Assessment of carbon monoxide in exhaled breath using smokerlyzer among in-school adolescents in Osun State: A cross sectional study

Funmito Omolola Fehintola; Adesola Olumide; Adesegun Fatusi; Olayemi Omotade

doi:10.1371/journal.pone.0347739

Peer Review History

Original SubmissionJune 15, 2025
29 Jul 2025 Decision Letter - Billy Morara Tsima, Editor Dear Dr. Fehintola, Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. Please submit your revised manuscript by Sep 12 2025 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org . When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file. 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CARTA is funded by: The Carnegie Corporation of New York [grant no. G-19-57145], The Sida [grant no. 54100113], and by the Uppsala Monitoring Centre and the DELTAS Africa Initiative [grant no. 107768/Z/15/Z]. The DELTAS Africa Initiative is an independent funding scheme of the African Academy of Sciences (AAS)’s Alliance for Accelerating Excellence in Science in Africa (AESA) and supported by the New Partnership for Africa’s Development Planning and Coordinating Agency (NEPAD Agency) with funding from the Wellcome Trust (UK) and the UK government. The statements made and views expressed are solely the responsibility of the authors.]. Please state what role the funders took in the study. If the funders had no role, please state: ""The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript."" If this statement is not correct you must amend it as needed. 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Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice. [Note: HTML markup is below. Please do not edit.] Reviewers' comments: Reviewer's Responses to Questions Comments to the Author 1. Is the manuscript technically sound, and do the data support the conclusions? Reviewer #1: Yes Reviewer #2: Yes ******** 2. Has the statistical analysis been performed appropriately and rigorously? -->?> Reviewer #1: Yes Reviewer #2: No ****** 3. Have the authors made all data underlying the findings in their manuscript fully available??> The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.--> Reviewer #1: Yes Reviewer #2: Yes ****** 4. Is the manuscript presented in an intelligible fashion and written in standard English??> Reviewer #1: Yes Reviewer #2: Yes ****** Reviewer #1: A few important issues require attention before the paper can be accepted for publication. 1. The rationale for testing only 50% of participants with the Smokerlyzer should be clearly explained. Was this due to budget constraints, time limitations, or another methodological consideration? 2. Several adjusted odds ratios reported in the logistic regression (e.g., age group and sex) have confidence intervals that appear excessively wide or imprecise. Please review these values to confirm their accuracy. The interpretation of Cohen’s Kappa (κ = 0.048) as “purely coincidental” should be revised to reflect standard interpretations (i.e., "slight agreement"). 3. The study reports associations between school environment (lack of health clubs, absence of anti-smoking materials) and smoking behavior. While these are interesting findings, potential residual confounding (e.g., school-level SES, teacher influence, peer smoking norms) should be acknowledged and discussed as a limitation. Reviewer #2: Reviewing points: 1- The introduction should be revised and rewritten. 2- The introduction does not mention the possible risks and side effects of smoking in adolescents. 3- The study objectives are not well stated at the end of the introduction. 4- The data collection method needs to be revised and explained further. 5- In performing data analysis, in addition to logistic regression, a rank regression analysis should also be considered. Because the response variable of smoking is defined as a rank variable. 6- The entire text of the article should be shortened. 7- Grammatical and reference errors should be corrected. ****** what does this mean? ). If published, this will include your full peer review and any attached files.). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our For information about this choice, including consent withdrawal, please see our Privacy Policy .--> Reviewer #1: Yes: Pious AboagyePious Aboagye Reviewer #2: Yes: Solaiman AfroughiSolaiman Afroughi ******** [NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". 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Please note that Supporting Information files do not need this step.--> Attachments Attachment Submitted filename: Reviewing points.docx https://doi.org/10.1371/journal.pone.0347739.r001
Revision 1
21 Oct 2025 Author Response Reviewer 1 S/N COMMENTS REPONSES Page 1 The rationale for testing only 50% of participants with the Smokerlyzer should be clearly explained. Was this due to budget constraints, time limitations, or another methodological consideration? This was due to financial constraints Page 5 Lines 102-103 2 Several adjusted odds ratios reported in the logistic regression (e.g., age group and sex) have confidence intervals that appear excessively wide or imprecise. Please review these values to confirm their accuracy. The interpretation of Cohen’s Kappa (κ = 0.048) as “purely coincidental” should be revised to reflect standard interpretations (i.e., "slight agreement"). The values have been reviewed Page 16-17 Lines 264-265 Page 13-14 Lines 230-232 3 The study reports associations between school environment (lack of health clubs, absence of anti-smoking materials) and smoking behavior. While these are interesting findings, potential residual confounding (e.g., school-level SES, teacher influence, peer smoking norms) should be acknowledged and discussed as a limitation. done Lines 342-345 Pages 21-22 Reviewer 2 S/N COMMENTS REPONSES Page 1 The introduction should be revised and rewritten. Introduction has been revised and rewritten Pages 3-4 Lines 43-76 2 The introduction does not mention the possible risks and side effects of smoking in adolescents. These have been included Pages 3-4 Lines 56-65 3. The study objectives are not well stated at the end of the introduction. They have been included Page 4 Line 75-76 4. The data collection method needs to be revised and explained further. This section has been revised and further explained Page 7 Lines 134-151 5. In performing data analysis, in addition to logistic regression, a rank regression analysis should also be considered. Because the response variable of smoking is defined as a rank variable A table on rank regression analysis has been included Page 25 Lines 280-281 6. The entire text of the article should be shortened. Done 7. Grammatical and reference errors should be corrected. Done 8. Additional References have been included while the introduction was rewritten. Lines 365-440 Pages22-25 Attachments Attachment Submitted filename: Responses_reviwers_comments_PLOSONE_25.docx https://doi.org/10.1371/journal.pone.0347739.r002
12 Dec 2025 Decision Letter - Billy Morara Tsima, Editor Dear Dr. Fehintola, Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. Please submit your revised manuscript by Jan 26 2026 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org . When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file. A letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'. A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'. An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'. If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols . Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at . Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols .. We look forward to receiving your revised manuscript. Kind regards, Billy Morara Tsima, MD MSc Academic Editor PLOS One Journal Requirements: 1. If the reviewer comments include a recommendation to cite specific previously published works, please review and evaluate these publications to determine whether they are relevant and should be cited. There is no requirement to cite these works unless the editor has indicated otherwise. 2. Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice. [Note: HTML markup is below. Please do not edit.] Reviewer's Responses to Questions Comments to the Author Reviewer #1: (No Response) Reviewer #2: (No Response) ******** 2. Is the manuscript technically sound, and do the data support the conclusions??> Reviewer #1: Yes Reviewer #2: Yes ****** 3. Has the statistical analysis been performed appropriately and rigorously? -->?> Reviewer #1: Yes Reviewer #2: Yes ****** 4. Have the authors made all data underlying the findings in their manuscript fully available??> The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.--> Reviewer #1: Yes Reviewer #2: Yes ****** 5. Is the manuscript presented in an intelligible fashion and written in standard English??> Reviewer #1: Yes Reviewer #2: Yes ****** Reviewer #1: There are specific technical inconsistencies in the statistical analysis, which were likely introduced during the revision process, and methodological details that require clarification to ensure the validity of the conclusions. Major Comments 1. Statistical Inconsistency & Multicollinearity (Page 21-22, Tables 7 & 8) I note that in response to previous reviewer comments, you have included a rank regression analysis (Table 8) alongside the logistic regression (Table 7). However, the results of these two models are contradictory regarding the key predictors: age and class. In the logistic regression (Table 7), age is a risk factor (AOR=1.59), while class is a protective factor (higher classes have lower odds). In the Rank Regression (Table 8), age appears protective (negative coefficient), while class is a strong risk factor (positive association). Action Required: Please check the Variance Inflation Factor (VIF) for age and class in your models. If high multicollinearity exists, you may need to remove one of these variables or combine them to ensure the reported predictors are accurate. You must explain or resolve this contradiction in the results; currently, the conclusion that "older age and class are predictors" is ambiguous because the direction of the effect depends on which table the reader looks at. Selection Bias in Sub-sample (Methodology Section) You state that due to financial constraints, 50% of the survey sample was selected for the Smokerlyzer assessment (n=616). Action Required: Please explicitly clarify the randomization method used to select this 50\% sub-sample. If it was simple random sampling or systematic random sampling within the schools, please state this clearly to ensure the technical soundness of the 27.3% prevalence rate. Minor Comments Title Correction There is a typo in the manuscript title. Current: "...using Smokerlyze" Correction: Please change to "...using Smokerlyzer..." 4. Discussion of Age/Class Dynamic In the Discussion section, you recommend targeted education for "older adolescents" and "lower classes." Comment: Please briefly elaborate on the interaction between these two demographics. Are the "high risk" students specifically older adolescents who have been held back in lower classes? Clarifying this profile would make your public health recommendations more actionable. 5. Table Formatting Please ensure the table footnotes for Tables 7 and 8 clearly define the reference categories used for the regression analyses to assist reader interpretation. Reviewer #2: Reviewing tips for authors and editors 1-In the method section, all subsections from the study site to the exclusion criteria should be combined and written in one subsection. 2- In the sample size determination subsection, the relevant formula is incorrect, correct it. 3- In the final calculation of the sample size, a reference should be mentioned for applying the coefficient of 1.5 based on the category. 4- In the abstract section of the article, there is no mentioned or reported result of the rank regression. The result of the rank regression should be reported or deleted altogether. 5- A reference should be introduced for the use of rank regression. ****** what does this mean? ). If published, this will include your full peer review and any attached files.). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. 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NAAS will assess whether your figures meet our technical requirements by comparing each figure against our figure specifications. https://doi.org/10.1371/journal.pone.0347739.r003
Revision 2
10 Jan 2026 Author Response RESPONSE TO THE REVIEWERS COMMENTS Manuscript Title: Assessment of Carbon Monoxide in Exhaled Breath using Smokerlyze among in-school adolescents in Osun State: A Cross Sectional Study Reviewer 1 S/N COMMENTS Action required Responses Page 1 Statistical Inconsistency & Multicollinearity (Page 21-22, Tables 7 & 8) I note that in response to previous reviewer comments, you have included a rank regression analysis (Table 8) alongside the logistic regression (Table 7). However, the results of these two models are contradictory regarding the key predictors: age and class. In the logistic regression (Table 7), age is a risk factor (AOR=1.59), while class is a protective factor (higher classes have lower odds). In the Rank Regression (Table 8), age appears protective (negative coefficient), while class is a strong risk factor (positive association). Please check the Variance Inflation Factor (VIF) for age and class in your models. If high multicollinearity exists, you may need to remove one of these variables or combine them to ensure the reported predictors are accurate. You must explain or resolve this contradiction in the results; currently, the conclusion that "older age and class are predictors" is ambiguous because the direction of the effect depends on which table the reader looks at Thank you for this important observation. We would like to clarify that the apparent difference in direction of association between Tables 7 and 8, arises from differences in outcome definition and model interpretation, rather than statistical inconsistency or multicollinearity. Table 7 presents a binary logistic regression modelling the likelihood of being a smoker versus a non-smoker, whereas Table 8 applies rank regression to model the relative ordering of smoking behaviour. Rank regression does not estimate risk or severity but rather examines associations with higher or lower ranks of the outcome. Accordingly, coefficients in Table 8 is not interpreted as indicators of smoking severity or initiation and are not directly comparable with odds ratios from logistic regression. We have revised the table title, footnote, and manuscript text (Pages 21–22) to explicitly clarify this distinction and to prevent misinterpretation. In addition, diagnostic checks showed no evidence of problematic multicollinearity among predictors (all VIFs < 2). Pages 17 -18 Lines 264-275 2 Selection Bias in Sub-sample (Methodology Section) You state that due to financial constraints, 50% of the survey sample was selected for the Smokerlyzer assessment (n=616). Action Required: Please explicitly clarify the randomization method used to select this 50\% sub-sample. If it was simple random sampling or systematic random sampling within the schools, please state this clearly to ensure the technical soundness of the 27.3% prevalence rate. Done Page 5 Lines 90-97 3 Title Correction There is a typo in the manuscript title. Current: "...using Smokerlyze" Correction: Please change to "...using Smokerlyzer..." Correction: Please change to "...using Smokerlyzer..." Done Line 1 Page 1 4. 4. Discussion of Age/Class Dynamic In the Discussion section, you recommend targeted education for "older adolescents" and "lower classes." Comment: Please briefly elaborate on the interaction between these two demographics. Are the "high risk" students specifically older adolescents who have been held back in lower classes? Clarifying this profile would make your public health recommendations more actionable. No,it does not and all VIFs are less than or equal to 2.This does not reveal there are interaction. It has been corrected Page 2 Line 38 5. Table Formatting Please ensure the table footnotes for Tables 7 and 8 clearly define the reference categories used for the regression analyses to assist reader interpretation. The reference categories for Table 7 is indicated as Ref in the table. Table 8 is a rank regression where all variables are entered as continuous variable and not binary outcome variable, hence no reference categories are presented. Page 17 Line 261 Reviewer 2 S/N Comments Action required Responses Page 1 In the method section, all subsections from the study site to the exclusion criteria should be combined and written in one subsection. This has been done Page 4-5 Lines 79-88 2 In the sample size determination subsection, the relevant formula is incorrect, correct it. We thank you for this observation. This study was part of a multiphase study where the initial sample size was determined using the formula (Zα + Zβ)² P (1 – P) d² . The estimate of true proportion in the population; was taken as the prevalence of media health literacy among secondary school students in Osun State 37.7%.Hence the formula that was used. A subset of the sample size (50%) was used for the objective measurement of smoking due to the financial constraints Page 5 Lines 90-97 3. In the final calculation of the sample size, a reference should be mentioned for applying the coefficient of 1.5 based on the category This has been done Page 5 Lines 93-94 4. In the abstract section of the article, there is no mentioned or reported result of the rank regression. The result of the rank regression should be reported or deleted altogether. This has been included Page 2 Line 33-34 5. A reference should be introduced for the use of rank regression. This has been done Page 8 Line 160 and 161 Attachments Attachment Submitted filename: Response_to_reviewer2026_PLOSone.docx https://doi.org/10.1371/journal.pone.0347739.r004
7 Apr 2026 Decision Letter - Billy Morara Tsima, Editor <p>Assessment of Carbon Monoxide in Exhaled Breath using Smokerlyzer among in-school adolescents in Osun State: A Cross Sectional Study PONE-D-25-32127R2 Dear Dr. Fehintola, We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements. Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication. An invoice will be generated when your article is formally accepted. Please note, if your institution has a publishing partnership with PLOS and your article meets the relevant criteria, all or part of your publication costs will be covered. Please make sure your user information is up-to-date by logging into Editorial Manager at Editorial Manager® and clicking the ‘Update My Information' link at the top of the page. For questions related to billing, please contact and clicking the ‘Update My Information' link at the top of the page. For questions related to billing, please contact billing support .. If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org. Kind regards, Billy Morara Tsima, MD MSc Academic Editor PLOS One Additional Editor Comments (optional): Reviewers' comments: https://doi.org/10.1371/journal.pone.0347739.r005
Formally Accepted
Acceptance Letter - Billy Morara Tsima, Editor PONE-D-25-32127R2 PLOS One Dear Dr. Fehintola, I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS One. Congratulations! Your manuscript is now being handed over to our production team. At this stage, our production department will prepare your paper for publication. This includes ensuring the following: * All references, tables, and figures are properly cited * All relevant supporting information is included in the manuscript submission, * There are no issues that prevent the paper from being properly typeset You will receive further instructions from the production team, including instructions on how to review your proof when it is ready. Please keep in mind that we are working through a large volume of accepted articles, so please give us a few days to review your paper and let you know the next and final steps. Lastly, if your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org. You will receive an invoice from PLOS for your publication fee after your manuscript has reached the completed accept phase. If you receive an email requesting payment before acceptance or for any other service, this may be a phishing scheme. Learn how to identify phishing emails and protect your accounts at https://explore.plos.org/phishing. If we can help with anything else, please email us at customercare@plos.org. Thank you for submitting your work to PLOS ONE and supporting open access. Kind regards, PLOS ONE Editorial Office Staff on behalf of Dr. Billy Morara Tsima Academic Editor PLOS One https://doi.org/10.1371/journal.pone.0347739.r006

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