Assessment of exposure to secondhand smoke by questionnaire and salivary cotinine in the general population of Barcelona, Spain (2004–2005)

doi:10.1016/j.ypmed.2008.12.020

Preventive Medicine

Volume 48, Issue 3, March 2009, Pages 218-223

https://doi.org/10.1016/j.ypmed.2008.12.020 Get rights and content

Abstract

Objectives

To estimate the prevalence of self-reported exposure to secondhand smoke (SHS) in different settings and to describe salivary cotinine concentration and its determinants among non-smokers.

Methods

Cross-sectional study of a representative sample (N = 775) of adult non-smokers in Barcelona, Spain (years 2004–2005). We assessed exposure to SHS using a questionnaire and measurement of salivary cotinine concentration. We calculated prevalence rates of self-reported exposure and medians and geometric means of salivary cotinine concentration. We adjusted for potential confounding factors with multinomial logistic regression models.

Results

The prevalence rate of self-reported exposure to SHS among non-smokers in any setting was 75.7% (95% CI: 72.7%–78.8%). The prevalence of exposure to SHS tended to decrease with age. The geometric mean of cotinine concentrations among non-smokers was 1.49 ng/ml (95% CI: 1.39–1.60 ng/ml) among all subjects, and 1.80 ng/ml (95% CI: 1.37–2.35 ng/ml) in subjects who reported exposure to SHS in all settings. In bivariate and multivariate analyses, the cotinine concentration increased with the number of smokers and the number of cigarettes smoked per day in the presence of non-smokers in the household.

Conclusions

In this population, self-reported exposure to SHS is very high. Salivary cotinine concentrations in non-smokers are associated with exposure at home.

Introduction

Secondhand smoke (SHS) has been associated with a variety of health effects among non-smokers, especially lung cancer and ischemic heart disease, as well as other respiratory effects and diseases in children and adults (US Department of Health and Human Services, 2006, IARC, 2004). In Spain, little attention was directed at exposure to SHS, until a national smoke-free law came into effect in January, 2006 to protect non-smokers' health. The law bans smoking in all enclosed workplaces except in some hospitality venues (Fernandez, 2006). Exposure to SHS had been assessed in Spain using questionnaires (Nebot et al., 2004, Perez-Rios et al., 2007, Twose et al., 2007) and airborne markers (Jane et al., 2002, Lopez et al., 2004, Nebot et al., 2005) before the law was enacted. The prevalence of self-reported SHS exposure in any setting among non-smokers was approximately 60–70% before January 2006 (Twose et al., 2007). Airborne nicotine measurements showed high levels of SHS in bars and restaurants, schools, airports, and subways (Lopez et al., 2004). However, studies using personal biomarkers, such as nicotine or cotinine in body fluids, at the population level have not been conducted in Spain. Salivary cotinine is a specific biomarker of recent exposure to SHS that has been used in observational studies (Benowitz, 1996).

Our aims were to describe the salivary cotinine concentrations among the smoking and non-smoking population, to estimate the prevalence of self-reported SHS exposure in a variety of settings and the determinants of salivary concentrations among the adult non-smoking population of Barcelona (Spain). The study was carried out before the new national regulations went into effect.

Section snippets

Design and study participants

This is a cross-sectional study conducted between March 2004 and December 2005 on a representative random sample (1245 people, 694 women and 551 men) of the non-institutionalized population of Barcelona, Spain. We obtained the personal data and addresses from the updated official Census, as provided by the Municipal Institute of Statistics of Barcelona. We sent a letter of introduction about the study; afterwards trained interviewers visited the subjects at home. When the index person was not

Salivary cotinine in smokers and non-smokers

The distribution of the salivary cotinine concentrations is shown in Fig. 1. The distribution for the entire sample (smokers and non-smokers) is bimodal (panel A), with peaks at approximately 1.1 and 150.0 ng/ml. The distributions of the salivary cotinine concentration for smokers (panel B) and non-smokers (panel C) showed some overlap. All subjects had detectable cotinine concentrations and 66.3% of subjects who had reported being non-smokers had a cotinine concentration ≥ 1 ng/ml.

Self-reported exposure to SHS in non-smokers

The

Discussion

In this study, data from questionnaires and measurement of salivary cotinine concentrations provided information about exposure to SHS. The salivary cotinine concentrations in non-smokers were most strongly related to SHS exposure at home, and were associated with both the number of smokers at home and the number of cigarettes smoked in presence of the subject at home.

Conclusions

This study jointly describes the exposure to SHS by means of self-report and salivary cotinine, the first to do so at the population level in Spain. The prevalence of exposure to SHS in this population is high and is inversely associated with age. Moreover, the main setting of exposure to SHS is the home, as shown by the association between salivary cotinine concentrations and the number of smokers and cigarettes smoked at home in the presence of non-smokers. The results of this study,

Determinants of COTinine (DCOT) Study investigators

Antoni Agudo, Carles Ariza, Josep M. Borràs, Esteve Fernández, Marcela Fu, Mireia Jané, Jose M. Martínez-Sánchez, Albert Moncada, Manel Nebot, José A. Pascual, Mercè Peris, Esteve Saltó, Jonathan M. Samet, Anna Schiaffino, Jorge Twose.

Conflicts of interest

The authors declare that there are no conflicts of interest.

Acknowledgments

This project was funded by Instituto de Salud Carlos III (FIS PI020261) and the Thematic Network of Cooperative Research on Cancer RD06/0020/0089) from the Government of Spain, and the Ministry of Universities and Research (SGR200500646), Government of Catalonia. The authors acknowledge the patient collaboration of the participants and field workers, and Chupa-Chups Spain for providing the Smint® candies.

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High levels of cotinine in non-smokers indicate passive exposure to tobacco smoke. This study aims to evaluate variations in salivary cotinine cut-offs to discriminate smokers and non-smokers before and after the implementation of smoke-free legislation (Law 28/2005 and Law 42/2010) in a sample of the adult population of Barcelona, Spain.
This longitudinal study analyzes salivary cotinine samples and self-reported information from a representative sample (n = 676) of the adult population from Barcelona before and after the approval of smoke-free legislation. We calculated the receiver operating characteristic (ROC) curves, to obtain optimal cotinine cut-off points to discriminate between smokers and non-smokers overall, by sex and age, and their corresponding sensitivity, specificity, and area under the curve. We used linear mixed-effects models, with individuals as random effects, to model the percentage change of cotinine concentration before and after the implementation of both laws.
The mean salivary cotinine concentration was significantly lower post-2010 law (−85.8%, p < 0.001). The ROC curves determined that the optimal cotinine cut-off points for discriminating non-smokers and smokers were 10.8 ng/mL (pre-2005 law) and 5.6 ng/mL (post-2010 law), with a post-2010 law sensitivity of 92.6%, specificity of 98.4%, and an area under the curve of 97.0%. The post-2010 law cotinine cut-off points were 5.6 ng/mL for males and 1.9 ng/mL for females.
The implementation of Spanish smoke-free legislation was effective in reducing secondhand smoke exposure and, therefore, also in reducing the cut-off point for salivary cotinine concentration. This value should be used to better assess tobacco smoke exposure in this population.
Third-hand exposure at homes: Assessment using salivary cotinine
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While exposure to secondhand smoke (SHS) is a well-established problem, exposure to third-hand smoke (THS) is scanty known and needs to be studied. The objective of this work is to characterize salivary cotinine concentrations among people who self-reported exposure to SHS and THS at home.
Cross-sectional study of a representative sample (n = 736) of the adult population (≥16 years) from the city of Barcelona carried out in 2013–2014. A questionnaire on tobacco use and passive exposure was administered, and a saliva sample was collected for cotinine determination. For this study, the information of the non-smoker participants who provided saliva sample (n = 519) was used. The geometric means (GM) and geometric standard deviations (GSD) of the cotinine concentration were compared according to the type of self-reported exposure at home: (1) Not exposed to SHS or THS; (2) Exposed to SHS and THS; and (3) Only exposed to THS. We used log-linear models to compare the cotinine concentration of each exposed group with respect to the unexposed group, adjusting for sex, age, educational level, and tobacco exposure in other settings.
The GM of the salivary cotinine concentration was 0.34 ng/ml (GSD = 0.16) among individuals reporting SHS and THS exposure, 0.22 ng/ml (GSD = 0.15) among those reporting only THS exposure and 0.11 ng/ml (GSD = 0.04) among those who declared not to be exposed to SHS nor THS (p-value for trend <0.001). The regression model showed a statistically significant increase in cotinine concentration among those exposed to SHS and THS (188% higher, 95% CI: 153%; 223%), and only exposed to THS (106% higher, IC95. %: 74.5%; 137.0%) when comparing with the unexposed group. No statistically significant differences in cotinine concentration were observed between those exposed to SHS and THS compared to the THS group (−25.8%, 95% CI: −69.5%; 17.9%).
People exposed to third-hand smoke at home had quantifiable cotinine levels in saliva. No differences in cotinine levels were found between those exposed to second-hand and third-hand smoke at home. The reduction of exposure to third-hand smoke at home should be put into the agenda of tobacco control.
Toward a correct measure of third-hand exposure
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Comparison of TSNAs concentration in saliva according to type of tobacco smoked
2019, Environmental Research
To compare tobacco-specific nitrosamines (TSNAs) measured in saliva according to different types of tobacco smoked in a sample of smokers of the city of Barcelona (Spain).
We used data from a cross-sectional study of a sample of the adult smoking population of Barcelona, Spain in 2013–2014 (n = 165). We classified smokers in five groups according to the type of tobacco smoked: a) manufactured cigarettes only, b) roll-your-own (RYO) cigarettes only, c) dual smokers (both manufactured and RYO cigarettes), d) manufactured plus other types of tobacco products different from RYO and e) other types of tobacco products different from manufactured and RYO cigarettes. We calculated the geometric mean (GM) and geometric standard deviation (GSD) of TSNAs concentration in saliva (pg/mL), including N’-nitroaonornicotine (NNN), 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone (NNK) and 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol (NNAL) according to the five tobacco groups. We also described all TSNAs concentration in each tobacco group stratified by the number of cigarettes smoked per day.
Smokers from the RYO cigarette group had higher TSNAs concentration than smokers from the manufactured cigarette group: 13 pg/mL vs 4.9 pg/mL of NNN, 1.9 pg/mL vs 1.7 pg/mL in NNK and 1.1 pg/mL vs 0.9 pg/mL of NNAL. There were significant differences in NNN concentrations between smokers of RYO vs manufactured cigarettes. The higher the number of cigarettes smoked, the higher the TSNAs concentrations. After adjusted by number of cigarettes smoked, there were not statistically significant differences in TSNAs between RYO and manufactured cigarettes.
Our data shows that RYO cigarette is at least as hazardous as manufactured cigarettes. Regulating RYO tobacco prices could be an effective strategy to control tobacco use.
Impact of the Spanish smoking legislation among smokers: A longitudinal study with biomarkers in Barcelona (Spain)
2018, Addictive Behaviors
Citation Excerpt :
This is a longitudinal study (cohort study) from a representative sample of the adult population (≥16 years at baseline, ≥25 at follow-up) of the city of Barcelona (Catalonia, Spain). The baseline study was carried out during the years 2004–2005 (Fu et al., 2009; Martínez-Sánchez et al., 2009b) (n = 1245) and the follow-up took place in 2013–2014, after the implementation of both Spanish tobacco control legislations. To obtain the baseline sample, a representative random sample by age, sex, and district was drawn from the official 2001 population census of Barcelona, a reliable source of population-based information explained elsewhere (Fu et al., 2009; Martínez-Sánchez et al., 2009b).
The aim of this study is to assess the impact of the Spanish tobacco control legislation on smoking behavior and salivary cotinine concentration among smokers.
We used data from a longitudinal study, before (2004–2005) and after (2013–2014) the implementation of the two national smoking bans (in 2006 and 2011), in a representative sample of adults (≥16 years old) from Barcelona (Spain). We only analyzed a subsample of continuing smokers (n = 116). We conducted a survey on smoking behavior and obtained saliva sample for cotinine analyses. For this report, we analyzed a subsample of continuing smokers (n = 116). We calculated geometric means (GM).
Among continuing smokers, salivary cotinine concentration significantly increased by 28.7% (GM from 91.7 ng/ml to 117.3 ng/ml, p = 0.015) after the implementation of the two Spanish smoke-free bans. Nonetheless, no pattern of change was observed in the self-reported number of cigarettes smoked daily.
Our study shows a significant increase in the salivary cotinine concentration among adult continuing smokers after both Spanish legislations. This increase could be due to differences in smoking topography (increase in the depth of inhalation when smoking) along with changes in the type of tobacco smoked (increase in smoking roll-your-own cigarettes or mixed use of roll-your-own and manufactured cigarettes). Our results suggest the need to extend tobacco control policies, focusing on the reduction of use of any type of tobacco product and implementing better treatment to help smokers stop smoking.
Assessment of salivary cotinine concentration among general non-smokers population: Before and after Spanish smoking legislations
2017, Cancer Epidemiology
Citation Excerpt :
Follow-up participants overestimate the young people and smokers in comparison with lost participants. Previous cross-sectional studies conducted in Spain [18,30,32] found that young people are more exposed to SHS exposure than older ones. This aspect could affect the reduction of SHS exposure observed in our study.
In Spain, two smoke-free laws have been passed (Law 28/2005 and Law 42/2010).This study evaluates the association between Spanish smoking legislations and the second-hand smoke (SHS) exposure in an adult non-smoking population cohort in Barcelona (Spain).
This is a longitudinal study, before and after the implementation of two national smoking bans, in a representative sample of adults (≥16 years old) from Barcelona (Spain) surveyed in 2004–2005 and followed up in 2013–2014 (n = 736). We only analyzed non-smokers (n = 397). We obtained 9 ml of saliva sample for analysis of cotinine, a biomarker of recent tobacco exposure. We calculated geometric means of salivary cotinine concentration and their geometric standard deviation. We used linear mixed effect models, with individuals as random effects, to model the percentage change in salivary cotinine concentration and their 95% confidence intervals.
The percentage of participants with saliva samples with measurable concentrations of cotinine fell from 92.4% to 64.2% after both Spanish smoking legislations. The geometric mean of salivary cotinine concentration significantly decreased 88% (from 0.98 ng/mL to 0.12 ng/mL, p < 0.001) after the implementation of the two Spanish smoke-free legislations. The decrease of the GM salivary cotinine concentration was statistically significant independently of the sociodemographic variables.
There was a large reduction in the salivary cotinine concentration among adult non-smokers and higher cotinine concentrations among those declaring exposure to SHS at home after both legislations. Moreover, after both Spanish smoke-free laws salivary cotinine concentration was homogenized according to sociodemographic variables.

View all citing articles on Scopus

¹: Determinants of COTinine (DCOT) Study investigators listed at the end of manuscript.

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Assessment of exposure to secondhand smoke by questionnaire and salivary cotinine in the general population of Barcelona, Spain (2004–2005)

Abstract

Objectives

Methods

Results

Conclusions

Introduction

Section snippets

Design and study participants

Salivary cotinine in smokers and non-smokers

Self-reported exposure to SHS in non-smokers

Discussion

Conclusions

Determinants of COTinine (DCOT) Study investigators

Conflicts of interest

Acknowledgments

Prev. Med.

Prev. Med.

Prev. Med.

Gac. Sanit.

Rev. Esp. Cardiol.

Environ. Res.

Cotinine as a biomarker of environmental tobacco smoke exposure

Epidemiol. Rev.

Biomarkers of environmental tobacco smoke exposure

Environ. Health Perspect.

Cotinine concentration in smokers from different countries: relationship with amount smoked and cigarette type

Cancer Epidemiol. Biomark. Prev.

Determinants of salivary cotinine levels among current smokers in Mexico

Nicotine Tob. Res. Gac. Sanit.

Spain: going smoke free

Tob. Control

Validez de un cuestionario sobre exposición percibida al humo ambiental del tabaco

Gac. Sanit.

Impact of the “Tobacco control law” on exposure to environmental tobacco smoke in Spain

BMC Public Health

Nicotine concentrations in deciduous teeth and cumulative exposure to tobacco smoke during childhood

JAMA

Changes in exposure of adult non-smokers to secondhand smoke after implementation of smoke-free legislation in Scotland: national cross sectional survey

BMJ

Tobacco smoke and involuntary smoking

IARC Monographs Volume 83