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Can We Trust National Smoking Prevalence Figures? Discrepancies Between Biochemically Assessed and Self-Reported Smoking Rates in Three Countries

¹ Health Behaviour Unit, Department of Epidemiology and Public Health, University College London, London, United Kingdom and ² Cancer Epidemiology and Prevention Division, The Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Warsaw, Poland

Requests for reprints: Robert West, Epidemiology and Public Health, University College London, Torrington Place, London, United Kingdom. Phone: 44-2076796633. E-mail: robert.west{at}ucl.ac.uk

Background: National smoking prevalence estimates are the primary basis for assessing progress in tobacco control across the world. They are based on surveys of self-reported cigarette smoking. It has been assumed that this is sufficiently accurate for policy purposes, but this assumption has not been adequately tested.

Methods: We report data from the 2003 Health Survey for England, the U.S. National Health and Nutrition Examination Survey for 2001-2002, and the 2004 national smoking behaviors survey in Poland as examples of countries at different stages in the "tobacco epidemic." Self-reported cigarette and total tobacco smoking prevalence were assessed by means of the standard questions used in each country. In subsamples, specimens were collected for analysis of cotinine (saliva, N = 1,613 in England; serum, N = 4,687 in the United States; and saliva, N = 388 in Poland) providing an objective means of determining active smoking. A cut point of 15 ng/mL was used to discriminate active smoking from passive smoke exposure.

Results: Self-reported cigarette smoking prevalence using the standard methods underestimated true tobacco smoking prevalence by an estimated 2.8% in England, 0.6% in the United States, and 4.4% in Poland. Cotinine concentrations in those misclassified as nonsmokers were indicative of high levels of smoke intake.

Interpretation: Underestimation of smoking prevalence was minimal in the United States but significant in England and Poland. A review of methodologies for assessing tobacco smoking prevalence worldwide is urgently needed. (Cancer Epidemiol Biomarkers Prev 2007;16(4):820–2)

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