Research Article of American Journal of Orthopedic Research and Reviews
Expired Air Carbon Monoxide Testing Is Effective for Preoperative Screening of Cigarette Use in Orthopaedic Patients: A Prospective Pilot Study of 70 Veterans
Sean R. Sterrenberg, MD1; David M. Gallacher, BS1; John P. Tabb, BS1; Melissa S. Schmidt, RN2; Lucas Anissian, MD2; Kenneth R. Gundle, MD1,2; Ryan B. Wallenberg, MD2
1Oregon Health and Science University, Department of Orthopaedics and Rehabilitation, Portland, OR, USA; 2 Portland VA Medical Center, Operative Care Division, Portland, OR, USA
Introduction: Screening for cigarette use is standard in the orthopedic pre-operative clinic, however traditional biochemical testing methods, including serum and urine cotinine assays, do not differentiate active smoking from nicotine replacement therapy (NRT). In this prospective pilot study, we hypothesize that exhaled carbon monoxide (eCO) testing will be non-inferior to the gold standard serum cotinine (SC) test in screening for pre-operative cigarette use, will differentiate active smoking from NRT, and will allow for substantial cost savings in a clinic setting.
Methods: Adult orthopaedic veterans indicated for elective surgery at our institution were offered inclusion. Self-reported smoking status (SRS), eCO and SC levels were obtained preoperatively. An eCO level of >6 parts per million and a SC level >3 ng/ml were considered positive for recent cigarette use. Agreement between SRS, eCO levels and SC levels, and eCO level test-retest reliability were evaluated.
Results: Of the 55 patients enrolled into the study, 4 were self-reported Current Smokers and 51 were self-reported Ex-Smokers or Non-Smokers. Combining SRS with eCO levels as a screening tool for recent cigarette use yielded a sensitivity of 100%, a specificity of 98%, a positive predictive value of 95% and a negative predictive value of 100%. eCO testing differentiated NRT from cigarette use in all non-smoking patients. Test-retest reliability for eCO levels showed perfect agreement for 16 patients that had two or more eCO levels pre-operatively.
Conclusion: Exhaled CO testing is as effective as SC testing but can differentiate active smoking from NRT, while maintaining a high level of accuracy and reliability when combined with SRS as a screening tool.
Keywords: Orthopaedic surgery, smoking, surgical outcomes, nicotine replacement
How to cite this article:
Sean R. Sterrenberg, David M. Gallacher, John P. Tabb, Melissa S. Schmidt, Lucas Anissian,Kenneth R. Gundle, Ryan B. Wallenberg.American Journal of Orthopedic Research and Reviews, 2021, 4:24. DOI: 10.28933/ajorr-2021-07-1505
References:
1. McKinney, W P, McIntire, D D, Carmody, T J, & Joseph, A. Comparing the smoking behavior of veterans and nonveterans. Public Health Reports 1997; 112(3): 212.
2. Singh, J A, Houston, T K, Ponce, B A et al. Smoking as a risk factor for short‐term outcomes following primary total hip and total knee replacement in veterans. Arthritis Care & Research 2011; 63(10): 1365-1374.
3. Tsai, J, Edens, E L, & Rosenheck, R A. Nicotine Dependence and Its Risk Factors Among Users of Veterans Health Services, 2008-2009 Posted on October 13, 2011.
4. Duffy, S A, Kilbourne, A M, Austin, K L et al. Risk of smoking and receipt of cessation services among veterans with mental disorders. Psychiatric Services 2012; 63(4): 325-332.
5. Duchman, K R, Gao, Y, Pugely, A J, Martin, C T, Noiseux, N O, & Callaghan, J J. The effect of smoking on short-term complications following total hip and knee arthroplasty. JBJS 2015; 97(13): 1049-1058.
6. Lee, S M, Landry, J, Jones, P M, Buhrmann, O, & Morley-Forster, P. The effectiveness of a perioperative smoking cessation program: a randomized clinical trial. Anesthesia & Analgesia 2013; 117(3): 605-613.
7. Goldstein, A O, Gans, S P, Ripley-Moffitt, C, Kotsen, C, & Bars, M. Use of expired air carbon monoxide testing in clinical tobacco treatment settings. Chest 2018; 153(2): 554-562.
8. Noonan, D, Jiang, Y, & Duffy, S A. Utility of biochemical verification of tobacco cessation in the Department of Veterans Affairs. Addictive Behaviors 2013; 38(3): 1792-1795.
9. Gorber, S C, Schofield-Hurwitz, S, Hardt, J, Levasseur, G, & Tremblay, M. The accuracy of self-reported smoking: a systematic review of the relationship between self-reported and cotinine-assessed smoking status. Nicotine & Tobacco Research 2009; 11(1): 12-24.
10. Al-Sheyab N, Kheirallah K A, Mangnall L J T, Gallagher R. Agreement between exhaled breath carbon monoxide threshold levels and self-reported cigarette smoking in a sample of male adolescents in Jordan. Int J Environ Res Public Health 2015; 12(1): 841-54.
11. Low, E C, Ong, M C, & Tan, M. Breath carbon monoxide as an indication of smoking habit in the military setting. Singapore Med J 2004; 45(12): 578-82.
12. Sandberg, A, Sköld, C M, Grunewald, J, Eklund, A, & Wheelock, Å M. Assessing recent smoking status by measuring exhaled carbon monoxide levels. PLoS One 2011; 6(12): e28864.
13. Odani, S, Agaku, I T, Graffunder, C M, Tynan, M A, & Armour, B S. Tobacco product use among military veterans—United States, 2010–2015. Morbidity and Mortality Weekly Report 2018; 67(1): 7.
14. Benowitz N L, Bernert J T, Foulds J et al. Biochemical verification of tobacco use and abstinence: 2019 update. Nicotine Tob Res 2020; 22(7): 1086-97.
15. Bedfont Scientific Ltd, Kent, U.K. Our family, innovating health, for yours – Based in Maidstone. Accessed May 10, 2021. https://www.bedfont.com/smokerlyzer
16. Middleton, E T, & Morice, A H. Breath carbon monoxide as an indication of smoking habit. Chest 2000; 117(3): 758-763.
17. Deveci, S E, Deveci, F, Açik, Y, & Ozan, A T. The measurement of exhaled carbon monoxide in healthy smokers and non-smokers. Respiratory Medicine 2004; 98(6): 551-556.
18. Moolchan, E T, Zimmerman, D, Sehnert, S S, Zimmerman, D, Huestis, M A, & Epstein, D H. Recent marijuana blunt smoking impacts carbon monoxide as a measure of adolescent tobacco abstinence. Substance Use & Misuse 2005; 40(2): 231-240.
19. Bender, D, Haubruck, P, Boxriker, S, Korff, S, Schmidmaier, G, & Moghaddam, A. Validity of subjective smoking status in orthopedic patients. Therapeutics and Clinical Risk Management 2015; 11: 1297.
20. Salandy, A, Malhotra, K, Goldberg, A J, Cullen, N, & Singh, D. Can a urine dipstick test be used to assess smoking status in patients undergoing planned orthopaedic surgery? a prospective cohort study. The Bone & Joint Journal 2016; 98(10): 1418-1424.
21. Matuszewski, P E, Comadoll, S M, Costales, T, Zerhusen, T, Coale, M, & O’Toole, R V. Novel Application of Exhaled Carbon Monoxide Monitors: Smoking Cessation in Orthopaedic Trauma Patients. Journal of Orthopaedic Trauma 2019; 33(11): e433-e438.
22. Rothschild-Pearson, B., Gerard-Wilson, M, Cnudde, P, & Lewis, K. Exhaled carbon monoxide monitoring as a pre-operative test for smoking habitus in elective orthopaedic patients. In Orthopaedic Proceedings. The British Editorial Society of Bone & Joint Surgery 2017; 99(16): 10
23. Sterrenberg, S, Gallacher, D, Schmidt, M et al. Is Expired Air Carbon Monoxide Testing Effective for Screening of Cigarette Use in Orthopaedic Patients? 2019; protocols.io https://dx.doi.org /10.17504/protocols.io.7crhiv6
24. Duffy, S A, Karvonen-Gutierrez, C A, Ewing, L A, & Smith, P M. Implementation of the Tobacco Tactics program in the Department of Veterans Affairs. Journal of General Internal Medicine 2010; 25(1): 3-10.
25. Jarvis, M J, Tunstall-Pedoe, H, Feyerabend, C, Vesey, C, & Saloojee, Y. Comparison of tests used to distinguish smokers from nonsmokers. American Journal of Public Health 1987; 77(11): 1435-1438.
Terms of Use/Privacy Policy/ Disclaimer/ Other Policies:
You agree that by using our site/services, you have read, understood, and agreed to be bound by all of our terms of use/privacy policy/ disclaimer/ other policies (click here for details).
CC BY 4.0
This work and its PDF file(s) are licensed under a Creative Commons Attribution 4.0 International License.