Optimal Carbon Monoxide Criteria to Confirm 24-hr Smoking Abstinence

Introduction: Smoking cessation is typically verified biochemically by expired-air carbon monoxide (CO) levels below 9 ppm (i.e., <= 8 ppm), but this CO criterion may lead many who have smoked within 24hr to be misclassified as abstinent. Methods: Adult dependent smokers (N = 261; 124 men, 137 women) prospectively recorded each cigarette smoked and provided CO on five consecutive days during each of two short-term attempts to quit smoking. Participants were those recruited for crossover tests of the effects of placebo versus medication (nicotine patch or varenicline) on the ability to initiate 24-hr abstinence. All had either a high or low interest in permanently quitting smoking soon (within 3 months) and were randomized to the presence or absence of daily ($12) monetary reinforcement of abstinence. Results: Total accuracy of sensitivity to detect smoking (83%) plus specificity to verify abstinence (87%) was optimal at a CO criterion for abstinence below 5 ppm (<= 4 ppm), compared with below 9 ppm (sensitivity of 60%, specificity of 97%). Overall CO detection of sensitivity and specificity was higher in those with high versus low quit interest, but reinforcement of abstinence made no difference. Conclusions: Results indicate a CO criterion half that used in most clinical research may optimally validate 24-hr cessation and reduce misclassification of smokers as "abstinent."