Age related macular degeneration (AMD) is a leading cause of irreversible blindness with strong and consistently reported causal linkages with cigarette smoking. Econometric analyses have demonstrated sufficient rationale in promoting smoking cessation as an effective strategy for primary prevention of AMD (Hurley et al, 2008). Japan shares many of the contemporary health issues with the developed countries including its demographic profile (long life expectancy, aging population) and disease burden (lifestyle related disorders). The prevalence of AMD in Japanese population has been found comparable to that in White population (Nakata et al, 2013).This provides sufficient basis for replication of evidence-based strategies that have proved successful elsewhere.
Health system overview
Japan’s national health strategy (Medical Care Plan) places emphasis on appropriate division of roles and responsibilities and integration of medical functions aimed at providing a seamless continuum of care extending down to the community level. There is a robust legislative and regulatory framework guiding the establishment of a national health promotion program with decentralized monitoring of the lifestyle related disease trends at local government level. The primarily responsible for delivering public health services lies at the municipal level while disease prevention and health promotion responsibilities are shared jointly by prefectural and municipal health authorities. The local administrative structures, health infrastructure and care delivery systems are particularly suited to strategic, multi-sectoral health promotion interventions in line with spirit of Ottawa Charter.
Evidence-based smoking cessation interventions in Japan
Smoking prevention in Japan should be part of a comprehensive strategy to reduce risk of cardiovascular and life style related disorders rather than focusing on AMD alone. Preventing initiation of smoking among adolescents, delaying start of smoking, behavior modification approaches targeting schools, work places, community and personal support systems, aided by legislative framework and stringent regulatory regime targeting tobacco marketing and media exposure have all been shown to have an impact on smoking prevention and cessation efforts in western countries. Many of the smoking prevention interventions proposed below consist of activities that thematically fall in more than one domain (out of the five) of essential health promotion actions proposed by the Ottawa Charter.
- Prevention of smoking among adolescents should be a top priority. Most adolescents start smoking out of curiosity and vulnerability to peer group pressure and aggressive media advertising. Moreover, susceptibility to these social influences has proven association with lack of self esteem and psychosocial skills among adolescents. The ‘Information based’ smoking preventive approaches that were in vogue in Japanese schools are in the process of being replaced by ‘comprehensive life skills training’ programs that have demonstrated their effectiveness in other western countries. Available evidence from similar interventions in United States, too, have proved efficacy of this approach. Training of teachers in student centered, interactive teaching styles will be an important input towards this end. (Kawabata, 2002)
- AMD is strongly related with certain genetic risk factors. Moreover, coexistence of smoking and genetic predisposition were found to have an additive effect on risk for developing AMD. Since a pilot study has demonstrated that awareness of genetic predisposition is a significant motivating factor for smoking cessation, genetic screening could be an important component intervention. However, not much literature is available on the cost implications and practicability of routine genetic screening for AMD (Rennie et al, 2012).
- Work place policies discouraging smoking; banning of smoking in public offices with high flow of people; behavioral counseling and work place health programs all have a role to play.
- Reduced exposure of environmental smoke in home with the help of family and carer smoking control programs has sufficient rationale (Cochrane review).
- Legislation banning advertisement of tobacco products, prohibition of sale of cigarette to minor children with strict enforcement. But no conclusive evidence available as to their effectiveness in longer term.
- Other interventions like mobile phone messages, partner support for smoking cessation, incentives for preventing smoking in adolescents and children, family and carer smoking control programs to reduce children’s environmental smoke exposure, all appear rational approaches. However, conclusive evidence is lacking. More targeted research needed to demonstrate their effectiveness. (Cochrane reviews)
- Institutionalization of health education as an integral part of health care services at community level has far reaching benefits going beyond any single disease.
- Encouragement of support groups, like, ‘Smokers Anonymous’ have proved successful elsewhere.
Hurley, Susan F., Jane P. Matthews, and Robyn H. Guymer. "Cost-effectiveness of smoking cessation to prevent age-related macular degeneration." Cost Effectiveness and Resource Allocation 6 (2008): 18.
KAWABATA, Tetsuro. "Smoking Prevention Education for Adolescents in Japan." the Journal of the Japan Medical Association 45.8 (2002): 324-328. Web. 7 Nov. 2014. <http://www.med.or.jp/english/pdf/2002_08/324_328.pdf>.
Nakata, I., K. Yamashiro, H. Nakanishi, Y. Akagi-Kurashige, M. Miyake, A. Tsujikawa, F. Matsuda, and N. Yoshimura. "Prevalence and characteristics of age -related macular degeneration in the japanese population: The nagahama study." American journal of Ophthalmology 156.5 (2013): 1002. D.O.I. : 10.1016/j.ajo.2013.06.007. Web.
Rennie, C. A., A. Stinge, E. A. King, S. Sothirachagan, and C. Osmond. "Can genetic risk information for age -related macular degeneration influence motivation to stop smoking ? A pilot study." Eye 26.1 (2012): 109. Web. 7 Nov. 2014. <http://ovidsp.ovid.com/ovidweb.cgi?T=JS&CSC=Y&NEWS=N&PAGE=fulltext&D=medl&AN=22037055>.
Thornton, J., R. Edwards, P. Mitchell, R. A. Harrison, I. Buchan, and S. P. Kelly. "Smoking and age-related macular degeneration: a review of association." Eye 19.9 (2005): 935-944.
Ruchi Baxi , Mohit Sharma , Robert Roseby , Adam Polnay , Naomi Priest , ElizabethWaters , Nick Spencer and Premila Webster. Family and carer smoking control programmes for reducing children's exposure to environmental tobacco smoke. Cochrane Database of systematic reviews. Online Publication Date: March 2014.
Vlasta Vodopivec-Jamsek , Thyra de Jongh , Ipek Gurol-Urganci , Rifat Atun and Josip Car. Mobile phone messaging for preventive health care. Cochrane Database of systematic reviews. Online Publication Date: December 2012
Alessandro Coppo , Maria Rosaria Galanti , Livia Giordano , Daria Buscemi , Sven Bremberg and Fabrizio Faggiano (2014). School policies for preventing smoking among young people. Cochrane Database of systematic reviews. Online Publication Date: October 2014