Health Policy Manag.  2020 Dec;30(4):505-512. 10.4332/KJHPA.2020.30.4.505.

Differences in Environmental Tobacco Smoke Exposure between Self-reporting and Cotinine Test: The Application of Biomarkers

  • 1Department of Gerontology Health and Welfare, Pai Chai University, Daejeon, Korea
  • 2Review and Assessment Research Division, Health Insurance Review & Assessment Service, Wonju, Korea


In monitoring exposure to environmental smoke (ETS), biomarkers can overcome the subjectivity and inaccuracy of self-reporting measurements, and have the advantage of reflecting ETS exposure in all places. This study aims to evaluate the effectiveness of ETS exposure measurement using biomarkers such as urine cotinine.
This study used the Korea National Health and Nutrition Survey data from 2009 to 2018. A total of 28,574 non-smokers with urine cotinine data were selected for the study. The cotinine concentration and ETS exposure rate using urine cotinine was estimated and then compared with the self-reporting measurements. The degree of agreement among measurements of ETS exposure was confirmed.
As a result of measuring ETS exposure with urine cotinine, 23,594 (83.8%) out of 28,574 subjects were classified as to exposure groups. This estimate differs significantly from measurements made by self-reporting. In addition, the average concentration of cotinine in non-smokers has decreased to a 10th level over the past 10 years. Based on the biomarker, the sensitivity of the self-reporting was 8.5%–29.0%, the specificity was 16.4%–19.5%, and the kappa value was 2.0%–5.8%.
The findings of our study show that self-reporting measurement does not well reflect the extent to which non-smoker’s exposure to smoking materials. Whereas cotinine concentration has decreased significantly over the past 10 years, the ETS exposure rate has not reduced. It strongly suggests the need for intervention in the group of non-smokers exposed to low concentrations of smoke. Therefore, an assessment using biomarkers such as cotinine-based measurement should be made in the Health Plan 2030.


Environmental smoke; Self-reporting; Cotinine; Biomarker; Health Plan
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