26128 Nicotine and Metabolites, Serum (NICOS)

​Collection in an SST

Knowledge of time elapsed between last dose and specimen collection is important for interpretation of test results.​

Fatalities related to tobacco use are a leading cause of death in United States. Nicotine, coadministered in tobacco products such as cigarettes, pipe tobacco, cigars, or chew, is an addicting substance that causes individuals to continue use of tobacco despite concerted efforts to quit. Nicotine stimulates dopamine release and increases dopamine concentration in the nucleus accumbens, a mechanism that is thought to be the basis for addiction for drugs of abuse. 

Nicotine-dependent patients use tobacco products to achieve a peak serum nicotine value of 30 to 50 ng/mL, the concentration at which the nicotine high is maximized. Nicotine is metabolized in the liver to cotinine. Cotinine accumulates in serum in proportion to dose and hepatic metabolism (which is genetically determined); most tobacco users accumulate cotinine in the range of 200 to 800 ng/mL. Serum concentrations of nicotine and metabolites in these ranges indicate the patient is using tobacco or is receiving high-dose nicotine patch therapy.

Nicotine is rapidly metabolized, exhibiting an elimination half-life of approximately 2 hours. Cotinine exhibits an apparent elimination half-life of approximately 24 hours. Heavy tobacco users who abstain from tobacco for 2 weeks exhibit serum nicotine values <3.0 ng/mL and cotinine <3.0 ng/mL.

Passive exposure to tobacco smoke can cause accumulation of nicotine metabolites in nontobacco users. Serum cotinine has been observed to accumulate up to 8 ng/mL from passive exposure.

Tobacco users engaged in programs to abstain from tobacco require support in the form of counseling, pharmacotherapy, and continuous encouragement. Occasionally, counselors may elect to monitor abstinence by biochemical measurement of nicotine and metabolites in serum to verify abstinence. If results of biologic testing indicate the patient is actively using a tobacco product during therapy, additional counseling or intervention may be appropriate.

Serum nicotine concentration in the range of 30 to 50 ng/mL with cotinine in the range of 200 to 800 ng/mL indicates the subject is either actively using a tobacco product or on nicotine replacement therapy.

To discriminate if a patient on nicotine replacement therapy is also actively using a tobacco product, see NICOU / Nicotine and Metabolites, Urine analysis; the presence of anabasine in urine, a tobacco alkaloid not present in nicotine replacement products, indicates recent tobacco use.

Typical findings are as follows:

While using a tobacco product:

-Peak nicotine concentration: 30 to 50 ng/mL

-Peak cotinine concentration: 200 to 800 ng/mL*

*Higher values may be seen in subjects with high cytochrome P450 2D6 activity

Tobacco user after 2 weeks complete abstinence:

-Nicotine concentration: <3.0 ng/mL

-Cotinine concentration: <3.0 ng/mL

Nontobacco user with passive exposure:

-Nicotine concentration: <3.0 ng/mL

-Cotinine concentration: <8.0 ng/mL

Nontobacco user with no passive exposure:

-Nicotine concentration: <3.0 ng/mL

-Cotinine concentration: <3.0 ng/mL