Comparison of CO breath testing and women's self-reporting of smoking behaviour for identifying smoking during pregnancy

BACKGROUND: Healthcare services often use a carbon monoxide (CO) breath test to validate self-reported smoking and to assess reductions in smoking habit. A cut-off level of ≥ 8 parts per million (p.p.m.) is used to identify smoking. This cut-off requires further validation in pregnant women. METHODS: Data on self-reported smoking were assessed in conjunction with breath CO levels. Subjects in the study were 2548 women attending antenatal booking during 12 months. RESULTS: 546/2584 (21.4%) women self-reported as current smokers. A cut-off of 8 ppm identified only 325/546 self-reported smokers (sensitivity 59.4%). 27/2002 self-reported non-smokers had levels greater than 8 ppm (specificity 98.7%). Sensitivity and specificity analysis revealed that CO cut-off levels of 2 or 3 p.p.m. resulted in the best sensitivity and specificity for discriminating apparent smokers and non-smokers. A cut-off of 2 p.p.m. would have identified 468/546 of self-reported smokers (sensitivity 86%). 206/2002 self-reported non-smokers had levels > 2 ppm (specificity 90 %). If all these women were 'true' smokers, the real prevalence of smoking in pregnancy was 26.5% (752/2548) and 27% of true smokers provided false answers to the self-reported question at maternity booking. CONCLUSION: At 8 ppm, many smokers are missed and there may be gross underestimating of levels of smoking in a pregnant population. Results emphasise the need to support a lower cut-off level for the breath CO test closer to 2 or 3 p.p.m. These cut-offs may be more appropriate in the antenatal clinic setting, and are in line with recent recommendations in the non-pregnant population.