Evaluation of the accuracy of self-reported smoking in pregnancy when the biomarker level in an active smoker is uncertain

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Our main objective was to estimate smoking prevalence as well as sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of self-reported smoking among pregnant women in Edmonton, Canada, at 15–16 weeks of gestation.


We used serum samples to assemble a cohort of pregnant women who underwent an optional second-trimester screening for chromosomal and developmental anomalies. We determined cotinine concentrations for 92 self-reported smokers (11% of the cohort) and for 285 self-reported nonsmoking mothers, using adapted urinary cotinine assay. Self-reports were collected at the time of delivery. In a validation study, serum cotinine was determined for known smokers and nonsmokers and used, within a Bayesian statistical framework, to define the distribution of cutoffs that differentiate true smokers from nonsmokers. This distribution of cutoffs was used to construct multiple two-by-two tables to obtain the distribution of sensitivity, specificity, PPV, NPV, and prevalence.


Sensitivity was poor (M=47.4%, SD=17.3%), but specificity was nearly perfect (M=94.9%, SD=1.1%). PPV (M=66.6%, SD=11.7%) was smaller than NPV (M=84.7%, SD=14.3%). In our sample, the prevalence of true smoking at 15–16 weeks of gestation was described by a skewed distribution with a mean of 21.6% (SD=13.8%) and a median of 16.6%.


The strength of the present study includes blinding of subjects to the intention to test their sera for a biomarker of smoking. A limitation was the use of a nonrandom sample restricted to pregnancies that resulted in live births. We discuss data collection methods that would elicit more accurate smoking histories from pregnant women.

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