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Context Although cigarette smoking has been shown to be a risk factor for age-related
cataract, data are inconclusive on the risk of cataract in individuals who quit smoking.
JoAnn E. Manson, MD
shown to be an important
independent risk factor for
development of age-related
cataract.1-11 However, risk of cataract in
individuals who quit smoking is uncertain. Some studies have found that risk
of cataract remains elevated for many
yearsfollowingsmokingcessation.4,9 Othershavereportedthat the risk approaches
the level of never smokers several years
after quitting smoking, suggesting that
damage to the lens may be reversible.5,6,10
In a report from the Physicians Health
Study I, based on the first 5 years of follow-up, we showed that current smokers of 20 or more cigarettes per day, compared with never smokers, had a 2-fold
increased risk of cataract, while past
smokers had a 15% increased risk of cataract that was not statistically significant.8 In this article, we extend these findings by including cataracts diagnosed
during more than 13 years of follow-up
and by examining the relationship of time
since quitting smoking with risk of cataract following smoking cessation.
METHODS
The Physicians Health Study I was a randomized, double-blind, placebocontrolled trial of low-dosage aspirin
and b-carotene in the prevention of cardiovascular disease and cancer among
Main Outcome Measures Incident age-related cataract defined as self-report confirmed by medical record review, diagnosed after study randomization and responsible for vision loss to 20/30 or worse, and surgical extraction of incident age-related
cataract, in relation to smoking status and years since quitting smoking.
Results At baseline, 11% were current smokers, 39% were past smokers, and 50%
were never smokers. Average reported cumulative dose of smoking at baseline was
approximately 2-fold greater in current than in past smokers (35.8 vs 20.5 pack-years).
Two thousand seventy-four incident cases of age-related cataract and 1193 cataract
extractions were confirmed during follow-up. Compared with current smokers, multivariate relative risks (RRs) of cataract in past smokers who quit smoking fewer than
10 years, 10 to fewer than 20 years, and 20 or more years before the study were 0.79
(95% confidence interval [CI], 0.64-0.98), 0.73 (95% CI, 0.61-0.88), and 0.74 (95%
CI, 0.63-0.87), respectively, after adjustment for other risk factors for cataract and
age at smoking inception. The RR for never smokers was 0.64 (95% CI, 0.54-0.76).
The reduced risk in past smokers was principally due to a lower total cumulative dose
(RR of cataract for increase of 10 pack-years of smoking, 1.07; 95% CI, 1.04-1.10). A
benefit of stopping smoking independent of cumulative dose was suggested in some
analyses. Results for cataract extraction were similar.
Conclusion These prospective data indicate that while some smoking-related damage to the lens may be reversible, smoking cessation reduces the risk of cataract primarily by limiting total dose-related damage to the lens.
www.jama.com
JAMA. 2000;284:713-716
Author Affiliations: Division of Preventive Medicine (Drs Christen, Glynn, Ajani, Schaumberg, Buring, and Manson) and Channing Laboratory (Dr
Manson), Department of Medicine, and Department of Ambulatory Care and Prevention (Dr Buring), Harvard Medical School and Brigham and
Womens Hospital, and Departments of Biostatistics
(Dr Glynn) and Epidemiology (Drs Buring and Manson), Harvard School of Public Health, Boston,
Mass; and Departments of Medicine, Epidemiology,
and Public Health, University of Miami School of
Medicine, Miami, Fla (Dr Hennekens).
Corresponding Author: William G. Christen, ScD, 900
Commonwealth Ave E, Boston, MA 02215-1204.
713
Table 1. Age-Adjusted Prevalence of Baseline Characteristics That Are Possible Risk Factors
for Cataract by Smoking Status at Baseline, Physicians Health Study I*
Never Smokers
(n = 10 444)
Past Smokers
(n = 8190)
Current Smokers
(n = 2273)
48.0
32.1
36.4
37.0
41.7
37.4
60-69
15.5
20.5
17.2
70-84
4.4
6.1
3.7
Diabetes, %
Hypertension, %
2.1
12.7
2.2
14.1
2.7
13.9
24.8
25.1
25.1
Alcohol use, %
Daily
Weekly
17.6
49.3
29.5
51.8
34.5
43.8
Monthly
Age range, %, y
40-49
50-59
12.6
9.5
11.1
Physical activity, %
Parental history of MI, %
73.4
13.3
73.2
13.1
64.2
14.3
Multivitamin use, %
18.5
20.3
21.3
Smoking history
Pack-years, mean (SD)
...
20.5 (17.4)
35.8 (21.0)
...
19 (14-26)
19 (14-29)
...
38 (23-56)
...
*BMI indicates body mass index; MI, myocardial infarction; and ellipses, data not applicable.
Reported systolic blood pressure of 160 mm Hg or higher, diastolic blood pressure of 95 mm Hg or higher, or history
of treatment for hypertension.
Reported vigorous exercise once per week or more.
Reported MI in either parent before age 60 years.
examined the independent contributions of total cumulative dose and smoking status (past vs current) to risk of cataract in ever smokers. The significance of
variables was tested using the likelihood ratio test. To calculate total cumulative dose, subjects were classified by
pack-years of smoking. We used baseline data on amount smoked for current
smokers and 60-month follow-up questionnaire data on amount smoked for past
smokers (since information on amount
smoked was collected only for current
smokers at baseline) to calculate packyears of smoking at baseline. We defined
pack-years as the number of years of
smoking times the number of packs of
cigarettes smoked per day.
Cigarette smoking is associated with
an increased risk of age-related macular degeneration (AMD) in this population,13 and subjects with cataract may
have been identified because of presence
of AMD. Therefore, we also conducted
analyses in which we included diagnosis of AMD as a time-varying covariate.
Relative risk (RR) estimates derived from
these models, however, were not materially different from estimates derived
from models that were unadjusted for
diagnosis of AMD (data not shown).
RESULTS
At baseline, 11% of the study participants were current smokers, 39% were
past smokers, and 50% were never smokers. Compared with current smokers,
past smokers were older and, after adjusting for age, tended to report less alcohol use, diabetes, parental history of
myocardial infarction, and multivitamin use, but more physical activity
(TABLE 1). Mean age at starting smoking was similar in past and current smokers, but total pack-years of smoking at
baseline were almost 2-fold greater in
current smokers than in past smokers
(35.8 vs 20.5 pack-years) (Table 1).
During an average of 13.6 years of
follow-up, there were 2074 agerelated cataract diagnoses and 1193
cataract extractions confirmed by medical record review. Risk of cataract in
past smokers was intermediate between current and never smokers.
Table 2. Relative Risks of Cataract Diagnosis and Extraction by Years Since Quitting Smoking*
Past Smokers, Years Since Quitting Smoking
Current Smokers
(n = 2272)
No. of cases
Age- and treatment-adjusted RR (95% CI)
Multivariate RR (95% CI)
Multivariate RR (95% CI)
250
1.00
1.00
1.00
Never Smokers
(n = 10 450)
Cataract Diagnosis
868
0.66 (0.57-0.76)
0.67 (0.58-0.77)
0.64 (0.54-0.76)
No. of cases
Age- and treatment-adjusted RR (95% CI)
Multivariate RR (95% CI)
Multivariate RR (95% CI)
155
1.00
1.00
1.00
Cataract Extraction
507
0.64 (0.54-0.77)
0.66 (0.54-0.79)
0.65 (0.53-0.79)
,10
(n = 1640)
10 to ,20
(n = 2795)
$20
(n = 2541)
149
0.83 (0.68-1.02)
0.81 (0.66-1.00)
0.79 (0.64-0.98)
261
0.77 (0.65-0.92)
0.75 (0.63-0.90)
0.73 (0.61-0.88)
450
0.79 (0.67-0.92)
0.79 (0.67-0.92)
0.74 (0.63-0.87)
85
0.78 (0.60-1.02)
0.76 (0.58-0.99)
0.75 (0.57-0.98)
152
0.74 (0.59-0.93)
0.72 (0.57-0.91)
0.70 (0.56-0.88)
243
0.73 (0.59-0.89)
0.73 (0.59-0.90)
0.69 (0.56-0.85)
715
9. Hankinson SE, Willett WC, Colditz GA, et al. A prospective study of cigarette smoking and risk of cataract surgery in women. JAMA. 1992;268:994998.
10. West S, Munoz B, Schein OD, et al. Cigarette
smoking and risk for progression of nuclear opacities.
Arch Ophthalmol. 1995;113:1377-1380.
11. Hiller R, Sperduto RD, Podgor MJ, et al. Cigarette smoking and risk of development of lens opacities. Arch Ophthalmol. 1997;115:1113-1118.
12. Department of Health and Human Services. The
Health Benefits of Smoking Cessation: A Report of
the Surgeon General, 1990. Rockville, Md: Dept of
Health and Human Services; 1990. DHHS publication (CDC)90-8416.
13. Christen WG, Glynn RJ, Manson JE, Ajani UA, Buring JE. A prospective study of cigarette smoking and
risk of age-related macular degeneration in men.
JAMA. 1996;276:1147-1151.
14. Ramakrishnan S, Sulochana KN, Selvaraj T, et al.
Smoking of beedies and cataract. Br J Ophthalmol.
1995;79:202-206.
15. Paik DC, Dillon J. The nitrite/alpha crystallin reaction. Exp Eye Res. 2000;70:73-80.
16. Mohan M, Sperduto RD, Angra SK, et al. India-US case-control study of age-related cataracts. Arch
Ophthalmol. 1989;107:670-676.
17. Bunce GE, Kinoshita J, Horwitz J. Nutritional factors in cataract. Ann Rev Nutr. 1990;10:233-254.
18. Jacques PF, Chylack LT, McGandy RB, Hartz SC.
Antioxidant status in persons with and without senile
cataract. Arch Ophthalmol. 1988;106:337-340.
19. Chow CK, Thacker RR, Changchit C, et al.
Lower levels of vitamin C and carotenes in plasma
of cigarette smokers. J Am Coll Nutr. 1986;5:305312.
20. Stryker WS, Kaplan LA, Stein EA, et al. The relation of diet, cigarette smoking, and alcohol consumption to plasma beta-carotene and alpha-tocopherol levels. Am J Epidemiol. 1988;127:283-296.
21. Taylor A, Davies KJA. Protein oxidation and loss
of protease activity may lead to cataract formation in
the aged lens. Free Radic Biol Med. 1987;3:371377.
22. National Advisory Eye Council. Vision Research:
A National Plan, 1999-2003. Rockville, Md: Dept of
Health and Human Services; 1998. NIH publication
98-4120.
Funding/Support: This study was supported by research grants HL 26490, HL 34595, CA 34944, CA
40360, and EY 06633 from the National Institutes of
Health.
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