The changes in saliva cotinine during Ramadan among a group of Muslim smokers in Malaysia


  • Nuraisyah H. Zulkifley Department of Community Medicine, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Selangor, Malaysia
  • Suriani Ismail Department of Community Medicine, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Selangor, Malaysia
  • Rosliza A. Manaf Department of Community Medicine, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Selangor, Malaysia



Smoking cessation, Month of Ramadan environment, Saliva cotinine


Background: Smoking is a negative health behaviour that brought in health and social problems into the community. The effects of smoking can be decreased by promoting smoking cessation. One of the approaches in smoking cessation intervention focuses on the supportive environment that can be naturally found during the Ramadan where every Muslim is obligated to fast which included abstaining from smoking.

Methods:A total of 61 male, Muslim smokers who currently smoke cigarette on daily basis were recruited. The study was conducted by using the one-group pretest-posttest study design to evaluate the effect of Ramadan environment on saliva cotinine among a group of smokers who work at a local authority in Selangor. The data were collected three times which were one week before Ramadan, 21st of Ramadan and 21 days after Ramadan. The saliva cotinine were measured by using SalivaBio oral swab (SOS) and cotinine biomarker research salivary assay kits and protocols by Salimetrics with the sensitivity of 0.15ng/ml. Data analysis was conducted by using One-way ANOVA with repeated measures and paired t-test.

Results: The study showed a significant difference in the saliva cotinine level from before, during and after Ramadan (p = 0.002). From the post-hoc test, there is a significant positive changes in the saliva cotinine level from before Ramadan to during Ramadan (t (60) = 3.66, p = 0.001).

Conclusions:The saliva cotinine level of the smokers decreased during Ramadan. This can provide an opportunity for easier initiation of smoking cessation for the smokers. 


Global Adult Tobacco Survey (GATS) Malaysia. Kuala Lumpur: Institute for Public Health, National Institute of Health, Ministry of Health, Malaysia. 2011:18-44.

Randhawa, S. 20,000 dies yearly due to smoking. The Star Online, 2015. Available at Accessed at 10 November 2016.

Tan A, Yen S, Nayga Jr R. Role of Education in Cigarette Smoking: An Analysis of Malaysian Household Survey Data. Asian Economic J. 2009;23(1):1-17.

West R. Beginning the Journey. In: Theories of addiction. 1st ed. Oxford: Blackwell; 2005.

Tennekoon V, Rosenman R. Bias in Measuring Smoking Behavior. Washington State University, 2013. Available at WorkingPapers/ rosenman/WP2013-10.pdf. Accessed at 10 November 2016.

Petersen G, Leite C, Chatkin J, Thiesen F. Cotinine as a biomarker of tobacco exposure: Development of a HPLC method and comparison of matrices. J Sep Sci. 2010;33(4-5):516-21.

Salimetrics. Cotinine Testing in Saliva & Salivary Cotinine Research, 2015. Available at Accessed 10 November 2016.

Dhar P. Measuring tobacco smoke exposure: quantifying nicotine/cotinine concentration in biological samples by colorimetry, chromatography and immunoassay methods. J Pharmaceutical and Biomedical Analysis. 2004;35(1):155-68.

Kataoka H, Inoue R, Yagi K, Saito K. Determination of nicotine, cotinine, and related alkaloids in human urine and saliva by automated in-tube solid-phase microextraction coupled with liquid chromatography–mass spectrometry. J Pharmaceutical And Biomedical Analysis. 2009:49(1):108-14.

Nuca C, Amariei C, Badae V, Zaharia A, Bucur L, Arendt C. Salivary Cotinine - Biomarker of Tobacco Consumption in the Assessment of Passive Smoking Prevalence. Farmacia. 2012;60(5):662 -47.

Curvall M, Elwin C, Kazemi-Vala E, Warholm C, Enzell C. The pharmacokinetics of cotinine in plasma and saliva from non-smoking healthy volunteers. European J Clinical Pharmacology. 1990;38(3):281-7.

American Association for Clinical Chemistry. Nicotine / Cotinine: The Test | Nicotine Test: Cotinine Test; Nicotine & Metabolites (urine, serum or plasma), 2015. Available at Accessed 10 November 2016.

Marrone G, Paulpillai M, Evans R, Singleton E, Heishman S. Breathe carbon monoxide and semiquantitative saliva cotinine as biomarkers for smoking. Human Psychopharmacology: Clinical and Experimental. 2010;25(1):80-3.

Centers for Disease Control and Prevention. Nicotine Addiction: Past and Present. Atlanta (GA): National Center for Chronic Disease Prevention and Health Promotion (US), 2010. Available at Accessed 10 November 2016.

Fagerstrom K, Schneider N. Measuring nicotine dependence: A review of the Fagerstrom Tolerance Questionnaire. J Behavioral Medicine. 1989;12(2):159-82.

Benowitz N, Henningfield J. Reducing the nicotine content to make cigarettes less addictive. Tobacco Control, 2013;22(1): 14-17.

Nuraisyah Hani Z, Suriani I, Rosliza A, Ahmad FA. Effect of Ramadan Environment on Fagerstrom Test for Nicotine Dependence (FTND) Among Smokers. Int J Public Health and Clinical Sciences. 2016;3(5):59-69.

Gray M, Critchley H. Interoceptive Basis to Craving. Neuron. 2007;54(2):183-6.

Fidler J, Shahab L, West R. Strength of urges to smoke as a measure of severity of cigarette dependence: comparison with the Fagerström Test for Nicotine Dependence and its components. Addiction. 2010;106(3):631-8.

Ramahi I, Seidenberg A, Kennedy R, Rees V. Second-hand smoke emission levels in enclosed public places during Ramadan. The European J Public Health. 2012;23(5):789-91.

Hughes J. Effects of abstinence from tobacco: Valid symptoms and time course. Nicotine & Tobacco Res. 2007;9(3):315-27.

Chandola T, Head J, Bartley M. Socio-demographic predictors of quitting smoking: how important are household factors? Addiction. 2004;99(6): 770-7.

Allwright, S. Legislation for smoke-free workplaces and health of bar workers in Ireland: before and after study. BMJ. 2005;331(7525):1117.

Aveyard P, Begh R, Sheikh A, Amos A. Promoting smoking cessation through smoking reduction during Ramadan. Addiction. 2011;106(8):1379-80.

Lincoln T, Tuthill R, Roberts C, Kennedy S, Hammett T, Langmore-Avila E, et al. Resumption of Smoking After Release From a Tobacco-Free Correctional Facility. J Correctional Health Care. 2009;15(3):190-6.

Suriani I, Zulkefli N, Chung C, Sulaiman MZ. Factors Influencing Smoking Behaviour Changes during Ramadan among Malay Male Students. J Fasting And Health. 2015;3(3):97-102.

Bakar AAM, Johari LH, Nasir AM, Anselm ST, Chan WH, Rahman NA, et al. Religious belief in relation to smoking: a cross-sectional study among Muslim males in the month of Ramadan. Malaysian J Med Health Sci. 2010;12(25):32-3.

Yong H, Hamann S, Borland R, Fong G, Omar M. Adult smokers' perception of the role of religion and religious leadership on smoking and association with quitting: A comparison between Thai Buddhists and Malaysian Muslims. Social Science & Medicine. 2009;69(7):1025-31.

Fagerström K, Furberg H. A comparison of the Fagerström Test for Nicotine Dependence and smoking prevalence across countries. Addiction. 2008;103(5):841-5.




How to Cite

Zulkifley, N. H., Ismail, S., & Manaf, R. A. (2017). The changes in saliva cotinine during Ramadan among a group of Muslim smokers in Malaysia. International Journal Of Community Medicine And Public Health, 4(2), 481–486.



Original Research Articles