Dr. Rigatti explores how evolving nicotine use and shifting insurer screening practices are prompting a closer look at what cotinine thresholds may reveal.
For many years, the insurance industry has used urine cotinine as a marker for nicotine use. This practice was nearly universal across insurance companies, though there was some differentiation based on the threshold used to determine positivity. While most companies used 200 mg/dL, some used higher levels such as 250, 300, or even 500 mg/dL.
This contrasts with the clinical literature, which often uses 100 mg/dL to determine firsthand smoking and 50 mg/dL to detect secondhand exposure. In the current environment, with increasing rates of nicotine usage in the form of e-cigarettes, and rising rates of nicotine non-disclosure, some insurers have moved, or are considering a move, to lower thresholds of cotinine to determine smoker versus non-smoker status. So, it might be helpful to evaluate the mortality effects of these varying levels of urine cotinine.
The graph below was produced using the CRL data with over 13.4 million applicants who were tested for urine cotinine dating back to the 1990s. The average exposure time was over 12 years. The vast majority of applicants have no detectable cotinine, so this group makes an ideal reference against which the groups of applicants testing positive at various thresholds may be compared. This was done using Cox models controlled for age and separated by sex. Importantly, this study was done only using individuals who denied the use of tobacco products on the lab slip.
The results are quite clear. Those with cotinine levels between 100 and 200 mg/dL had mortality ratios virtually indistinguishable from those with higher levels, and markedly higher than both the reference (zero cotinine) group and the group with detectable cotinine less than 100 mg/dL. This group contains about 0.5% to 1% of all applicants. So, companies currently using 200 mg/dL as the cotinine threshold would expect to capture up to 1% of non-admitting applicants as smokers – and their expected mortality would be very similar to the current smoker pool.
Because this is historical data, it does not include large numbers of oral nicotine or e-cigarette users; therefore, these results should be interpreted in light of the evolving patterns of nicotine use among the applicant pool.
About the Author
Dr. Steven J. Rigatti is a consulting medical director with Clinical Reference Laboratory, with 12 years’ experience in the life insurance industry. He is the current chair of the Mortality Committee of the American Academy of Life Insurance Medicine.