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Pitfalls in the assessment of smoking status detected in a cohort of South African RA patients

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Abstract

This study was conceived in an attempt to explain the unexpectedly high frequency of elevated levels of serum cotinine measured retrospectively in a cohort of predominantly black South African females with rheumatoid arthritis (RA), findings that were inconsistent with the smoking histories derived from health questionnaires. The discrepant findings suggested either a greater tendency towards underreporting of smoking status in the study cohort, or possible confounding effects of the use of smokeless tobacco products. In addition to the cohort of RA patients (n = 138, of whom 115 (83 %) were female), blood samples were also taken from a second cohort consisting of 29 declared smokers, 18 (62 %) of whom where females, 29 smokeless tobacco (SLT) users (all female), and 22 non-users of any tobacco products, 18 (82 %) of whom were females. Serum cotinine levels were determined using an ELISA procedure. Cotinine levels of >10.0 ng/ml were detected in serum specimens from 43 (31 %), RA patients of whom 35 (81 %) were female, with a median value of 50.1 ng/ml and interquartile range (iqr) of 68.6. Only 18 of the 35 females indicated that they smoked. The groups of declared smokers and SLT users had equivalent median serum cotinine levels of 88.0 ng/ml (iqr = 10.8 ng/ml) and 87.0 ng/ml (iqr = 15.6 ng/ml), respectively, while cotinine was undetectable in specimens from non-tobacco product users (<0.2 ng/ml). Users of SLT products in South Africa are predominantly female and have serum cotinine levels which are comparable with those of current smokers, raising concerns about the validity of measurement of cotinine as the sole objective marker of smoking status in populations with high usage of SLTs. This situation can be rectified by ensuring that usage of SLT products is accurately recorded in health questionnaires, while inclusion of measurement of one or more additional, objective biomarkers of smoking in combination with cotinine may enable reliable distinction between smoking and usage of SLTs which, given the associated risks, is a strategy of particular relevance in RA.

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Fig. 1

Abbreviations

CDC:

Centers for disease control

CI:

Confidence interval

DALYs:

Disability-adjusted life-years

ELISA:

Enzyme-linked immunosorbent assay

F:M:

Female-to-male ratio

HQ(s):

Health questionnaire(s)

iqr:

Interquartile range

ng/ml:

Nanograms per millilitre

RA:

Rheumatoid arthritis

SLT(s):

Smokeless tobacco(s)

WHO:

World Health Organization

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Authors’ contribution

NGovind, MMTM, Ally, M Tikly, and B Hodkinson were involved in study design, clinical assessment, and analysis and communication of data; R Anderson involved in study design and analysis and communication of data; and PWA Meyer involved in study design, generation, and analysis and communication of data.

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Authors and Affiliations

  1. Division of Rheumatology, Chris Hani Baragwanath Academic Hospital, Faculty of Health Sciences, University of the Witwatersrand, Chris Hani Road, Johannesburg, 2013, South Africa

    Nimmisha Govind, Mohammed Tikly & Bridget Hodkinson

  2. Department Internal Medicine, Faculty of Health Sciences, University of Pretoria, 9th Floor Steve Biko Academic Hospital, Dr Savage Road, Pretoria, 0002, South Africa

    Mahmood M. T. M. Ally

  3. Department of Immunology, Faculty of Health Sciences, University of Pretoria, Prinshof Campus, 5 Bophelo Rd, PO Box X323, Pretoria, 0001, South Africa

    Ronald Anderson & Pieter W. A. Meyer

  4. Tshwane Academic Division of the National Health Laboratory Service, PO Box X323, Pretoria, 0001, South Africa

    Pieter W. A. Meyer

Authors
  1. Nimmisha Govind
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  2. Mahmood M. T. M. Ally
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  3. Mohammed Tikly
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  4. Ronald Anderson
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  5. Bridget Hodkinson
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  6. Pieter W. A. Meyer
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Corresponding author

Correspondence to Pieter W. A. Meyer.

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The authors of this manuscript have no relationships or interests that could influence or bias the work.

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Govind, N., Ally, M.M.T.M., Tikly, M. et al. Pitfalls in the assessment of smoking status detected in a cohort of South African RA patients. Rheumatol Int 36, 1365–1369 (2016). https://doi.org/10.1007/s00296-016-3527-y

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  • DOI: https://doi.org/10.1007/s00296-016-3527-y

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