Cancer Screening Adherence of Asian Women According to Biochemically-verified Smoking Status: Korea National Health and Nutrition Examination Survey

  • Ko, Young-Jin (Department of Family Medicine, Korea Cancer Center Hospital) ;
  • Kim, Soyeun (Department of Family Medicine, Korea Cancer Center Hospital) ;
  • Kim, Kyae-Hyung (Department of Family Medicine, Seoul National University Hospital) ;
  • Lee, Kiheon (Department of Family Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine) ;
  • Lee, Cheol Min (Department of Family Medicine, Healthcare System Gangnam Center, Seoul National University Hospital)
  • Published : 2015.05.18


Background: Men and women who smoke tend to show less compliance to screening guidelines than non-smokers. However, a recent study in Korea showed that self-reported female smokers constituted less than half of cotinine-verified smokers. Therefore, the aim of this study was to identify hidden smokers using cotinine-verified method and examine cancer screening behavior according to biochemically verified smoking status. Materials and Methods: Among 5,584 women aged 30 years and older who participated in the Fourth and Fifth Korea National Health and Nutrition Examination Survey (KNHANES), 372 (6.66%) hidden smokers were identified based on interview responses and verified by urinary cotinine levels. We compared cancer-screening behavior (cervical, breast, stomach, and colon cancer) of female hidden smokers to that of non-smokers and selfreported smokers by cross-sectional analysis. Results: Hidden female smokers had significantly lower adherence to breast cancer screening compared to non-smokers (aOR (adjusted odds ratio) [95% CI] = 0.71 [0.51-0.98]). Adherence to stomach cancer (aOR [95% CI] = 0.75 [0.54-1.03]) and cervical cancer (aOR [95% CI] = 0.85 [0.66-1.10]) screening was also lower among hidden female smokers compared to non-smokers. Self-reported (current) smokers showed lowest adherence to cervical cancer (aOR: 0.64, 95% CI0.47-0.87), breast cancer (0.47 [0.32-0.68]), stomach cancer (0.66[0.46-0.95]), and colon cancer (0.62 [0.38-1.01]) screening compared to non-smokers, followed by female hidden smokers, then non-smokers. These lower adherence rates of current smokers were attenuated after we incorporated hidden smokers into the current smoker group. Conclusions: Cancer screening adherence of female hidden smokers was lower than cotinine-verified non-smokers but higher than current smokers. Considering the risk of smoking-related cancer among women, identifying hidden smokers is important to encourage appropriate cancer screening.


  1. Berrigan D, Dodd K, Troiano RP, et al (2003). Patterns of health behavior in U.S. adults. Prev Med, 36, 615-23.
  2. Botteri E, Iodice S, Bagnardi V, et al (2008). Smoking and colorectal cancer: a meta-analysis. JAMA, 300, 2765-78.
  3. Carlos RC, Fendrick AM, Patterson SK, et al (2005). Associations in breast and colon cancer screening behavior in women. Acad Radiol, 12, 451-8.
  4. Centers for Disease C, Prevention (2008). Smoking-attributable mortality, years of potential life lost, and productivity losses--United States, 2000-2004. Morb Mortal Wkly Rep, 57, 1226-8.
  5. Cho HJ, Khang YH, Jun HJ, et al (2008). Marital status and smoking in Korea: the influence of gender and age. Soc Sci Med, 66, 609-19.
  6. de Vries H, van't Riet J, Spigt M, et al (2008). Clusters of lifestyle behaviors: results from the Dutch SMILE study. Prev Med, 46, 203-8.
  7. Gaudet MM, Gapstur SM, Sun J, et al (2013). Active smoking and breast cancer risk: original cohort data and meta-analysis. J Natl Cancer Inst, 105, 515-25.
  8. Haufroid V, Lison D (1998). Urinary cotinine as a tobacco-smoke exposure index: a minireview. Int Arch Occup Environ Health, 71, 162-8.
  9. International Collaboration of Epidemiological Studies of Cervical Cancer (2007). Comparison of risk factors for invasive squamous cell carcinoma and adenocarcinoma of the cervix: collaborative reanalysis of individual data on 8,097 women with squamous cell carcinoma and 1,374 women with adenocarcinoma from 12 epidemiological studies. Int J Cancer, 120, 885-91.
  10. International Collaboration of Epidemiological Studies of Cervical Cancer, Appleby P, Beral V, et al (2006). Carcinoma of the cervix and tobacco smoking: collaborative reanalysis of individual data on 13,541 women with carcinoma of the cervix and 23,017 women without carcinoma of the cervix from 23 epidemiological studies. Int J Cancer, 118, 1481-95.
  11. Johnson KC, Miller AB, Collishaw NE, et al (2011). Active smoking and secondhand smoke increase breast cancer risk: the report of the Canadian Expert Panel on Tobacco Smoke and Breast Cancer Risk (2009). Tob Control, 20, 2.
  12. Jun-Sik N (2010). National Cancer Screening Program. J Korean Medical Association, 53, 386-91.
  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 SM, Jo HS (2014). Intrinsic motivation factors based on the self-determinant theory for regular breast cancer screening. Asian Pac J Cancer Prev, 15, 10101-6.
  15. Kim JH, Park EC, Yoo KB (2014). Impact of perceived cancer risk on the cancer screening rate in the general korean population: results from the korean health panel survey data. Asian Pac J Cancer Prev, 15, 10525-9.
  16. Korea Centers for Disease C, Prevention, (2007). Guide to the utilization of the data from the third Korea National Health and Nutrition Examination Survey.
  17. Korea Centers for Disease C, Prevention, (2010). Korean National Health and Nutrition Examination Survey. 2010
  18. Ladeiras-Lopes R, Pereira AK, Nogueira A, et al (2008). Smoking and gastric cancer: systematic review and metaanalysis of cohort studies. Cancer Causes Control, 19, 689-701.
  19. Larkin FA, Basiotis PP, Riddick HA, et al (1990). Dietary patterns of women smokers and non-smokers. J Am Diet Assoc, 90, 230-7.
  20. Lee CY, Shin S, Lee HK, et al (2009). Validation of self-report on smoking among university students in Korea. Am J Health Behav, 33, 540-9.
  21. Lee K, Lim HT, Park SM (2010). Factors associated with use of breast cancer screening services by women aged >or=40 years in Korea: the third Korea National Health and Nutrition Examination Survey 2005 (KNHANES III). BMC Cancer, 10, 144.
  22. Ma J, Zhu J, Li N, et al (2013). Severe and Differential Underestimation of Self-reported Smoking Prevalence in Chinese Adolescents. Int J Behav Med, 21, 662-6.
  23. Marteau TM, Hankins M, Collins B (2002). Perceptions of risk of cervical cancer and attitudes towards cervical screening: a comparison of smokers and non-smokers. Fam Pract, 19, 18-22.
  24. McKee SA (2009). Developing human laboratory models of smoking lapse behavior for medication screening. Addict Biol, 14, 99-107.
  25. Myong JP, Shin JY, Kim SJ (2012). Factors associated with participation in colorectal cancer screening in Korea: the Fourth Korean National Health and Nutrition Examination Survey (KNHANES IV). Int J Colorectal Dis, 27, 1061-9.
  26. Rakowski W, Clark MA, Truchil R, et al (2005). Smoking status and mammography among women aged 50-75 in the 2002 behavioral risk factor surveillance system. Women Health, 41, 1-21.
  27. Rakowski W, Meissner H, Vernon SW, et al (2006). Correlates of repeat and recent mammography for women ages 45 to 75 in the 2002 to 2003 health information national trends survey (HINTS 2003). Cancer Epidemiol Biomarkers Prev, 15, 2093-101.
  28. Ruidavets JB, Bataille V, Dallongeville J, et al (2004). Alcohol intake and diet in France, the prominent role of lifestyle. Eur Heart J, 25, 1153-62.
  29. Schumann A, Hapke U, Rumpf HJ, et al (2001). The association between degree of nicotine dependence and other health behaviours. Findings from a German general population study. Eur J Public Health, 11, 450-2.
  30. Shapiro JA, Seeff LC, Nadel MR (2001). Colorectal cancer-screening tests and associated health behaviors. Am J Prev Med, 21, 132-7.
  31. SNRT Subcommittee on Biochemical Verification (2002). Biochemical verification of tobacco use and cessation. Nicotine Tob Res, 4, 149-59.
  32. The IPAQ Group (2005). Guidelines for data processing and analysis of the international physical activity questionnaire (IPAQ) - Short and Long Forms
  33. Vineis P, Alavanja M, Buffler P, et al (2004). Tobacco and cancer: recent epidemiological evidence. J Natl Cancer Inst, 96, 99-106.
  34. Wang Z, Ma J (2012). Prevalence and patterns of tobacco use in Asia. Lancet, 380, 1905-6.
  35. West R, Zatonski W, Przewozniak K, et al (2007). Can we trust national smoking prevalence figures? Discrepancies between biochemically assessed and self-reported smoking rates in three countries. Cancer Epidemiol Biomarkers Prev, 16, 820-2.
  36. World Health Organization (2000). World health organization regional office for the western pacific region, international association for the study of obesity, international obesity task force. the asian-pacific perspective: redefining obesity and its treatment. sydney: health communications Australia.
  37. World Health Organization (2011). Who report on the global tobacco epidemic, 2011: Warning about the dangers of tobacco. 2013.06.14.
  38. Wong SL, Shields M, Leatherdale S, et al (2012). Assessment of validity of self-reported smoking status. Health Rep, 23, 47-53.
  39. Yeager DS, Krosnick JA (2010). The validity of self-reported nicotine product use in the 2001-2008 national health and nutrition examination survey. Med Care, 48, 1128-32.

Cited by

  1. Association of Cigarette Prices with the Prevalence of Smoking in Korean University Students: Analysis of Effects of the Tobacco Control Policy vol.16, pp.13, 2015,