Cotinine Testing Improves Smoking Cessation Before Total Joint Arthroplasty

Adam Hart, William G. Rainer, Michael J. Taunton, Tad M. Mabry, Daniel J. Berry, Matthew P. Abdel

Research output: Contribution to journalArticlepeer-review

6 Scopus citations


Background: Patients who are actively smoking at the time of primary total joint arthroplasty (TJA) are at an increased risk of perioperative complications. Serum cotinine testing is a sensitive and specific method to verify abstinence from smoking and may therefore improve a patient's chance of smoking cessation. The primary purpose of this study was to assess whether cotinine testing improves the self-reported quit rate among smokers before TJA. Methods: Our hospital performs a high volume of TJAs and documents smoking status at each clinic visit (at 6-month intervals), as well as at the time of surgery through an institutional total joint registry. As part of a retrospective analysis, this information was used to identify all self-reported smokers (regularly cigarette smoking within 1 year of TJA) who underwent unilateral TJA from 2007 to 2018. The cohort had a mean age of 66 years, 55% were female, and the mean body mass index was 31 kg/m2. Patients whose serum cotinine was obtained within 1 month before surgery were then separated from the cohort and compared to the smokers who did not undergo cotinine testing. Results: Of the 28,758 primary TJAs identified, 8.8% (2514) were smokers. Serum cotinine testing was obtained on 103 of these patients. The abstinence rate (by means of self-reporting) before surgery significantly improved from 15.8% to 28.2% in the untested vs cotinine-tested groups, respectively (P = .005). Among all patients who underwent cotinine testing, 77% were negative (abstinent) and an additional 15% had cotinine levels between 3 and 8 ng/mL representing passive tobacco exposure. Among patients who stated they had quit smoking, 15% still had positive cotinine tests. Conclusion: Smoking cessation remains a major challenge in contemporary TJA practices despite a concerted effort to help patients quit. Our findings suggest that cotinine testing significantly improves the self-reported quit rates of smokers before surgery and helps identify the 15% who falsely report abstinence to ensure appropriate counseling of inherent risks. Level of Evidence: Therapeutic level III.

Original languageEnglish (US)
Pages (from-to)S148-S151
JournalJournal of Arthroplasty
Issue number7
StatePublished - Jul 2019


  • cigarette
  • cotinine
  • nicotine
  • quit
  • tobacco
  • total joint arthroplasty

ASJC Scopus subject areas

  • Orthopedics and Sports Medicine


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