Broughton and colleagues¹ state that consideration should be given to the use of prophylactic palivizumab to infants born at less than 32 weeks in the case of maternal smoking or even if they have siblings. However, the authors present no data from their own or other studies to indicate that this would be in any way cost effective or justified. Certainly the word “consider” is fortunate, given the stated funding provided to one author by the manufacturer.

The study demonstrated a relationship between lower respiratory morbidity from respiratory syncytial virus (RSV) and smoking which has been widely shown elsewhere. The numbers of smokers were in fact very small—surprisingly so at 18 per 126 babies, given both their prematurity and the catchment population for this hospital, although 28 experienced smoking in the home. One wonders if the 61 non-consenters and non-attenders may have comprised a higher proportion.

Perhaps because of the small numbers there was actually very little relationship shown with smoking in pregnancy—the strong relationships were instead with the 28 passive smokers in the home. If palvizumab was to be given to this group, the cost would be something over £56 000. I have unfortunately had to extrapolate from other data in the paper which would indicate that about 8 of the 16 hospital admissions (excluding the two who were given palvizumab anyway) would have been from smoking families. Assuming a halving of the hospital admission rate from treatment, this amounts to £56 000 to prevent four “admissions” (with a median length of stay of 0 days) while 24 babies would have received 120 needless injections. No savings are likely to accrue from this reduction as the effect on the total RSV workload would be miniscule.

Some might consider this a small price to pay, but one wonders whether £56 000 spent on providing smoking cessation groups to antenatal mothers and householders of premature babies could be a better use of resources.