Biochemically-verified Smoking Rate Trends and Factors Associated with Inaccurate Self-reporting of Smoking Habits in Korean Women

  • Kang, Hyun Goo (Yonsei University College of Medicine) ;
  • Kwon, Kyoung Hyun (Yonsei University Medical School) ;
  • Lee, In Wook (Yonsei University College of Medicine) ;
  • Jung, Boyoung (Department of Public Health, Yonsei University College of Medicine) ;
  • Park, Eun-Cheol (Yonsei University College of Medicine) ;
  • Jang, Sung-In (Yonsei University College of Medicine)
  • Published : 2013.11.30


Background: Lung cancer is a major cause of Korean female mortality and is clearly associated with smoking. The Korean National Health and Nutrition Examination Survey (KNHANES IV-2,3), which included both self-reports of smoking and urinary cotinine data, revealed a significant discrepancy between the prevalence of self-reported and biochemically-verified female smokers. The factors associated with accurate self-reporting of current smoking status remain poorly understood, however. Materials and Methods: We assessed the prevalence of smoking in KNHANES using both self-report and urinary cotinine data. Subsequently, using univariate and multivariate tests, we assessed whether age, intensity of smoking, marital status, relationship with cohabitants, education, occupation, residential area, or annual household income were associated with inaccurate self-reporting in Korean females. We also investigated whether the prevalence of inaccurate self-reports changed over the survey period, 2008-2009. Results: The prevalence of self-reported smoking was 47.8% in males and 6.6% in females. By contrast, the prevalence of smoking as assessed by urinary cotinine levels was 52.2% in males and 14.5% in females. Of the 746 females with urinary cotinine levels >50ng/ml, 407 (56.0%) provided inaccurate self-reports. In a multivariate model, age group(40-49: OR 3.54, 95%CI 1.42-8.86, p=0.007; ref :20-29), cotinine intensity(OR 0.999, 95%CI 0.998-0.999, p<0.001), marital status (married but without spouse: OR 0.37, 95%CI 0.15-0.94, p=0.037; ref :never married), relationship with cohabitants (living with a spouse and unmarried child: OR 2.63, 95%CI 1.44-4.80, p=0.002; living with 2 generations except unmarried child: OR 2.53, 95%CI 1.09-5.87, p=0.030; living with ${\geq}3$ generations: OR 3.25, 95%CI 1.48-7.10, p=0.003; ref :spouse only) and education(college or higher: OR 2.73, 95%CI 1.04-7.18, p=0.042; ref :elementary or less) were independently associated with inaccurate self-reports. Conclusions: The trend of smoking prevalence of Korean females is likely to decrease. However, an elevated prevalence of inaccurate self-reports by females remains. Factors related to the intensity of smoking and family status appear to influence whether a Korean female provides an accurate self-report when asked about smoking behavior.


Smoking rates;cotinine;surveillance and monitoring;self-reporting;Korean females


  1. Amos A, Greaves L, Nichter M, Bloch M (2012). Women and tobacco: a call for including gender in tobacco control research, policy and practice. Tob Control, 21, 236-43.
  2. Bae JM, Jung KW, Won YJ (2002). Estimation of cancer deaths in Korea for the upcoming years. J Korean Med Sci, 17, 611-5.
  3. Benowitz NL, Bernert JT, Caraballo RS, et al (2009). Optimal serum cotinine levels for distinguishing cigarette smokers and nonsmokers within different racial/ethnic groups in the United States between 1999 and 2004. Am J Epidemiol, 169, 236-48.
  4. Caraballo RS, Giovino GA, Pechacek TF, Mowery PD (2001). Factors associated with discrepancies between self-reports on cigarette smoking and measured serum cotinine levels among persons aged 17 years or older: Third National Health and Nutrition Examination Survey, 1988-1994. Am J Epidemiol, 153, 807-14.
  5. Centers for Disease C, Prevention (2010). Vital signs: nonsmokers’ exposure to secondhand smoke --- United States, 1999-2008. MMWR Morb Mortal Wkly Rep, 59, 1141-6.
  6. Cho HJ, Khang YH, Jun HJ, Kawachi I (2008). Marital status and smoking in Korea: the influence of gender and age. Soc Sci Med, 66, 609-19.
  7. Connor Gorber S, Schofield-Hurwitz S, Hardt J, et al (2009). The accuracy of self-reported smoking: a systematic review of the relationship between self-reported and cotinine-assessed smoking status. Nicotine Tob Res, 11, 12-24.
  8. Fakhfakh R, Klouz A, Lakhal M, et al (2011). Validity of self-reported smoking among women hospital staff in Tunisia. Tob Control, 20, 86.
  9. Jang SY, Kim JH, Lim MK, et al (2012). Relationship between BMI, body image, and smoking in Korean women as determined by urine cotinine: results of a nationwide survey. Asian Pac J Cancer Prev, 13, 1003-10.
  10. Jarvis MJ, Fidler J, Mindell J, et al (2008). Assessing smoking status in children, adolescents and adults: cotinine cut-points revisited. Addiction, 103, 1553-61.
  11. Jarvis MJ, Sims M, Gilmore A, Mindell J (2012). Impact of smoke-free legislation on children’s exposure to secondhand smoke: cotinine data from the Health Survey for England. Tob Control, 21, 18-23.
  12. Jarvis MJ, Tunstall-Pedoe H, Feyerabend C, et al (1987). Comparison of tests used to distinguish smokers from nonsmokers. Am J Public Health, 77, 1435-8.
  13. Jung-Choi KH, Khang YH, Cho HJ (2012). Hidden female smokers in Asia: a comparison of self-reported with cotinine-verified smoking prevalence rates in representative national data from an Asian population. Tob Control, 21, 536-42.
  14. Jung KW, Won YJ, Kong HJ, et al (2013). Cancer statistics in Korea: incidence, mortality, survival and prevalence in 2010. Cancer Res Treat, 45, 1-14.
  15. Kang YH LY-J, Kim HK, et al (2003). Usefulness of urinary cotinine test ot distinguish smokers from nonsmokers. Korean J Lab Med, 23, 92-7.
  16. Keskinoglu P, Cimrin D, Aksakoglu G (2007). Which cut-off level of urine cotinine:creatinine ratio (CCR) should be used to determine passive smoking prevalence in children in community based studies? Tob Control, 16, 358-9.
  17. Lerman C, Orleans CT, Engstrom PF (1993). Biological markers in smoking cessation treatment. Semin Oncol, 20, 359-67.
  18. Martiniuk A, Lee CM, Woodward M, Huxley R (2010). Burden of lung cancer deaths due to smoking for men and women in the WHO Western Pacific and South East Asian regions. Asian Pac J Cancer Prev, 11, 67-72.
  19. Nagano T, Shimizu M, Kiyotani K, et al (2010). Biomonitoring of urinary cotinine concentrations associated with plasma levels of nicotine metabolites after daily cigarette smoking in a male Japanese population. Int J Environ Res Public Health, 7, 2953-64.
  20. Park HY, Leistikow B, Tsodikov A, et al (2007). Smoke load/cancer death rate associations in Korea females, 1985-2004. Prev Med, 45, 309-12.
  21. Roth MA A-SA, Wardle H, Mindell J. (2009). Under-reporting of tobacco use among Bangladeshi women in England. J Public Health (Oxf), 31, 9.
  22. Russell T, Crawford M, Woodby L (2004). Measurements for active cigarette smoke exposure in prevalence and cessation studies: why simply asking pregnant women isn’t enough. Nicotine Tob Res, 6, 141-51.
  23. Sarraf-Zadegan N, Boshtam M, Shahrokhi S, et al (2004). Tobacco use among Iranian men, women and adolescents. Eur J Public Health, 14, 76-8.
  24. Verification SSoB (2002). Biochemical verification of tobacco use and cessation. Nicotine Tob Res, 4, 149-59.
  25. Wagenknecht LE, Burke GL, Perkins LL, et al (1992). Misclassification of smoking status in the CARDIA study: a comparison of self-report with serum cotinine levels. Am J Public Health, 82, 33-6.
  26. Wong SL, Shields M, Leatherdale S, et al (2012). Assessment of validity of self-reported smoking status. Health Rep, 23, 47-53.
  27. Yarnall NJ, Hughes LM, Turnbull PS, Michaud M (2012). Evaluating the effectiveness of the US Navy and Marine Corps Tobacco Policy: an assessment of secondhand smoke exposure in US Navy submariners. Tob Control, 22, 66-72.
  28. Zielinska-Danch W, Wardas W, Sobczak A, Szoltysek-Boldys I (2007). Estimation of urinary cotinine cut-off points distinguishing non-smokers, passive and active smokers. Biomarkers, 12, 484-96.

Cited by

  1. Association between Cigarette Smoking History and Mortality in 36,446 Health Examinees in Korea vol.15, pp.14, 2014,
  2. Compliance with Smoke-Free Policies in Korean Bars and Restaurants in California: a Descriptive Analysis vol.16, pp.3, 2015,
  3. Influence of Maternal Environmental Tobacco Smoke Exposure Assessed by Hair Nicotine Levels on Birth Weight vol.16, pp.7, 2015,
  4. The prevalence of positive urinary cotinine tests in Korean infertile couples and the effect of smoking on assisted conception outcomes vol.42, pp.4, 2015,
  5. Association between Second-Hand Smoking and Laryngopathy in the General Population of South Korea vol.11, pp.11, 2016,
  6. Analysis of the Paternalistic Justification of an Agenda Setting Public Health Policy: The Case of Tobacco Plain Packaging vol.9, pp.2, 2016,
  7. Can a urine dipstick test be used to assess smoking status in patients undergoing planned orthopaedic surgery?: a prospective cohort study vol.98-B, pp.10, 2016,
  8. Self‐Reported Smoking, Urine Cotinine, and Risk of Cardiovascular Disease: Findings From the PREVEND (Prevention of Renal and Vascular End‐Stage Disease) Prospective Cohort Study vol.7, pp.10, 2018,
  9. The Association between Smoking Status and Influenza Vaccination Coverage Rate in Korean Adults: Analysis of the 2010–2012 Korea National Health and Nutrition Examination Survey vol.39, pp.2, 2018,
  10. Dose-Dependent Toxic Effect of Cotinine-Verified Tobacco Smoking on Systemic Inflammation in Apparently Healthy Men and Women: A Nationwide Population-Based Study vol.16, pp.3, 2019,
  11. Deterioration of semen quality and sperm-DNA integrity as influenced by cigarette smoking in fertile and infertile human male smokers-A prospective study pp.07302312, 2019,