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Smoking Increases Need for Pneumococcal Vaccine

Katherine M. Bennett

New research indicates that cigarette smoking places nonelderly adults at the greatest risk for pneumococcal infection of the blood or cerebrospinal fluid and makes them prime candidates for vaccination.

Canadian and U.S. researchers looked at the contribution of active and passive smoking and various demographic, medical, and socioeconomic factors to adults’ risk for invasive pneumococcal disease. The findings appear in the March 9 issue of the New England Journal of Medicine.

The researchers identified immunocompetent patients, 18 to 64 years old, who had had community-acquired invasive pneumococcal disease that had been diagnosed by isolation of Streptococcus pneumoniae from a normally sterile site, most commonly blood or cerebrospinal fluid. Between January 1995 and May 1996, patients were systematically selected each month from all reported cases in three metropolitan areas, including Atlanta and Baltimore, giving a total sample of 228 patients.

Noninfected people were selected, through random-digit telephone dialing, from the general population and matched with the patients according to the month of positive pneumococcal culture, metropolitan area, and age.

Trained investigators used a standard set of questions to interview the patients and controls by telephone. Participants were characterized, on the basis of self-reports, as current smokers, former smokers without passive exposure to smoke, those who never smoked or formerly smoked and were exposed to tobacco smoke for more than one hour daily, and people who never smoked and had no passive exposure. Information about the number of cigarettes smoked daily, time since quitting, and other characteristics was also gathered.

Researchers found that patients with invasive pneumococcal disease were 4.1 times as likely as the controls to be current smokers. Overall, 28 percent of the patients had a condition or characteristic that made them a candidate for pneumococcal vaccination.

Risk for invasive pneumococcal disease increased as the number of cigarettes smoked daily increased, suggesting a dose-response relationship. Chronic obstructive pulmonary disease, by itself, was not a risk factor.

Former smokers seemed to be at increased risk for at least 10 years after quitting. Nonsmoking patients were 2.5 times as likely as nonsmoking controls to have passively been exposed to tobacco smoke. Men, Blacks, people with any chronic illness, people with a low level of education, and people living with young children who were in day care were 2.6 to 3.4 times as likely as other people to have had invasive pneumococcal disease.

Because this study found cigarette smoking to be the strongest independent risk factor for invasive pneumococcal disease among immunocompetent nonelderly adults, the researchers suggested that their findings might be of interest to groups that formulate vaccination guidelines. The researchers also suggested that health care professionals and organizations consider incorporating the pneumococcal vaccine into smoking-cessation programs and vaccinating people who continue to smoke.

ASHP’s Therapeutic Position Statement on identifying and preventing pneumococcal resistance advocates vaccination of high-risk patients. In February, a pneumococcal vaccine became available for use in infants and children younger than 2 years old.