Nicotine & Metabolites

  • Diagnosis
  • Pharmacogenetics
  • Background
  • Lab Tests
  • References
  • Related Topics

Indications for Testing

  • Evaluate for recent use of nicotine-containing products
  • Document use of tobacco versus purified nicotine products (eg, assessing compliance with smoking cessation programs)
  • Verify that a person has abstained from nicotine-containing products (eg, qualifying patients for surgery)
  • Evaluate passive exposure to nicotine

Laboratory Testing

  • Nicotine and metabolites
    • Nicotine has a short half-life (24-84 minutes)
      • Nicotine levels are not always a good indicator of smoking status – better indicator is to measure metabolites
    • Metabolites of nicotine
      • Measure cotinine, trans-3’-hydroxycotinine (3-OH-cotinine), and nornicotine
      • Cotinine – major metabolite of nicotine
        • Half-life – approximately 16 hours
        • Metabolized to 3-OH-cotinine
      • Nornicotine – minor metabolite of nicotine
        • May be present in tobacco
  • Urine testing
    • Recommended over serum/plasma testing to detect chronic use
      • Analytes in urine are detectable over a longer period of time than in serum/plasma
    • 3-OH-cotinine metabolite may persist for weeks after cessation from long-term or heavy use of nicotine products
      • Cutoff of 100 ng/mL cotinine is frequently used for surgery qualification purposes
    • Anabasine – tobacco alkaloid also detected in urine
      • Not an expected result for individual using purified nicotine products
      • May distinguish active use of tobacco products from nicotine replacement therapy
  • Serum/plasma testing
    • Required when a valid urine specimen cannot be obtained (eg, anuretic or dialysis patient)
    • Detects recent use – typically within past 2 weeks
    • More closely correlated with oral fluid testing than urine
  • Metabolism affected by genetic and non-genetic factors
  • Actual dose of nicotine depends on the nicotine source, route of administration, and frequency of use
    • ~90% of a dose eliminated in the urine
    • ~70-80% metabolized to cotinine
  • CYP2A6
    • Nicotine primarily metabolized by CYP2A6, UDP-glucuronosyltransferase and flavin-containing monooxygenase
      • Nicotine may affect pharmacokinetics of other drugs
    • Metabolic ratios of 3-OH-cotinine/cotinine can be used to evaluate CYP2A6 phenotype
      • Phenotype may be associated with altered nicotine metabolism
      • CYP2A6 is associated with dozens of genetic variants that are relatively common, such as *4 allele  
        • 17-24% – Japanese
        • 5-15% – Chinese
        • <5% – Caucasians and African Americans
      • Food (eg, grapefruit juice) or drugs may inhibit CYP2A6, thereby affecting nicotine metabolism

Use of tobacco products, particularly smoking, is a leading but preventable cause of disease, disability, and death. Nicotine is also recognized as a risk factor for poor wound healing.

Epidemiology

  • Prevalence – 15-20% of adults are nicotine dependent
  • Sex – M>F

Pathophysiology

  • Principle source of exposure – tobacco products, purified nicotine products (eg, electronic cigarettes), or nicotine replacement therapy (eg, gum, patch, spray)
  • Found at low concentrations in potatoes, tomatoes,  eggplant, and sweet peppers
  • Absorbed through oral cavity, skin, urinary tract, and gastrointestinal tract
  • Increases heart rate, blood pressure, mobilization of blood sugars and catecholamines

Clinical Presentation

  • Cancers – lung, larynx, oral and nasal cavity, paranasal sinuses, esophagus, pancreas, liver, stomach, cervix, leukemia (AML, CML, CLL)
  • Cardiac and neurologic disease – leading cause of coronary disease, stroke
  • Pulmonary disease – chronic obstructive pulmonary disease (includes chronic bronchitis and emphysema), asthma, respiratory infections, overall decrease in pulmonary function
  • Pregnancy – difficulty in conceiving, intrauterine growth retardation, low birth weight
  • Second-hand smoke – a confirmed human carcinogen implicated in pulmonary disease, lung cancer and coronary artery disease in non-smokers
Tests generally appear in the order most useful for common clinical situations. Click on number for test-specific information in the ARUP Laboratory Test Directory.

Nicotine and Metabolites, Urine, Quantitative 0092356
Method: Quantitative Liquid Chromatography-Tandem Mass Spectrometry

Recommended Use 

Recommended for determination of active or passive nicotine use, or for differentiation between nicotine replacement and tobacco use

Use to confirm cotinine screening results; for a screening test to determine active exposure to nicotine and compliance with smoking-cessation programs, urine cotinine screen is preferred

Detects nicotine, cotinine (metabolite), 3-OH-cotinine (metabolite), nornicotine (metabolite), and anabasine (tobacco biomarker) in urine

A cutoff of 100 ng/mL cotinine is frequently used for surgery qualification purposes

Analytical sensitivity – 100 ng/mL

Limitations 

May not differentiate between passive and active nicotine exposure

Will not differentiate nicotine exposure from nicotine replacement therapy and tobacco use

Assay may crossreact with other nicotine metabolites

Failure to detect anabasine is not definitive evidence of tobacco abstinence

Nicotine and Metabolites, Serum or Plasma, Quantitative 0092361
Method: Quantitative Liquid Chromatography-Tandem Mass Spectrometry

Recommended Use 

Assess active exposure to nicotine and compliance with smoking-cessation programs

Use to detect and monitor nicotine, cotinine, and trans-3'-hydroxycotinine in serum or plasma

Limitations 

May not differentiate between passive and active nicotine exposure

Does not detect anabasine

Will not differentiate nicotine exposure from nicotine replacement therapy and tobacco use

Assay may crossreact with other nicotine metabolites

Cotinine Screen, Urine 2007081
Method: Enzyme Multiplied Immunoassay Technique

Recommended Use 

Urine screening test for determining active exposure to nicotine and compliance with smoking-cessation programs

Qualitative screen recommended for use in documenting abstinence from nicotine-containing products, such as in surgery qualifications

For determination of active or passive nicotine use, or for differentiation between nicotine replacement and tobacco use, quantitative nicotine and metabolites test is preferred

Positive result reported at 100 ng/mL

Confirm unexpected results by LC-MS/MS

Analytical sensitivity – 100 ng/mL

Limitations 

Assay may cross-react with other nicotine metabolites

May not differentiate between passive and active nicotine exposure

Will not differentiate nicotine exposure from nicotine replacement therapy and tobacco use

General References

Benowitz NL, Hukkanen J, Jacob P. Nicotine chemistry, metabolism, kinetics and biomarkers. Handb Exp Pharmacol. 2009; 29-60. PubMed

Davis RA, Stiles MF, deBethizy JD, Reynolds JH. Dietary nicotine: a source of urinary cotinine. Food Chem Toxicol. 1991; 29(12): 821-7. PubMed

Lee A, Gin T, Chui PT, Tan PE, Chiu CH, Tam TP, Samy W. The accuracy of urinary cotinine immunoassay test strip as an add-on test to self-reported smoking before major elective surgery. Nicotine Tob Res. 2013; 15(10): 1690-5. PubMed

Llaquet H, Pichini S, Joya X, Papaseit E, Vall O, Klein J, Garcia-Algar O. Biological matrices for the evaluation of exposure to environmental tobacco smoke during prenatal life and childhood. Anal Bioanal Chem. 2010; 396(1): 379-99. PubMed

Marin VP, Pytynia KB, Langstein HN, Dahlstrom KR, Wei Q, Sturgis EM. Serum cotinine concentration and wound complications in head and neck reconstruction. Plast Reconstr Surg. 2008; 121(2): 451-7. PubMed

References from the ARUP Institute for Clinical and Experimental Pathology®

Curtin K, Samowitz WS, Wolff RK, Herrick J, Caan BJ, Slattery ML. Somatic alterations, metabolizing genes and smoking in rectal cancer. Int J Cancer. 2009; 125(1): 158-64. PubMed

Curtin K, Samowitz WS, Wolff RK, Ulrich CM, Caan BJ, Potter JD, Slattery ML. Assessing tumor mutations to gain insight into base excision repair sequence polymorphisms and smoking in colon cancer. Cancer Epidemiol Biomarkers Prev. 2009; 18(12): 3384-8. PubMed

Marin SJ, Christensen RD, Baer VL, Clark CJ, McMillin GA. Nicotine and metabolites in paired umbilical cord tissue and meconium specimens. Ther Drug Monit. 2011; 33(1): 80-5. PubMed

Suh-Lailam BB, Haglock-Adler CJ, Carlisle HJ, Ohman T, McMillin GA. Reference interval determination for anabasine: a biomarker of active tobacco use. J Anal Toxicol. 2014; 38(7): 416-20. PubMed

Medical Reviewers

Johnson-Davis, Kamisha, PhD, DABCC, FACB, Medical Director, Clinical Toxicology at ARUP Laboratories; Assistant Professor of Clinical Pathology, University of Utah

McMillin, Gwendolyn A., PhD, DABCC (CC, TC), Medical Director of Toxicology and Pharmacogenomics at ARUP Laboratories; Professor of Clinical Pathology, University of Utah

Last Update: March 2017