At the completion of this article, the reader should be able to…
• Describe current trends in tobacco smoking and vape use in Australia and across populations.
• Recognise the health harms of smoking tobacco and vaping, including nicotine dependence.
• Describe how to provide fast, simple and effective brief advice in a supportive and non-judgmental manner.
• Highlight the important role of multi-session behavioural intervention and referral pathways, including Quitline.
• Identify additional resources and supports available for health professionals to support patients on their quitting journey.
Nicola Martin
Health systems manager
Quit Victoria
Sabine Ostrowski
State manager
Quit Victoria
When the new year begins, many people will resolve to quit smoking or vaping. Optometrists can support this goal by explaining how smoking and/or vaping affect eye health, providing brief advice, and connecting patients with Quitline and pharmacotherapy options. In doing so, they will play an important role in helping patients safeguard their vision and their overall health.
Tobacco use is one of the leading causes of preventable disease and death in Australia.1 Most people who smoke and vape want to stop, and studies show many people who smoke are interested in smoking cessation support from a health professional.2,3
The use of nicotine vaping products (vapes), also known as e-cigarettes, has increased rapidly since their introduction to markets around 2004. Vapes are battery-operated devices that work by heating a liquid vaping substance until it becomes an aerosol that users inhale.4
A series of legislative changes commenced in Australia in October 2021, eventually restricting consumer access to nicotine vapes for therapeutic use only.5
Evidence on the effects of vapes is diverse and quickly evolving, however, these relatively new products are considered to have substantial public health impacts.4
How eye health professionals can support cessation
A visit to a health professional is an ideal opportunity for all people who smoke or vape to receive best practice care to quit.
Research has shown that smoking cessation interventions delivered by more than one type of health professional can increase quitting and readiness to quit.3
An appointment with an eye health professional who can provide fast, simple and effective cessation care might be the catalyst for a quit attempt or support the patient on their quitting journey.
Despite smoking rates continuing to decrease over time, about 1.8 million Australians still smoke every day.6
The number of people who use vapes tripled over four years from 2019, and dual use of both tobacco and vapes also increased.6
Landmark vaping reforms introduced in 2024 encourage cautious optimism as vaping rates started to plateau among young people in December 2024 after rising sharply from 2020 to their peak in 2023.7
While a small number of people who smoke may use vapes to help quit smoking, dual use does not appreciably reduce the harms of smoking. Furthermore, vapes can potentially introduce independent or additive health risks.7
Most Australians who smoke have a general understanding there are health risks associated with smoking, however, the majority lack a thorough understanding of smoking-related disease.8
While lung cancer, emphysema and heart disease are more commonly identified as caused by smoking, an Australian study showed less than 10% of people who smoke spontaneously identified stroke, eye problems and oral cancers as smoking-related diseases.8
A representative survey of smokers in Victoria conducted by Cancer Council Victoria found only 5.2% of people who smoke had unprompted recall of smoking causing eye problems and 1.1% unprompted recall of smoking causing blindness.
Coupled with emerging evidence about the physical risks of eye damage from exploding vaping devices9 and ocular exposures to vape liquid,10 every clinical interaction focused on eye health is an opportunity to educate patients about the many risks of both smoking and vaping in a non-judgemental and supportive way.
Smoking prevalence among Aboriginal and Torres Strait Islander people has progressively decreased over time and the majority of Aboriginal and Torres Strait Islander people who smoke report wanting to quit.11
Even brief advice from health professionals has been identified as a significant motivating factor for Aboriginal and Torres Strait Islander people to quit smoking and ‘should affirm the importance of such conversations for health professionals.’11
Other populations with higher smoking prevalence also demonstrate motivation to quit, including people with mental illness and those from low socio-economic groups.12,13 Like smoking, many people who vape report wanting to quit, including adolescents and adults.4
How smoking and vaping impact eye health
It is now known that smoking damages the eye and has a dose-response impact on eye health.14
Smoking cigarettes has been proven to increase the risk of numerous common and serious eye conditions, including glaucoma, age-related macular degeneration (AMD), cataracts and dry eye disease.14
AMD is a leading cause of blindness and the risk of developing advanced AMD increases with the number of years smoked and is also linked to passive smoking.15
People who smoke have a 3-5 fold increased risk of developing advanced AMD and smoking is also a modifiable risk factor for the progression of age-related AMD and neovascular (wet) AMD.15,16
The good news is that quitting smoking has been shown to protect against AMD, and stopping smoking before treatment of wet AMD gives outcomes almost equivalent to those for non-smokers.15
Several studies have also observed an increased risk among people who smoke for developing the ocular complications of Grave’s disease.1
While the effects of smoking on diabetic retinopathy are yet to be clearly demonstrated, smoking is a cause of diabetes and a risk factor for developing central retinal and branch retinal vein occlusions.1,15
Cigarette smoke also contains a complex mix of harmful constituents, that travel in the bloodstream and affect ocular tissues, potentially inducing oxidative stress and inflammation which impact ocular health.14
Smoking cessation delivered by eye health professionals is important to improve the overall health and mortality of patients, while lessening the burden of smoking-related ocular illnesses for which smoking is a modifiable risk factor.14,15,17
Evidence continues to emerge about health harms of vapes and their potential impact on health outcomes, including effects on the ocular surface.
Vape liquid may or may not contain nicotine as labelling of these liquids in Australia is a poor indicator of the contents, and nicotine is often present even when not listed or when the product is labelled as ‘nicotine free’.
Vapes have a negative impact on the stability and quality of the tear film, which may lead to an increase in dry eye disease among people who vape.18
There are other potential dangers from vapes which users may not have considered, including corneoscleral laceration and ocular burns from exploding devices, or vape liquid containers being mistaken for eye drops.9,10,18
Due to the potential carcinogenic effects of some vape ingredients, people who vape should be informed of the potential risks of ocular-related conditions to support them to make an informed decision about their vape use.18
Although a clear causal link has yet to be established, vaping has been linked to an increased risk of the same ocular diseases as smoking: cataract, AMD, glaucoma and Graves’ disease complications.19
Understanding nicotine dependence
Nicotine is one of thousands of compounds released from burning tobacco, however it is the major addictive substance in cigarettes and one of the most addictive substances known.20
Non-therapeutic vapes can deliver nicotine in concentrations similar to, or in excess of, those delivered by tobacco cigarettes and people who vape report withdrawal when they abstain.4
Nicotine is assessed as a drug of addiction, with the main features including withdrawal, tolerance and cravings.20
People who want to quit vaping report similar motivations to people who smoke, including health, financial and social reasons.4
There are instances where nicotine vapes are prescribed for people to quit smoking tobacco when they have been unsuccessful with first-line cessation therapy (behavioural counselling and pharmacotherapy). It is recommended that people who use vapes for this purpose switch completely from smoking to vaping for the short term and are then supported to stop vaping.5
How eyecare professionals can help
Nicotine dependence is a clinical issue and like any other chronic disease or addiction it needs to be considered as part of holistic care.
The Royal Australian and New Zealand College of Ophthalmologists (RANZCO) recommends smoking and vaping cessation treatment is integrated into standard clinical care using the best practice three-step brief advice model.15
Brief advice is a simple, fast and effective way to promote cessation and to connect patients with best practice treatment – a combination of multi-session behavioural intervention (Quitline) plus smoking cessation pharmacotherapy such as prescribed tablets or nicotine replacement therapy (NRT).
Brief advice should be offered to all people who smoke or vape, regardless of their interest in quitting.12
There is currently limited research on interventions that specifically target vaping cessation; however, strategies that have been shown to be effective for smoking are considered appropriate to support vaping cessation.5
A visit to an eye health professional is a key opportunity to have a conversation about quitting, and this should be considered as part of routine care. Most patients who smoke or vape want to quit, and equipping health professionals with the knowledge, skills and confidence to provide cessation support is an important component of a patient-centred approach.
Supporting patients to quit is a step toward improving their overall health as well as their eye health.
The AAH model
The ‘Ask, Advise, Help’ (AAH) brief advice model is a streamlined way to have a conversation with your patient about smoking and vaping, and to connect them to best practice cessation support.
• Ask: ‘Can I ask, do you smoke or vape?’
• Advise: Advise all patients who smoke and / or vape of the benefits of quitting in a clear, non-confrontational and personalised way…
‘I need to let you know that smoking increases your risk of some serious eye diseases and there is also evidence that vaping poses risks for the eyes. Smoking (and / or vaping) could be worsening your dry eyes / making your cataracts grow faster / is a risk factor because you have diabetes, etc. I really recommend you have a go at quitting. By using some stop smoking medications from your GP or pharmacist, together with coaching from Quitline your chances of quitting really improve.’
• Help: ‘Would you like me to get Quitline to give you a call to chat about how they can help you?
This model only takes a few minutes to deliver and supports the patient on their quitting journey. By linking smoking or vaping to their clinical risk and providing support to seek help, this approach reduces stigma the patient may feel around their cigarette or vape use.
Some patients may refuse the offer of help either because they are not interested in quitting or it may not be the right time for them.
In these situations, it is recommended to offer the patient written quitting information, let them know you will check in about their smoking and vaping next visit and reiterate you are available to support them whenever they are ready to quit.
RANZCO recommends that eyecare professionals consider implementing systems to track smoking status and provision of offers of support, including referral to Quitline and GPs.15
For patients who are willing to accept help, eye health professionals should advise people who smoke or vape to visit their GP or pharmacist for support to access appropriate pharmacotherapy which may be NRT or other medications.
It is strongly recommended that health professionals actively make a referral to Quitline with their patient’s consent via the online form or fax (https://www.quit.org.au/referral-form).
Quitline is a free service and proactive referral leads to substantially higher rates of engagement than simply advising someone to call.13
Quitline counsellors provide professional behavioural counselling, which is confidential, non-judgemental and tailored to the individual. They also provide tailored youth and LGBTIQA+ counselling, interpreters for languages other than English and a dedicated Aboriginal Quitline for Aboriginal and Tores Strait Islander Communities.
Quit offers brief advice online training modules, with extended learning for eye health professionals and other resources available.
References:
1. Winstanley MH, Winnall WR, Hanley-Jones S, Scollo M, Greenhalgh EM. 3.0 Tobacco—a leading preventable cause of death and disease. In: Scollo MM, Winstanley MH, editors. Tobacco in Australia: Facts and issues. Melbourne: Cancer Council Victoria; 2025. Available from: https://www.tobaccoinaustralia.org.au/chapter-3-health-effects/3-0-background
2. Thomas D, Abramson MJ, Bonevski B, et al. Quitting experiences and preferences for a future quit attempt: a study among inpatient smokers. BMJ Open. 2015;5:e006959. doi:10.1136/bmjopen-2014-006959
3. An LC, Foldes SS, Alesci NL, Bluhm JH, Bland PC, et al. The impact of smoking-cessation intervention by multiple health professionals. Am J Prev Med. 2008;34(1):54–60. Available from: https://www.ncbi.nlm.nih.gov/pubmed/18083451
4. Greenhalgh EM, Scollo MM. Chapter 18 E-cigarettes and other alternative nicotine products. In: Greenhalgh EM, Scollo MM, Winstanley MH, editors. Tobacco in Australia: Facts and issues. Melbourne: Cancer Council Victoria; 2022. Available from: https://www.tobaccoinaustralia.org.au/chapter-18-e-cigarettes/18-10-policies-and-programs-to-reduce-e-cigarette-use-among-young-people-and-non-smokers
5. Royal Australian College of General Practitioners. Supporting smoking & vaping cessation: A guide for health professionals. Guidance on smoking and vaping cessation support related to changes to Australia’s vaping regulation. Available from: RACGP-NVP-and-Vaping-Cessation-September-2024.pdf.aspx
6. Australian Institute of Health and Welfare. Tobacco smoking in the NDSHS [Internet]. Canberra: AIHW; 2024 [cited 2025 Aug 13]. Available from: https://www.aihw.gov.au/reports/smoking/tobacco-smoking-ndshs
7. Tabbakh T, Haynes A, Durkin S. Current vaping and current smoking in the Australian population aged 14+ years: 2018-2024. Melbourne: Cancer Council Victoria; 2025. Available from: https://www.health.gov.au/sites/default/files/2025-07/current-vaping-and-current-smoking-in-the-australian-population-aged-14-years-2018-2024.pdf
8. Greenhalgh EM, Hanley-Jones S, Purcell K, Winstanley MH. 3.34 Public perceptions of tobacco as a drug, and knowledge and beliefs about the health consequences of smoking. In: Greenhalgh EM, Scollo MM, Winstanley MH, editors. Tobacco in Australia: Facts and issues. Melbourne: Cancer Council Victoria; 2024. Available from: https://www.tobaccoinaustralia.org.au/chapter-3-health-effects/3-34-public-perceptions-of-tobacco-as-a-drug-and-k
9. Paley GL, Echalier E, Eck TW, Hong AR, Farooq AV, Gregory DG, Lubniewski AJ. Corneoscleral laceration and ocular burns caused by electronic cigarette explosions. Cornea. 2016 Jul;35(7):1015–8. doi:10.1097/ICO.0000000000000881
10. Wang B, Liu ST, Johnson MA, Trigger S. Trends and characteristics of ocular exposures related to e-cigarettes and e-liquids reported to Poison Control Centers in the United States, 2010–2019. Clin Toxicol (Phila). 2022 Mar;60(3):279–85. doi:10.1080/15563650.2021.1951284
11. Nicholson AK, Borland R, Davey ME, Stevens M, Thomas DP. Predictors of wanting to quit in a national sample of Aboriginal and Torres Strait Islander smokers. Med J Aust [Internet]. 2015 June 1 [cited October 2025]; 202 (10): S26-S32. Available from: 10.5694/mja15.00199
12. Stockings E, Bowman J, McElwaine K, Baker A, Terry M, Clancy R, et al. Readiness to quit smoking and quit attempts among Australian mental health inpatients. Nicotine Tob Res. 2013 May;15(5):942–9. doi:10.1093/ntr/nts206
13. Greenhalgh EM, Jenkins S, Stillman S, Ford C. 7.2 Quitting intentions, attempts and success among people who smoke. In: Greenhalgh EM, Scollo MM, Winstanley MH, editors. Tobacco in Australia: Facts and issues. Melbourne: Cancer Council Victoria; 2025. Available from: https://www.tobaccoinaustralia.org.au/chapter-7-cessation/7-2-quitting-activity
14. Kulkarni A, Banait S. Through the smoke: an in-depth review on cigarette smoking and its impact on ocular health. Cureus. 2023 Oct 27;15(10):e47779. doi:10.7759/cureus
15. Royal Australian and New Zealand College of Ophthalmologists. RANZCO Position Statement: Smoking Cessation as a protective factor against eye disease and vision loss – 2025 [Internet]. Available from: https://ranzco.edu/wp-content/uploads/2021/07/RANZCO-Position-Statement_Smoking-Cessation-as-a-protective-factor-against-eye-disease_2025.pdf
16. Pugazhendhi A, Hubbell M, Jairam P, Ambati B. Neovascular macular degeneration: a review of etiology, risk factors, and recent advances in research and therapy. Int J Mol Sci. 2021 Jan 25;22(3):1170. doi:10.3390/ijms22031170
17. Optometry Australia. Clinical Guideline – Examination and management of patients with diabetes [Internet]. Victoria: Optometry Australia; revised 2018 [cited 2025 Sept 1]. Available from: https://www.optometry.org.au/wp-content/uploads/Professional_support/Guidelines/clinical_guideline_diabetes_revised_sept_2018_final_designed.pdf
18. Bandara NA, Burgos-Blasco B, Zhou XR, Khaira A, Iovieno A, Matsubara JA, Yeung SN. The impact of vaping on the ocular surface: a systematic review of the literature. J Clin Med. 2024;13(9):2619. doi:10.3390/jcm13092619
19. Makrynioti D, Zagoriti Z, Koutsojannis C, Morgan P, Lagoumintzis G. Ocular conditions and dry eye due to traditional and new forms of smoking: a review. Contact Lens Anterior Eye. 2020 Jun;43(3):277–84. doi:10.1016/j.clae.2020.02.009
20. Christensen D. 6.1 Defining nicotine as a drug of addiction. In: Winstanley MH, Scollo MM, Greenhalgh EM, editors. Tobacco in Australia: Facts and issues. Melbourne: Cancer Council Victoria; 2018. Available from: https://www.tobaccoinaustralia.org.au/chapter-6-addiction/6-1-defining-nicotine-as-a-drug-of-addiction
