Clinical Information

Tobacco use remains the leading cause of preventable disease, disability, and death in the 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 less than 3.0 ng/mL and cotinine less than 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.