Vaccination disparities and structural barriers among current smokers and adults with COPD: implications for comprehensive respiratory prevention.

Comprehensive respiratory health management for populations with elevated respiratory and lung cancer-related risk remains a guideline-recommended component of comprehensive respiratory prevention, yet uptake has not been systematically characterized. Using vaccination as a sentinel marker of healthcare engagement, we examined 2020-2024 BRFSS data on influenza and pneumococcal vaccination among U.S. adults classified as healthy controls, current smokers without COPD, individuals with COPD who were former or never smokers, and current smokers with COPD. Adults with both current smoking and COPD showed a substantial prevention gap. Despite high clinical vulnerability, this Dual Risk group had lower vaccination uptake than the COPD-only group, particularly among adults aged 45-64 years. In multivariable models, current smoking was associated with attenuation of the expected disease-prompting effect observed among non-smoking individuals with COPD. Mediation analysis suggested that healthcare access barriers, especially absence of a personal healthcare provider and lack of routine checkups, explained much of the vaccination disparity, whereas broader socioeconomic indicators explained less. Although vaccination uptake is not a direct measure of low-dose computed tomography screening, it may serve as a sentinel marker of primary care engagement and missed opportunities for respiratory prevention. Findings should be interpreted cautiously given the cross-sectional design, potential age-related confounding for pneumococcal vaccination under pre-2024 CDC recommendations, and the broader BRFSS smoking definition compared with clinical screening criteria. Integrating vaccination assessment, smoking cessation services, and appropriate screening referral through primary care, pharmacies, and cessation clinics may reduce missed opportunities among high-risk adults.