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epithelial barrier integrity&#44; alveolar macrophages that recognize and phagocytize invading microorganisms&#41;&#46; Any failure of these mechanisms may result in microorganisms spreading to the bronchial tree&#44; triggering community-acquired pneumonia &#40;CAP&#41;&#44; which remains a major cause of morbidity and mortality in developed countries&#46; In the general adult population&#44; the annual incidence of CAP varies between 1&#46;6 and 13&#46;4 cases per 1000 inhabitants&#44; with a hospitalization rate of between 22 and 51&#37; and a mortality rate of 3&#37;&#8211;24&#37;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#8211;4</span></a> that has not changed in recent years&#44; despite the preventive measures undertaken&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Smoking and Pneumonia</span><p id="par0015" class="elsevierStylePara elsevierViewall">The most important risk factor for CAP is age&#46; So much so&#44; that the incidence triples or quadruples when age is &#62;65 years&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> The reason is unclear&#44; but several factors may be involved&#44; related to immune senescence due to weakness &#40;innate and adaptive&#41; of the immune system&#44; increased asymptomatic aspirations in this age group&#44;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> or the convergence of other risk factors &#40;RF&#41; that do not acquire statistical significance in younger people&#44; but that take center stage in older age groups&#44; possibly due to an additive effect&#46; One of these factors may be tobacco smoking&#44; the main RF for COPD&#44; which in turn is one of the main RFs for CAP&#46; Thus&#44; it is often difficult to determine the specific weight of smoking in the development of CAP&#44; especially considering that smoking is associated with lower socioeconomic status&#44; poor diet&#44; increased alcohol consumption&#44; and reduced physical activity&#44; that are also RFs for respiratory infection&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> Nevertheless&#44; enough studies using statistical analysis with logistic regression models are now available to allow the differentiation of any confounding factors&#44; showing that tobacco smoking in itself increases the risk of pneumonia&#46; In this regard&#44; a population-based study<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;3</span></a> was published that demonstrated an increased risk of CAP in smokers that was also directly related to the duration of tobacco consumption and the number of cigarettes consumed&#46; Concurrently&#44; it has been shown that this risk disappears when smokers quit&#46; In fact&#44; after 5 years&#44; the risk decreases by 50&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Moreover&#44; if we consider that one of the criteria for causality between two factors is dose-response&#44; the increase in risk associated with an increase in intensity of consumption and the overall amount of tobacco consumed further reinforces the notion that tobacco smoking is a direct causal agent of CAP&#46; On the other hand&#44; we know that tobacco smoking causes morphological changes in the epithelium of the bronchial mucosa&#44; with loss of cilia&#44; mucous gland hypertrophy and increased goblet cells that may favor the presence and spread of microbes in the bronchial tree&#46; An inflammatory reaction is produced in the airway causing macrophage and neutrophil activation that releases proteases&#46; Oxidative stress and cytokine release are triggered&#44; leading to both innate and adaptive immune response&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#8211;14</span></a> This may in turn make the bronchial mucosa epithelium more sensitive to the inflammatory aggression of the infection itself&#46;<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">15&#8211;17</span></a> Moreover&#44; it is now known that tobacco smoking inhibits some of the key functions of the innate and adaptive response&#44; including the response of two Toll-like receptors &#40;TLR2&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> nuclear factor kappaB &#40;NF-&#954;B&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> CD4-lymphocyte proliferation &#40;LTCD4&#41;&#44;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#44;19</span></a> maturation of dendritic cells&#44;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> and opsonization and phagocytosis capacities&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> Thus&#44; tobacco smoking can alter immunity against infection&#44; affecting the modulation of intra- and intercellular signaling of epithelium and immune cells&#44; and suppressing the activation of important elements of the innate and adaptive immune response&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">17&#44;21</span></a> The fact that tobacco smoking increases susceptibility to bacterial infection is well established&#46;<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">22&#44;23</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Passive Smoking and Pneumonia</span><p id="par0020" class="elsevierStylePara elsevierViewall">Passive smoking is considered a major epidemiological problem&#46; In 2004&#44; an international study including 192 countries found that 40&#37; of children&#44; 33&#37; of male non-smokers and 35&#37; of female non-smokers&#44; were passive smokers&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> There were wide geographical variations that could be explained by the different stages of the tobacco smoking epidemic in the country surveyed&#44; because passive smoking is directly related to active smoking rates&#46; In the year 2005&#44; prevalence data in Spain estimated that about 50&#37; of adults were exposed to second-hand smoke&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> Later&#44; as in most developed countries&#44; legislation was introduced to regulate tobacco smoking in public places&#46; This has reduced exposure to tobacco smoke by approximately 20&#37;&#8211;25&#37;&#44; due to falling consumption in public places and in the workplace&#44; but not at home&#46; Accordingly&#44; in recent years there has been growing interest in understanding the effect of passive tobacco smoking and some studies suggest that it could also involve a higher risk of respiratory infections in both the children of smoking parents&#44;<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">26&#44;27</span></a> and in adults&#46;<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">28&#44;29</span></a> Allowing smoking in the home has also been shown to be an important predictor of health loss in elderly people with CAP&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a> In fact&#44; lesions in the respiratory epithelium&#44; connective tissue and vascular endothelium of the lung caused by tobacco smoke can occur even at low smoke concentrations&#44;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">31</span></a> supporting the notion that exposure to tobacco smoke could be an important risk factor for CAP development in passive smokers&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Two separate case-controlled&#44;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">32</span></a> population-based studies have also demonstrated that passive smoking is a risk factor for developing pneumococcal bacteremia in immunocompetent adults&#44; resulting in an odds ratio &#40;OR&#41; of 2&#46;6 and attributable risk &#40;AR&#41; of 31&#37; in subjects aged &#60;65 years&#44;<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">28&#44;33</span></a> and OR 2&#46;2 and AR 13&#37; in those over 65 years of age&#46;<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">28&#44;32</span></a></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Smoking and Pneumococcal Pneumonia</span><p id="par0030" class="elsevierStylePara elsevierViewall">The most common causative organism of CAP&#44; regardless of care level and severity&#44; is <span class="elsevierStyleItalic">Streptococcus pneumoniae</span>&#46; This has also been shown to be the agent most frequently linked to smoking&#44; especially in patients with COPD&#46; An <span class="elsevierStyleItalic">in vitro</span> study has shown increased adherence of <span class="elsevierStyleItalic">S&#46; pneumoniae</span> to the epithelial cells in the oral cavity of smokers&#44;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a> persisting for up to three years after smoking cessation&#46; This may produce greater oropharyngeal colonization and lead to greater chance of developing CAP&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Smoking has also been related with invasive pneumococcal disease &#40;IPD&#41;&#44; which in approximately 80&#37; of cases is due to pneumonia&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">35</span></a> This association was reported in a study by Pastor et al&#46; in 1995&#44; with an OR of 2&#46;6 in smokers between 24 and 64 years of age and OR of 2&#46;2 in smokers older than 65 years&#46; Attributable risk &#40;AR&#41; was 31&#37; in the first group and 13&#37; in the second group&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Another population-based&#44; case-controlled study<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a> also highlighted that smoking is the largest independent RF for IPD in immunocompetent adults&#44; with an OR&#61;4&#46;1 in current smokers &#40;AR 51&#37;&#41;&#46; Furthermore&#44; there is a dose-response effect&#44; and smoking cessation dramatically reduces the risk after 10 years&#44; when it becomes the same as that of nonsmokers&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">The special relationship of active smoking with pneumococcus has been demonstrated by some studies that have shown tobacco-induced changes in the clearance and phagocytosis of <span class="elsevierStyleItalic">S&#46; pneumoniae</span> in the lungs&#44;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">36</span></a> and inhibition of the anti-pneumococcal activity of some innate immunity antimicrobial peptides&#46;<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">37&#44;38</span></a> Thus&#44; tobacco smoking impairs immunity to infection&#44; especially against some microorganisms&#44; including <span class="elsevierStyleItalic">S&#46; pneumoniae</span>&#44; and it seems well established that active smoking increases the risk of pneumonia&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">However&#44; the information as to whether active smokers have a worse CAP prognosis is not so clear&#46; Three longitudinal studies<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">39&#8211;41</span></a> involving large patient cohorts found higher mortality in smokers with pneumonia&#44; while two metaanalyses<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">42&#44;43</span></a> found that tobacco smoking did not affect prognosis&#46; Two large retrospective series that studied CAP mortality in relation to tobacco smoking have shown contradictory results&#46;<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">44&#44;45</span></a> Finally&#44; a recent study showed that tobacco smoking was an independent risk factor for septic shock in pneumococcal pneumonia&#44;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">46</span></a> and another epidemiological study concluded that smoking was an independent determinant of mortality in bacteremic CAP caused by <span class="elsevierStyleItalic">S&#46; pneumoniae</span>&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">47</span></a> Considering all these data&#44; we can conclude that there is evidence to suggest worse prognosis of pneumococcal pneumonia in active smokers&#44; while the picture is not so clear if we consider overall CAP&#44; independent of the etiology&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Smoking and <span class="elsevierStyleItalic">Legionella pneumophila</span> Pneumonia</span><p id="par0050" class="elsevierStylePara elsevierViewall">Less frequent&#44; but not less important&#44; is CAP due to <span class="elsevierStyleItalic">Legionella pneumophila</span>&#46; Its incidence varies according to published series&#58; some report sporadic cases while in others it is the second or third most common etiologic agent&#46; This depends on epidemiological factors&#44; the completeness of the diagnostic method used&#44; and the severity of CAP&#44; among other factors&#46; In population-based studies&#44; <span class="elsevierStyleItalic">L&#46; pneumophila</span> represents 1&#37;&#8211;3&#37; of diagnosed microorganisms&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">48</span></a> This type of CAP usually affects young individuals&#44; often without underlying disease&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">49</span></a> Smoking is the most important risk factor in these subjects&#44; as the risk may be increased by 121&#37; for each pack of cigarettes consumed daily&#44; with OR of 3&#46;48&#44;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">50</span></a> and as much as 7&#46;49 if analyzed in people without comorbidities&#46; This increased risk is attributed to the difficulty in eradicating the microorganism from the bronchial tree&#44; due to the deterioration of the respiratory mucosa and impaired cilia caused by tobacco smoking that&#44; depending on the individual&#39;s immune status&#44; facilitates entry into and subsequent invasion of the alveolar macrophages&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Smoking and Other Risk Factors of Pneumonia Acquired in the Community</span><p id="par0055" class="elsevierStylePara elsevierViewall">Tobacco smoking may also favor the presence of diseases which are in turn known risk factors of CAP&#44; including&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">-</span><p id="par0060" class="elsevierStylePara elsevierViewall">Periodontal diseases directly related to the development of CAP&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">51</span></a> Poorer oral hygiene has been shown to potentially lead to increased respiratory infection&#46;<a class="elsevierStyleCrossRefs" href="#bib0260"><span class="elsevierStyleSup">52&#44;53</span></a> Additionally&#44; smokers show higher subgingival bacterial colonization than non-smokers&#44; which is directly related to the number of cigarettes smoked by day&#46; Accordingly&#44; smokers of fewer than 10 cigarettes&#47;day present periodontitis between 2&#46;5 and 6 times more often than non-smokers &#40;OR 2&#46;79&#41;&#44; while OR is 5&#46;88 for those smoking &#62;30 cigarettes&#47;day&#59; OR decreases dramatically if the habit is quit and can reach OR 1&#46;15 after 11 years&#46;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">54</span></a></p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">-</span><p id="par0065" class="elsevierStylePara elsevierViewall">Viral upper respiratory tract infections&#46; Upper respiratory tract infections &#40;URTI&#41; are a risk factor of CAP&#44; independent of other related factors&#44;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;7</span></a> and smoking independently influences the presence of prior viral infection&#46; Blake et al&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">55</span></a> observed in a cohort of soldiers diagnosed with URTI that 22&#46;7&#37; were smokers&#44; <span class="elsevierStyleItalic">vs</span> 16&#37; non-smokers &#40;RR&#58; 1&#46;5&#41;&#46; Increased susceptibility to experimental viral infection has also been observed in smokers&#46;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">56</span></a></p></li></ul></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Prevention</span><p id="par0070" class="elsevierStylePara elsevierViewall">At present there is enough scientific evidence to show that active tobacco smoking is an important risk factor for CAP<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">26&#44;28&#44;29&#44;33</span></a>&#59; it has a direct and independent effect on the risk of CAP&#44; but it may also act indirectly causing chronic bronchitis or COPD which&#44; in turn&#44; are well recognized risk factors for CAP&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;33</span></a> Therefore&#44; one of the main ways of preventing CAP is to intervene in the smoking habit&#44; advising its cessation&#44; which may reduce the risk of CAP by 50&#37; after five years&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Furthermore&#44; a reduction of 14&#37; in IPD has been observed every year<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a> and&#44; after 10 years&#44; the risk of IPD can reach the same level as that of non-smokers&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">On the other hand&#44; pneumococcal vaccine is concomitantly recommended&#46; In fact&#44; the American scientific societies propose tobacco cessation combined with pneumococcal vaccine in patients hospitalized for CAP&#44;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">57</span></a> and further recommend the pneumococcal vaccine for active smokers in the population aged between 19 and 64 years&#44; regardless of the presence of comorbidities&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">58</span></a> This recommendation is even more relevant for active smokers&#44; in whom lower rates of influenza and pneumococcal immunization have been observed compared to former smokers and non-smokers&#46;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">59</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">At present&#44; two types of vaccine are available&#58; the 23-valent polysaccharide vaccine and 13-valent conjugated vaccine&#46; The former has been used in Spain since 1999&#44; and protective effect has been found in studies not designed to assess its effectiveness&#44;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;60</span></a> while clinical trials to test its efficacy against IPD do not establish such an effect&#44; and effectiveness on CAP in general cannot be estimated&#46;<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">61</span></a> Therefore&#44; pneumococcal immunization with the 13-valente conjugate vaccine&#44; authorized for adults in Europe since October 2011 and in Spain since July 2012&#44; has been recently recommended&#46;<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">62</span></a> The main advantage over the former is that&#44; being conjugated&#44; it is capable of inducing a T-dependent immune response that provides a better immune response and generates immune memory&#46;<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">63</span></a> Additionally&#44; it has been described to generate IgA responses in mucosa&#44; reducing nasopharyngeal colonization by serotypes represented in the vaccine&#44; thus breaking the infectious cycle and producing group immunity&#46;<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">64</span></a> Furthermore&#44; the serotype coverage of the 13-valent conjugate vaccine reaches up to 82&#37; of CAP-producing agents in healthy adults&#46;<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">65</span></a> Therefore&#44; it seems clear that the smoking population should be considered as a target for pneumococcal vaccination strategies&#46;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">66</span></a></p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Conflicts of Interest</span><p id="par0085" class="elsevierStylePara elsevierViewall">The authors declare no conflicts of interest&#46;</p></span></span>"
    "textoCompletoSecciones" => array:1 [
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          "identificador" => "xres342972"
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          "titulo" => "Palabras clave"
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          "identificador" => "sec0005"
          "titulo" => "Smoking and Pneumonia"
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          "identificador" => "sec0010"
          "titulo" => "Passive Smoking and Pneumonia"
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        6 => array:2 [
          "identificador" => "sec0015"
          "titulo" => "Smoking and Pneumococcal Pneumonia"
        ]
        7 => array:2 [
          "identificador" => "sec0020"
          "titulo" => "Smoking and Legionella pneumophila Pneumonia"
        ]
        8 => array:2 [
          "identificador" => "sec0025"
          "titulo" => "Smoking and Other Risk Factors of Pneumonia Acquired in the Community"
        ]
        9 => array:2 [
          "identificador" => "sec0030"
          "titulo" => "Prevention"
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        10 => array:2 [
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          "titulo" => "Conflicts of Interest"
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          "titulo" => "References"
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    "fechaRecibido" => "2013-09-20"
    "fechaAceptado" => "2013-11-19"
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        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec324609"
          "palabras" => array:4 [
            0 => "Smoking"
            1 => "Community-acquired pneumonia"
            2 => "Risk factors"
            3 => "Prevention"
          ]
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        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
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          "palabras" => array:4 [
            0 => "Tabaquismo"
            1 => "Neumon&#237;a adquirida en la comunidad"
            2 => "Factores de riesgo"
            3 => "Prevenci&#243;n"
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        "titulo" => "Abstract"
        "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Recent studies have left absolutely no doubt that tobacco increases susceptibility to bacterial lung infection&#44; even in passive smokers&#46; This relationship also shows a dose-response effect&#44; since the risk reduces spectacularly 10 years after giving up smoking&#44; returning to the level of non-smokers&#46;</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Streptococcus pneumoniae</span> is the causative microorganism responsible for community-acquired pneumonia &#40;CAP&#41; most frequently associated with smoking&#44; particularly in invasive pneumococcal disease and septic shock&#46;</p><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">It is not clear how it acts on the progress of pneumonia&#44; but there is evidence to suggest that the prognosis for pneumococcal pneumonia is worse&#46;</p><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">In CAP caused by <span class="elsevierStyleItalic">Legionella pneumophila</span>&#44; it has also been observed that smoking is the most important risk factor&#44; with the risk rising 121&#37; for each pack of cigarettes smoked a day&#46;</p><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Tobacco use may also favor diseases that are also known risk factors for CAP&#44; such as periodontal disease and upper respiratory viral infections&#46;</p><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">By way of prevention&#44; while giving up smoking should always be proposed&#44; the use of the pneumococcal vaccine is also recommended&#44; regardless of the presence of other comorbidities&#46;</p>"
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        "titulo" => "Resumen"
        "resumen" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">En estudios recientes ha quedando quedado perfectamente establecido que el tabaco incrementa la susceptibilidad a la infecci&#243;n bacteriana pulmonar&#44; incluso en fumadores pasivos&#46; Este efecto muestra tambi&#233;n dosis-respuesta&#44; ya que disminuye espectacularmente el riesgo 10 a&#241;os despu&#233;s de abandonar el h&#225;bito tab&#225;quico&#44; situ&#225;ndose a niveles de no fumadores&#46;</p><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Streptococcus pneumoniae</span> es el microorganismo causante de neumon&#237;a adquirida en la comunidad &#40;NAC&#41; que m&#225;s se ha relacionado con el tabaquismo&#44; especialmente en situaciones de enfermedad neumoc&#243;cica invasiva y shock s&#233;ptico&#46;</p><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Su influencia sobre la evoluci&#243;n de la neumon&#237;a no parece clara&#44; aunque existen evidencias que sugieren un peor pron&#243;stico de la neumon&#237;a neumoc&#243;cica&#46;</p><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">En NAC causadas por <span class="elsevierStyleItalic">Legionella pneumophila</span> tambi&#233;n se ha observado que el h&#225;bito tab&#225;quico es el factor de riesgo m&#225;s remarcable&#44; ya que puede suponer un aumento del riesgo del 121&#37; por cada paquete diario de cigarrillos consumidos&#46;</p><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Por otro lado&#44; el consumo de tabaco puede tambi&#233;n favorecer la presencia de enfermedades que a su vez son factores de riesgo conocidos de NAC&#44; como enfermedades periodontales e infecciones v&#237;ricas de la v&#237;a a&#233;rea superior&#46;</p><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Como medida preventiva&#44; si bien cabe proponer el abandono del tabaco&#44; tambi&#233;n es recomendable la vacuna neumoc&#243;cica&#44; independientemente de la presencia de comorbilidad&#46;</p>"
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    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Almirall J&#44; Blanquer J&#44; Bello S&#46; Neumon&#237;a adquirida en la comunidad en fumadores&#46; Arch Bronconeumol&#46; 2014&#59;50&#58;250&#8211;254&#46;</p>"
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    ]
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            2 => array:3 [
              "identificador" => "bib0015"
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                  "contribucion" => array:1 [
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                          "etal" => false
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                            3 => "I&#46; Bolibar"
                          ]
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                      ]
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                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Chest"
                        "fecha" => "1999"
                        "volumen" => "116"
                        "paginaInicial" => "375"
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Review
Community-Acquired Pneumonia Among Smokers
Neumonía adquirida en la comunidad en fumadores
Jordi Almiralla,
Corresponding author
jalmirall@csdm.cat

Corresponding author.
, José Blanquerb, Salvador Belloc
a Servicio de Cuidados Intensivos, Hospital de Mataró, Universitat Autónoma de Barcelona, CIBERES, Barcelona, Spain
b Cuidados Intensivos Respiratorios, Hospital Clínico Universitario, INCLIVA, Valencia, Spain
c Servicio de Neumología, Hospital Universitario Miguel Servet, CIBERES, Zaragoza, Spain

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