Determining Optimal Cutoffs for Exhaled Carbon Monoxide and Salivary Cotinine to Identify Smokers among Korean Americans in a Smoking Cessation Clinical Trial

Introduction. It is critical to accurately identify individuals who continue to smoke even after treatment, as this may prompt the use of more intensive and effective treatment strategies to help them attain complete abstinence. Aims. This study examined optimal cutoffs for exhaled carbon monoxide (CO) and salivary cotinine to identify smokers among Korean Americans in a smoking cessation clinical trial. Methods. CO and cotinine were measured three to four times over 12 months from the quit day. Statistical analysis was conducted using Receiver Operating Characteristic (ROC) curves. Results. A CO cutoff of 5 parts per million provided robust sensitivity (80.8-98.3%) and perfect specificity (100%), and a salivary cotinine cutoff of level 2 (30-100 ng/ml) provided the best sensitivity (91.2-95.6%) and perfect specificity (100%). Using these cutoffs, the agreement between self-reports and the two biomarkers ranged from 88.6% to 97.7%. The areas under ROC curves (AUCs) of exhaled CO ranged from 0.90 to 0.99, all of which were significant (all p values < 0.001), and the AUCs of salivary cotinine ranged from 0.96 to 0.98 (all p values < 0.001). Conclusion. Exhaled CO and salivary cotinine are complementary, and they should be used together to verify smoking abstinence for smokers in a clinical trial.