Nicotine Dependence Evaluated by Urinary Cotinine and Heaviness of Smoking Index among Smokers, Vapers, and Dual Users: A Cross-Sectional Study Using the Korea National Health and Nutrition Examination Survey Data

Protocol for the development of a vaping cessation intervention for young adult veterans

The use of e-cigarettes ("vaping") by young adults has increased substantially in the past decade. Although health risks of long-term e-cigarette use remain unknown, there is evidence of acute physiological harms. Most young adults who vape report intent to quit, but little is known about effective interventions. This protocol paper reports on the development and design of a pilot trial of a vaping intervention for young military Veterans. Young adult Veterans accessing VA healthcare (n = 20) who vape daily and have been referred for cessation services will be enrolled. To maximize accessibility the intervention will be delivered virtually; participants will be randomized to receive behavioral counseling by telephone or by video telehealth. The intervention was adapted from an existing program targeting young adult cigarette smokers and will include 6 individual counseling sessions delivered over 8 weeks. Assessment visits will occur at baseline, at end-of-treatment, and 4 weeks later. Analyses will evaluate feasibility and acceptability of the intervention overall, and will compare telephone and video telehealth modalities. Longitudinal regression will be used to evaluate changes in vaping behavior and in nicotine dependence over time. This study will provide assessment of a novel intervention adapted for Veterans who vape nicotine. The comparison of two modalities of virtual intervention delivery will increase knowledge and the potential to disseminate across VA and other healthcare systems. Findings from this pilot trial will inform the design of future, larger studies of vaping cessation interventions for younger Veterans.

Optimum Urine Cotinine and NNAL Levels to Distinguish Smokers from Non-Smokers by the Changes in Tobacco Control Policy in Korea from 2008 to 2018

INTRODUCTION

We examined the age- and sex-specific distributions of biomarkers of tobacco smoke exposure to determine the optimal cutoffs to distinguish smokers from non-smokers over the last 10 years in Korea, during which smoking prevalence and secondhand smoke (SHS) exposure declined due to changes in tobacco control policy.

METHODS

We analyzed data from the Korea National Health and Nutrition Examination Survey on creatinine-adjusted urinary cotinine (2008-2018; 33 429 adults: 15 653 males and 17 776 females) and 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol (NNAL; 2016-2018; 6337 adults: 3091 males and 3246 females). We determined the optimal cutoffs and confidence intervals (CIs) to distinguish smokers from non-smokers using receiver operator characteristic curve analysis and bootstrapping (1000 resamples).

RESULTS

The optimal cutoff values of creatinine-adjusted urine cotinine and NNAL concentration were 20.9 ng/mg (95% CI: 20.8-21.0, sensitivity: 96.6%, specificity: 93.8%) and 8.9 pg/mg (95% CI: 8.8-8.9, sensitivity: 94.0%, specificity: 94.7%), respectively, in 2016-2018. The optimal cutoffs of both biomarkers increased with age and were higher in females than in males for NNAL concentration. In both sexes, the optimal cutoff of urine cotinine continuously declined over the study period.

CONCLUSIONS

The optimal cotinine cutoff declined along with smoking prevalence and levels of SHS exposure due to enforcement of tobacco control policies, including smoke-free ordinances and tax increases. Monitoring of biomarkers of tobacco exposure appears necessary for verification of smoking status and regulatory use.

IMPLICATIONS

Our results based on nationally representative data suggest that a large decrease in the optimal cutoff value of urine cotinine to distinguish smokers from non-smokers was caused by decreases in smoking prevalence and SHS exposure following enforcement of tobacco control policies over the last 10 years. We determined the optimal cutoff values of urine 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol (NNAL), which were not previously reported in representative population in Asia, to enable more accurate estimation of exposure to tobacco smoke and proper assessment of disease risks. Gender- and age-specific differences in the optimal cutoffs require further study. Monitoring of biomarkers of tobacco smoke exposure seems necessary for verification of smoking status and regulatory use.