci. 2010;87(5):367-372.
15
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Lois N, Abdelkader E, Reglitz K, et al. Environmental tobacco smoke exposure
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and eye disease. Br J Ophthalmol. 2008;92(10):1304-1310.
Klein R, Knudtson MD, Cruickshanks KJ, Klein BEK. Further observations on
the association between smoking and the long-term incidence and progression of age-related macular degeneration: The Beaver Dam Eye Study. Arch Ophtalmol.
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2008;126(1):115-121.
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Table 1. Eye care provider responses to survey questions (n=292) How Often Do You Always Periodically/ Seldom
Never
34.59% (101)
62.33% (182)
3.08% (9)
Assess patient willingness to quit smoking? Advise patients to stop smoking?
13.70% (40)
73.63% (215)
12.67% (37)
36.64% (107)
60.28% (176)
3.08% (9)
Refer patients who smoke to other providers for smoking cessation? Recommend nicotine replacement therapy? Recommend switching to electronic cigarettes?
7.19% (21)
52.40% (153)
40.41% (118)
1.71% (5)
35.27% (103)
63.01% (184)
15.76% (46)
83.56% (244)
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0.68% (2)
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Ask about smoking status?
0.34% (1)
5.14% (15)
94.52% (276)
1.37% (4)
12.33% (36)
86.30% (252)
33.22% (97)
62.67% (183)
4.11% (12)
20.21% (59)
68.15% (199)
11.64% (34)
0.34% (1)
13.02% (38)
86.64% (253)
5.48% (16)
36.64% (107)
57.88% (169)
4.79% (14)
33.91% (99)
61.30% (179)
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Prescribe other medications for the purpose of facilitating smoking cessation? Provide brochures/self-help materials? Educate patients about ocular diseases associated with smoking? Educate patients about systemic diseases associated with smoking? Arrange follow-up visits with patients to address smoking? Monitor patient progress in attempting to quit smoking? Ask about second-hand smoke exposure in the home?
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Table 2. “Always” responses by provider type How Often Do You Ophthalmology Ophthalmology Faculty Residents 19.61% (20)
69.57% (16)
18.24% (27)
8.82% (9)
13.04% (3)
41.22% (61)
30.39% (31)
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41.89% (62)
39.13% (9)
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Always ask about smoking status? Always assess patient willingness to quit smoking? Always advise patients to stop smoking?
Optometrists
S0002-9394(17)30225-8
DOI:
10.1016/j.ajo.2017.05.023
Reference:
AJOPHT 10153
To appear in:
American Journal of Ophthalmology
Received Date: 25 July 2016 Revised Date:
24 May 2017
Accepted Date: 25 May 2017
Please cite this article as: Landis ZC, Rolius R, Scott IU, Practice Patterns Among Eye Care Providers at US Teaching Hospitals with Regards to Assessing and Educating Patients About Smoking, American Journal of Ophthalmology (2017), doi: 10.1016/j.ajo.2017.05.023. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Abstract
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Purpose To investigate practice patterns of eye care providers at academic medical centers in the United States (US) with regards to assessing patients’ smoking status and exposure, educating patients regarding ocular risks of smoking, and counseling patients about smoking cessation. Design Cross-sectional survey.
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SC
Methods An anonymous survey including multiple choice and Likert-style questions was constructed on http://www.surveymonkey.com and emailed to the coordinators of all 113 US ophthalmology residency programs, with a request to forward to all faculty, fellows, residents, and optometrists at their institution. Main outcome measures include proportion of eye care providers who assess patients’ smoking status, educate patients regarding ocular risks of smoking, and discuss with patients smoking cessation options. Results Of the 292 respondents, 229 (78%) “always” or “periodically” ask patients about their smoking status, 251 (86%) “seldom” or “never” ask patients about second-hand smoke exposure, 245 (84%) “always” or “periodically” educate patients about ocular diseases associated with smoking, 142 (49%) “seldom” or “never” ask patients who smoke about their willingness to quit smoking, and 249 (85%) “seldom” or “never” discuss potential methods to assist with smoking cessation.
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EP
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Conclusions Most eye care providers assess patients’ smoking status and educate patients regarding ocular risks of smoking. However, approximately half do not ask, or seldom ask, about patients’ willingness to quit smoking, and most do not discuss smoking cessation options.
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Practice Patterns Among Eye Care Providers at US Teaching Hospitals with Regards to Assessing and Educating Patients About Smoking
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Short Title: Practice Patterns Regarding Educating Patients About Smoking
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Zachary C. Landis,1 Ramunas Rolius,1 Ingrid U. Scott1,2
1
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Penn State Eye Center, Department of Ophthalmology, Penn State College of
Medicine, Hershey, PA 17033, USA 2
Department of Public Health Sciences, Penn State College of Medicine,
Correspondence to:
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Hershey, PA 17033, USA
Ingrid U. Scott, MD, MPH
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Department of Ophthalmology
Penn State College of Medicine
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500 University Dr, HU19
Hershey, PA 17033-0850 Phone: (717) 531-8783 Fax: (717) 531-5475
Email: [email protected]
1
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Introduction
Smoking is a significant modifiable risk factor for various ocular diseases. The relationship between smoking and age-related macular degeneration (AMD)
RI PT
has been well documented in numerous epidemiologic studies.1-3 A recent metaanalysis of five case-control studies and five cross-sectional studies found
smoking to be the strongest and most consistent modifiable risk factor for late
SC
AMD.2 In addition, the relationship between smoking and cataract has been well established, most consistently with the development of nuclear cataract.3,4 A
M AN U
weaker association has been demonstrated between smoking and open-angle glaucoma.3 While the current literature does not demonstrate an association between smoking and diabetic retinopathy, several studies have documented the detrimental systemic health effects of smoking in patients with diabetes
TE D
mellitus.3,5
Despite the proven associations between smoking and several ocular and systemic diseases of public health importance, there has been little investigation
EP
into the role eye care providers play in educating patients about the health risks of smoking and encouraging smoking cessation. In a recent pilot study performed
AC C
at a single center in the United States (US), a survey was distributed to all faculty, fellows, and residents at an academic medical center.6 Forty-six of the 90 eye care providers (51%) responded. Of the 46 respondents, 40 (87%) periodically/seldom or never asked about patients’ smoking status, 43 (93%) periodically/seldom or never assessed patient willingness to quit smoking, and 33 (72%) periodically/seldom or never advised patients to quit smoking.6
2
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To our knowledge, there is only one study in the literature that investigated, on a broader level, the role eye care providers in the United States play in educating patients about the health risks of smoking and encouraging
RI PT
smoking cessation, and that study was performed over a decade ago.7 In that
study, a survey was distributed to licensed ophthalmologists and optometrists in four western states of the United States (no resident or fellowship-level eye care
SC
providers were included); 30% of ophthalmologists and 16% of optometrists
reported that they regularly advise patients to quit smoking.7 According to a more
M AN U
recent study conducted in the United Kingdom and consisting predominantly of optometrists, about one-third of eye care providers assess smoking status and counsel patients about smoking cessation.8
It has been reported that fear of blindness is greater than fear of other
TE D
diseases related to smoking, such as lung cancer and heart disease.9,10 Nearly half of the United States population in a large survey rank losing vision as the worst health condition that could happen to them.11 However, only approximately
EP
33% to 50% of the population is aware that smoking is a risk factor for eye disease that can lead to blindness.9,11 The role of public health approaches
AC C
specifically targeting smoking prevention and cessation through graphic health warning labels (GHWL) was reported to be effective specifically in younger populations, but more recent cross-sectional studies have demonstrated that repeated exposure to GHWL may decrease their effectiveness.10,12 As public health approaches through GHWL may be losing traction in certain populations, more weight may be placed on the individual patient-provider interaction. To our
3
ACCEPTED MANUSCRIPT
knowledge, there is minimal evidence specifically on the role of eye care provider-patient interactions in preventing smoking and aiding in smoking cessation.
RI PT
The current study aims to investigate practice patterns of eye care
providers and providers-in-training at academic medical centers in the US with
regards to assessing patients’ smoking status and exposure, educating patients
M AN U
smoking cessation methods and resources.
SC
regarding ocular risks of smoking, and providing information to patients about
Methods
The study protocol was approved by the Institutional Review Board of the Penn State College of Medicine. An email containing a description of the study,
TE D
an invitation to participate, and the survey link was sent to the coordinator of each ophthalmology residency program accredited by the Accreditation Council for Graduate Medical Education (ACGME), with a request to forward the email to
EP
all ophthalmologists, optometrists, fellows, and residents at their institution. Demographic information, including age, gender, race, current level of
AC C
training (resident, fellow, or attending), and years since completion of residency/fellowship training (if applicable), was collected, followed by a 13question survey consisting of multiple choice and Likert-style questions (Table 1). Participants were asked to select among four response options (always, periodically, seldom, never). Weekly reminders were emailed for 4 consecutive weeks. Additional follow-up was performed through phone calls to all of the
4
ACCEPTED MANUSCRIPT
residency program coordinators to confirm that the survey had been distributed. In addition, in order to determine the response rate while maintaining anonymity, the program coordinator was requested to provide the number of faculty, fellows,
RI PT
and residents to whom the survey was distributed; however, in some cases the residency program coordinator did not provide this information.
SC
Results
The survey was emailed to the program coordinator of each of the 113
M AN U
ACGME-accredited ophthalmology residency programs in the US. Forty-six program coordinators confirmed that the survey was distributed to all eye care providers at their institutions and provided an exact number of eye care providers to whom it was distributed (n=1374). Seven program coordinators confirmed that
TE D
their program was not participating in the study. Seventy program coordinators provided no response. Two hundred ninety-two eye care providers responded to the survey. Thus, although the actual response rate is unknown, the highest
21.25%.
EP
possible response rate, based on the confirmed number of surveys distributed, is
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Fifty-one percent of the respondents were male. Seventy-five percent of
the respondents identified themselves as Caucasian, 18% as Asian, 2% as Black/African-American, and the remainder as other or from multiple races. Two hundred sixty-nine (92%) of the respondents were trained as, or in training as, ophthalmologists, while the other 23 (8%) were trained as optometrists.
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Of the ophthalmology respondents, 148 (55%) were faculty members, 19 (7%) were fellows, and 102 (38%) were residents. Of the faculty respondents, 113 (76%) had completed fellowship training, and 33 (22%) had not (2 did not
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respond to the question). Ninety-six (33%) respondents believe they had not received adequate smoking counseling training during residency, 125 (43%) believe they had received adequate smoking counseling training during
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residency, and 71 (24%) were unsure. Despite receiving responses from
ophthalmologists in all of the subspecialties, the number of responses within
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each subspecialty was too small to analyze for potential differences among subspecialists.
All responses among the 292 providers to the thirteen questions are displayed in Table 1. Of the 292 respondents, 101 (35%) “always” ask patients
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about their smoking status, 179 (61%) “never” ask patients about second-hand smoke exposure, 97 (33%) “always” educate patients about ocular diseases associated with smoking, and 40 (14%) “always” ask patients who smoke about
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their willingness to quit smoking.
A breakdown of responses by provider type are displayed in Table 2.
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Sixty-two (42%) ophthalmology faculty “always” ask about smoking status, 27 (18%) “always” assess willingness to quit smoking, and 61 (41%) “always” advise smoking cessation. Twenty (20%) ophthalmology residents “always” ask about smoking status, 9 (9%) “always” assess willingness to quit, and 31 (30%) “always” advise smoking cessation. Eighty-five (32%) ophthalmologists (at all levels) “always” ask about smoking status, 37 (14%) “always” assess willingness
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to quit smoking, and 98 (36%) “always” advise smoking cessation. Sixteen (70%) optometrists “always” ask patients about smoking status, 3 (13%) “always” assess willingness to quit smoking, and 9 (39%) “always” advise smoking
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cessation.
Discussion
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The current study represents the first national survey of practice patterns among eye care providers and providers-in-training at teaching hospitals in the
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US with regards to assessing patients’ smoking status and exposure, educating patients regarding ocular and systemic risks of smoking, and providing patients with information about smoking cessation. In the current study, a minority of eye care providers consistently ask patients about their smoking habits and advise
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their smoking patients to stop smoking. Further, the majority of eye care providers do not ask patients about second-hand smoke exposure, do not consistently ask patients who smoke about their willingness to quit smoking, and
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do not discuss with patients potential methods to assist with smoking cessation. One major limitation for eye care providers with regards to facilitating
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smoking cessation among their patients is time. However, as the link between smoking and various eye and general health diseases is well-established in the literature, smoking cessation is an important part of optimizing ocular and systemic health. One time-efficient intervention that even very busy clinicians can perform is providing smokers with an educational brochure containing information regarding the ocular and general health risks of smoking and smoking cessation
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methods and resources which are available (including contact information for providers who administer/provide smoking cessation methods). In the current study, ophthalmology faculty members were twice as likely
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as ophthalmology residents to ask patients about smoking status (42% vs. 20%), and to assess patient willingness to quit smoking (18% vs. 9%). Faculty
members were also more likely than residents to advise smoking cessation (41%
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vs. 30%). This may be due, at least in part, to residents’ perceiving their role as supportive, rather than primary, and one focused on learning ophthalmologic
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concepts and technical skills and providing strictly ophthalmologic care. However, given the strong association between smoking and ocular disease, it is important for all eye care providers to be aware of the role they can play in encouraging smoking cessation among patients.
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Compared to ophthalmologists (42%) and ophthalmologists-in-training (20%), a higher proportion of optometrists (70%) ask patients about smoking status, yet a similar proportion in each group of eye care providers assesses
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patient willingness to quit smoking and advise smoking cessation. Optometrists may take a more comprehensive, rather than subspecialized, approach to eye
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care than ophthalmologists at teaching hospitals (most of whom are subspecialists) and, therefore, may be more likely to routinely ask about smoking. However, only slightly more than half of optometrists advise patients who smoke to quit smoking, which highlights the need for eye care providers to recognize the importance of not only screening for smoking, but educating patients regarding the importance of smoking cessation.
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The majority of eye care providers never assesses second-hand smoke exposure. Passive exposure to tobacco smoke has been demonstrated to not only have similar risks to active smoking in systemic disease, but also to have
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negative effects on ocular health. Several studies have documented the
relationship between passive smoke exposure and hypermetropia in children, as well as ocular surface epithelial damage in contact lens wearers.13,14 Overall,
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however, there are relatively few studies that look specifically at passive tobacco smoke exposure and ocular disease, indicating the need for further
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investigation.15,16
Study limitations include the relatively small number of responses, the inability to calculate a definite response rate, and the inability to compare practice patterns across ophthalmologic subspecialty providers. The reported response
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rate of 21.25% is based on confirmed data from 46 ophthalmology programs across the United States. Due to the lack of information from 70 programs, 21.25% is the highest possible response rate and the actual response rate is
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unknown. Additional limitations include the limited Likert-style response choices and the potential ambiguity of the response options. Despite our survey tool
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being based on a modified version of the only published survey on this topic, several of the questions may have been ambiguous to the respondents.6 For example, for such survey items as “educate patients about ocular diseases associated with smoking” and “educate patients about systemic diseases associated with smoking”, it is unknown whether the eye care providers responded to such questions as applied to only their smoking patients or as
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applied to all of their patients (smokers and nonsmokers). In addition, the answer choice “periodically” may be interpreted by respondents differently; “periodically” could be interpreted as more or less often than seldom, although the four choices
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were listed in order of what was perceived to be least frequent (“never”) to most frequent (“always”). In order to address this study limitation, “seldom” and
“periodically” were grouped together as a single column in Table 1. Finally, all
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comparisons are descriptive; given the relatively small group sample sizes (e.g. only 19 respondents were fellows), no statistical tests were performed to
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investigate whether group differences were statistically significant. Smoking is a well-known modifiable risk factor for various ocular diseases, including AMD and cataract. While most eye care providers assess patients’ smoking status and educate patients about the adverse effects of smoking on
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ocular diseases, most do not provide information regarding methods and resources to help patients quit smoking. This disconnect represents an opportunity for eye care providers to have a greater impact on not only patients’
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ocular health, but also patients’ systemic health. Ophthalmologists-in-training less frequently address smoking with their
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patients than do ophthalmology faculty. Ophthalmologists and optometrists at teaching hospitals also differ in their practice patterns. As the significance of smoking as a risk factor for numerous ocular and systemic diseases is well established, it is important to investigate further the role of eye care providers in facilitating smoking prevention and smoking cessation.
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Acknowledgements/Disclosure
annual meeting, May 3-7, 2015, Denver, Colorado.
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Presented in part at the Association for Research in Vision and Ophthalmology
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The authors have no financial or proprietary interest in the information presented.
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Table 1. Eye care provider responses to survey questions (n=292) How Often Do You Always Periodically/ Seldom
Never
34.59% (101)
62.33% (182)
3.08% (9)
Assess patient willingness to quit smoking? Advise patients to stop smoking?
13.70% (40)
73.63% (215)
12.67% (37)
36.64% (107)
60.28% (176)
3.08% (9)
Refer patients who smoke to other providers for smoking cessation? Recommend nicotine replacement therapy? Recommend switching to electronic cigarettes?
7.19% (21)
52.40% (153)
40.41% (118)
1.71% (5)
35.27% (103)
63.01% (184)
15.76% (46)
83.56% (244)
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0.68% (2)
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Ask about smoking status?
0.34% (1)
5.14% (15)
94.52% (276)
1.37% (4)
12.33% (36)
86.30% (252)
33.22% (97)
62.67% (183)
4.11% (12)
20.21% (59)
68.15% (199)
11.64% (34)
0.34% (1)
13.02% (38)
86.64% (253)
5.48% (16)
36.64% (107)
57.88% (169)
4.79% (14)
33.91% (99)
61.30% (179)
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Prescribe other medications for the purpose of facilitating smoking cessation? Provide brochures/self-help materials? Educate patients about ocular diseases associated with smoking? Educate patients about systemic diseases associated with smoking? Arrange follow-up visits with patients to address smoking? Monitor patient progress in attempting to quit smoking? Ask about second-hand smoke exposure in the home?
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Table 2. “Always” responses by provider type How Often Do You Ophthalmology Ophthalmology Faculty Residents 19.61% (20)
69.57% (16)
18.24% (27)
8.82% (9)
13.04% (3)
41.22% (61)
30.39% (31)
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41.89% (62)
39.13% (9)
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Always ask about smoking status? Always assess patient willingness to quit smoking? Always advise patients to stop smoking?
Optometrists