Monitoring tobacco use
Monitoring patients on nicotine-replacement therapy for concurrent use of tobacco products
1. Collect a random urine specimen.
2. No preservative.
Knowledge of time elapsed between last dose and specimen collection is important for interpretation of test results.
Tobacco use is the leading cause of death in the United States. Nicotine, coadministered in tobacco products such as cigarettes, pipes, cigars, or chew, is an addictive 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 to drugs of abuse.
Nicotine is rapidly metabolized in the liver to cotinine, exhibiting an elimination half-life of 2 hours. Cotinine exhibits an apparent elimination half-life of 15 hours. Patients using tobacco products excrete nicotine in urine in the concentration range of 1000 to 5000 ng/mL. Cotinine accumulates in urine in proportion to dose and hepatic metabolism (which is genetically determined); most tobacco users excrete cotinine in the range of 1000 to 8000 ng/mL. Urine concentrations of nicotine and metabolites in these ranges indicate the subject is using tobacco or is receiving high-dose nicotine patch therapy.
In addition to nicotine and metabolites, tobacco products contain other alkaloids that can serve as unique markers of tobacco use. Two such markers are anabasine and nornicotine. Anabasine is present in tobacco products but not in nicotine replacement therapies. Nornicotine is present as an alkaloid in tobacco products and as a metabolite of nicotine. The presence of anabasine (>10 ng/mL) or nornicotine (>30 ng/mL) in urine indicates current tobacco use, irrespective of whether the subject is on nicotine replacement therapy. The presence of nornicotine without anabasine is consistent with use of nicotine replacement products. Heavy tobacco users who abstain from tobacco for 2 weeks exhibit urine nicotine values below 30 ng/mL, cotinine values below 50 ng/mL, anabasine levels below 2 ng/mL, and nornicotine levels below 2 ng/mL.
Passive exposure to tobacco smoke can cause accumulation of nicotine metabolites in nontobacco users. Urine cotinine has been observed to accumulate up to 20 ng/mL from passive exposure. Neither anabasine nor nornicotine accumulates 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 a random urine specimen 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.
Quantification of urine nicotine and metabolites, while a patient is actively using a tobacco product, is useful to define the concentrations that a patient achieves through self-administration of tobacco. Nicotine replacement dose can then be tailored to achieve the same concentrations early in treatment to assure adequate nicotine replacement so the patient may avoid the strong craving they may experience early in the withdrawal phase. This can be confirmed by measurement of urine nicotine and metabolite concentrations at a steady state (2-3 days after replacement therapy is started). Once the patient is stabilized on the dose necessary to achieve complete replacement and responding well to therapy, the replacement dose can be slowly tapered to achieve complete withdrawal.
Non-tobacco user with no passive exposure:NICOTINE<5.0 ng/mL
Urine nicotine in the range of 1000 to 5000 ng/mL with cotinine in the range of 1000 to 8000 ng/mL indicates the subject is either actively using a tobacco product or on high-dose nicotine patch therapy.
The presence of anabasine and nornicotine indicates a subject on patch therapy who is actively using a tobacco product.
Typical findings are as follows:
While using a tobacco product:
-Peak nicotine concentration: 1000 to 5000 ng/mL
-Peak cotinine concentration: 1000 to 8000 ng/mL
-Anabasine concentration: 10 to 500 ng/mL
-Nornicotine concentration: 30 to 900 ng/mL
Tobacco user after 2 weeks complete abstinence:
-Nicotine concentration: <30 ng/mL
-Cotinine concentration: <50 ng/mL
-Anabasine concentration: <2.0 ng/mL
-Nornicotine concentration: <2.0 ng/mL
Nontobacco user with passive exposure:
-Nicotine concentration: <20 ng/mL
-Cotinine concentration: <20 ng/mL
Nontobacco user with no passive exposure:
-Nicotine concentration: <5.0 ng/mL
-Cotinine concentration: <5.0 ng/mL