Nicotine and Cotinine

At a Glance

Why Get Tested?

To detect the presence of and/or measure the quantity of nicotine or its metabolite cotinine in blood, urine, saliva, or sometimes hair; to determine whether someone uses products containing tobacco or nicotine or has been exposed to secondhand smoke; sometimes performed to evaluate for acute nicotine poisoning

When To Get Tested?

Whenever someone requires confirmation of tobacco or nicotine usage or exposure to secondhand smoke; occasionally when nicotine overdose is suspected

Sample Required?

A blood sample collected from a vein in your arm or a random urine sample; sometimes a saliva sample or, rarely, a hair sample

Test Preparation Needed?

None

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Looking For Reference Ranges?

You may be able to find your test results on your laboratory’s website or patient portal. However, you are currently at Lab Tests Online. You may have been directed here by your lab’s website in order to provide you with background information about the test(s) you had performed. You will need to return to your lab’s website or portal, or contact your healthcare practitioner in order to obtain your test results.

Lab Tests Online is an award-winning patient education website offering information on laboratory tests. The content on the site, which has been reviewed by laboratory scientists and other medical professionals, provides general explanations of what results might mean for each test listed on the site, such as what a high or low value might suggest to your healthcare practitioner about your health or medical condition.

The reference ranges for your tests can be found on your laboratory report. They are typically found to the right of your results.

If you do not have your lab report, consult your healthcare provider or the laboratory that performed the test(s) to obtain the reference range.

Laboratory test results are not meaningful by themselves. Their meaning comes from comparison to reference ranges. Reference ranges are the values expected for a healthy person. They are sometimes called “normal” values. By comparing your test results with reference values, you and your healthcare provider can see if any of your test results fall outside the range of expected values. Values that are outside expected ranges can provide clues to help identify possible conditions or diseases.

While accuracy of laboratory testing has significantly evolved over the past few decades, some lab-to-lab variability can occur due to differences in testing equipment, chemical reagents, and techniques. This is a reason why so few reference ranges are provided on this site. It is important to know that you must use the range supplied by the laboratory that performed your test to evaluate whether your results are “within normal limits.”

For more information, please read the article Reference Ranges and What They Mean.

What is being tested?

Nicotine is an addictive chemical found naturally in the tobacco plant and in some manufactured products, such as some e-cigarettes and nicotine-replacement products (e.g., gum, patch). It is inhaled or ingested and subsequently absorbed into the blood. This testing detects and/or measures nicotine and its primary breakdown product (metabolite) cotinine in the blood, urine, saliva, or hair.

Nicotine is metabolized by the liver into more than 20 compounds, which are eliminated from the body in the urine. Both tobacco use and exposure to tobacco smoke can increase nicotine and cotinine concentrations in the body. Levels also rise with use of nicotine replacement products such as nicotine patches and gums, and with the use of smokeless nicotine vapor (e-cigarettes). In large amounts, nicotine can be poisonous.

Long-term smoking of tobacco products can increase the risk of developing many diseases, including lung cancer, oral cancer, COPD, stroke, heart disease, and respiratory infections. Years of smokeless tobacco use also increases the risk of developing oral cancer (cheeks, gums, and lips). Long-term tobacco use can worsen asthma and help promote blood clot formation. In pregnant women, smoking can impair growth of the developing baby and lead to low birth weight babies.

Cotinine is usually the test of choice to evaluate tobacco use or exposure to tobacco smoke because it is stable and is only produced when nicotine is metabolized. Cotinine has a half-life in the body of between 7 and 40 hours, while nicotine has a half-life of 1 to 4 hours.

Blood and/or urine cotinine tests may be ordered along with nicotine tests. In some cases, other nicotine metabolites, such as nicotine-1′-N-oxide, trans-3′-hydroxycotinine, or nornicotine, or other tobacco chemicals, such as anabasine in urine, may also be tested. The presence of anabasine in someone’s urine indicates that the person is actively using a tobacco product, as it is not found in commercial nicotine replacement products, such as a patch.

The presence of nicotine and/or cotinine in an individual’s sample may indicate the use of tobacco or nicotine products or exposure to environmental tobacco smoke. Testing may be used in a number of situations to evaluate the possible use of tobacco products, such as in smoking cessation programs, prospective employment assessments, and evaluations of applicants for health or life insurance.

Nicotine and cotinine testing may also be ordered in cases of suspected nicotine poisoning. Acute overdoses of nicotine, such as might happen if a child ingests nicotine lozenges or gum, are relatively rare but generally require immediate medical attention.

Common Questions

How is it used?

Nicotine, and/or its primary metabolite cotinine, is most often tested to evaluate tobacco use. Because the use of tobacco products can greatly affect the health of individuals, companies may use nicotine/cotinine testing to evaluate prospective employees for tobacco use. Many health and life insurance companies test applicants for nicotine or cotinine as well.

Nicotine and cotinine can both be measured qualitatively or quantitatively. Qualitative testing detects the presence or absence of the substances, while quantitative testing measures the concentration of the substance. Quantitative testing can help distinguish between active smokers, tobacco users who have recently quit, non-tobacco users who have been exposed to significant environmental tobacco smoke, and non-users who have not been exposed.

Cotinine may also be measured in saliva and in hair, although hair testing is primarily used in a research setting, such as a study of non-smokers exposure to tobacco smoke.

A blood or urine nicotine test may be ordered by itself or along with cotinine if a healthcare practitioner suspects that someone is experiencing a nicotine overdose.

When a person has reported that he or she is using nicotine replacement products but is no longer smoking, nicotine, cotinine, and urine anabasine measurements may sometimes be ordered. Anabasine, an alkaloid, is present in tobacco but not in commercial nicotine replacement products. If a sample tests positive for anabasine, then the person is still using tobacco products.

When is it ordered?

Cotinine and/or nicotine testing may be ordered whenever an evaluation of tobacco use status or tobacco smoke exposure is required.

A court may order testing for child custody purposes. When a person enters a smoking cessation program, blood or urine cotinine tests may be ordered to evaluate his or her compliance. Urine, blood, or saliva testing may serve as a screen for tobacco use when someone is applying for life or health insurance.

Nicotine and cotinine are sometimes measured when someone has symptoms that a healthcare practitioner suspects may be due to a nicotine overdose. Symptoms of mild nicotine poisoning may include:

Nausea, vomiting
Dizziness
Drooling
Weakness

More serious nicotine poisoning may result in:

Increased blood pressure and/or heart rate, which suddenly drops
Slowed or difficulty breathing
Abdominal cramps
Agitation, restlessness, or excitement
Burning sensation in mouth
Confusion
Fainting
Headache
Muscular twitching
Seizures, convulsions
Coma

Hair testing is rarely performed in a clinical setting but may be ordered when an evaluation of longer-term tobacco use is desired.

What does the test result mean?

Nicotine and/or cotinine results may be reported as positive or negative, or as a level (e.g., nanograms per milliliter or ng/mL).

The level of nicotine and/or metabolites in a person’s sample depends on a few factors, such as how much the person inhales or ingests. Also, the rate at which nicotine is metabolized and cotinine is cleared from the body varies from person to person.

When someone stops using tobacco and nicotine products, it can take more than two weeks for the blood level of cotinine to drop to the level that a non-tobacco user would have and several weeks more for the urine level to decrease to a very low concentration.

In general, a high level of nicotine or cotinine indicates active tobacco or nicotine product use.
A moderate concentration indicates that the person has not had tobacco or nicotine for two to three weeks.
A lower level may be found in a non-tobacco user who has been exposed to environmental smoke.
Very low to non-detectible concentrations may be found in people who have not used tobacco or nicotine and have not been exposed to environmental smoke or in tobacco or nicotine users who have refrained from tobacco and nicotine for several weeks.

Is there anything else I should know?

Test results based on different samples (blood, urine, saliva) are not interchangeable.

Some pesticides contain high concentrations of nicotine. This can be another source of nicotine poisoning. In fact, nicotine is itself a pesticide sometimes used in “organic” farming as an alternative to organophosphate or pyrethrinoid derivatives.

Nicotine is found not just in the tobacco plant but also in other plants in the same family. These include potatoes, tomatoes, eggplants, and red peppers. The concentration of nicotine in these plants, however, is much lower than that in tobacco. The cutoffs of the nicotine/cotinine tests have been set to discriminate dietary sources of nicotine from tobacco use and second-hand smoking.

A person’s genetic makeup may influence how they metabolize nicotine. Variations in the genes that code for the CYP2A6 and CYP2B6 liver enzymes affect the rate of nicotine metabolism. (For more on this, see our article on Pharmacogenetic Tests.)

Do any forms of tobacco not contain nicotine?

No, they all contain nicotine. This includes pipe tobacco, cigars, snuff, chewing tobacco, etc. If you use any of these, nicotine may be detected in your system.

Can e-cigarettes and vaping cause a positive nicotine result?

E-cigarettes and other electronic nicotine delivery systems (ENDS) use concentrated liquids that are heated to produce a vapor that is then inhaled. The concentrates may contain nicotine, nicotine and flavorings, or just flavorings. If nicotine is present in the concentrate, then it may be detected in your system. This concentrate also poses a risk for accidental nicotine poisoning. The ENDS products are currently thought to be less harmful than smoking, but the medical community is concerned about their growing popularity. Because they are relatively new, their long-term health effects have yet to be determined.

View Sources

Sources Used in Current Review

(2017 October, Updated). Nicotine & Metabolites. ARUP Consult. Available online at https://arupconsult.com/content/nicotine-metabolites. Accessed on 2/11/18.

(2018 January 4, Revised). Oral Cavity and Oropharyngeal Cancer. American Cancer Society. Available online at https://www.cancer.org/cancer/oral-cavity-and-oropharyngeal-cancer.html. Accessed on 2/11/18.

Johnson-Davis, K. and McMilin, G. (© 1995–2018). Nicotine and Metabolites, Urine. Mayo Clinic Mayo Medical Laboratories. Available online at https://www.mayomedicallaboratories.com/test-catalog/Clinical+and+Interpretive/82510. Accessed on 2/11/18.

(2017 April 7, Updated). Cotinine Factsheet. Centers for Disease Control and Prevention, National Biomonitoring Program. Available online at https://www.cdc.gov/biomonitoring/Cotinine_FactSheet.html. Accessed on 2/11/18.

(2017 July, Revised). Tobacco, Nicotine, & E-Cigarettes. The National Institute on Drug Abuse Blog Team. Available online at https://teens.drugabuse.gov/drug-facts/tobacco-nicotine-e-cigarettes. Accessed on 2/11/18.

(2017 June, Revised). What are electronic cigarettes?. National Institute on Drug Abuse. Available online at https://www.drugabuse.gov/publications/drugfacts/electronic-cigarettes-e-cigarettes. Accessed on 2/11/18.

Drope, J. et. al. (2017 November). CA Cancer J Clin. 2017 Nov;67(6):449-471. Available online at https://www.ncbi.nlm.nih.gov/pubmed/28961314. Accessed on 2/11/18.

Sources Used in Previous Reviews

Wu, A. (2006). Tietz Clinical Guide to Laboratory Tests, Fourth Edition. Saunders Elsevier, St. Louis, Missouri. Pp 1326-1327, 1422-1425.

Perez, E. (2007 January 19, Updated). Nicotine. MedlinePlus Medical Encyclopedia [On-line information]. Available online at http://www.nlm.nih.gov/medlineplus/ency/article/002510.htm. Accessed on 9/9/07.

Wilson, S. et. al. (2007 April 10). The Role of Air Nicotine in Explaining Racial Differences in Cotinine Among Tobacco-Exposed Children. Medscape from CHEST 2007;131(3):856-862 [On-line information]. Available online at http://www.medscape.com/viewarticle/554042. Accessed on 9/9/07.

Barclay, L. (2007 July 20). Comprehensive Smoking Bans May Decrease Secondhand Smoke Exposure. Medscape Medical News [On-line information]. Available online at http://www.medscape.com/viewarticle/560150. Accessed on 9/9/07.

(2007 February). Nicotine and Related Compounds in Urine and Serum/Plasma. ARUP Technical Bulletin [On-line information]. PDF available for download through http://www.aruplab.com. Accessed on 9/9/07.

(1999-2000). Cotinine. CDC Laboratory Procedure Manual [On-line information]. PDF available for download at http://www.cdc.gov/nchs/data/nhanes/frequency/lab06_met_cotinine.pdf.

(2006 July). Nicotine Replacement Therapy. American Lung Association, Nicotine Replacement Therapy [On-line information]. Available online at http://www.lungusa.org/site/apps/s/content.asp?c=dvLUK9O0E&b=34706&ct=66696. Accessed on 10/6/07.

Thomas, Clayton L., Editor (1997). Taber’s Cyclopedic Medical Dictionary. F.A. Davis Company, Philadelphia, PA [18th Edition]. Pp. 1299-1300.

Boulton, M., et. al. Reported (2003 May 9). Nicotine Poisoning After Ingestion of Contaminated Ground Beef — Michigan, 2003. CDC MMWR [On-line information]. Available online at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5218a3.htm. Accessed on 10/6/07.

Michigan Department of Community Health. Nicotine Factsheet [On-line information] PDF available for download at http://michigan.gov/documents/Nicotine_Factsheet_82361_7.pdf. Accessed November 2007.

Arup Consult. Nicotine & Metabolites. Available online at http://www.arupconsult.com/Topics/NicotineMetabolites.html#tabs=0 through http://www.arupconsult.com. Accessed Nov 2010.

Medicinenet.com. MedTerms: Nicotine. Available online at http://www.medterms.com/script/main/art.asp?articlekey=22807. Accessed Nov 2010.

ARUP Consult. The Physician’s Guide to Test Selection and Interpretation. Nicotine and Metabolites. Available online at http://www.arupconsult.com/Topics/NicotineMetabolites.html. Accessed December 2, 2013.

MedlinePlus Medical Encyclopedia. Nicotine Poisoning. Available online at http://www.nlm.nih.gov/medlineplus/ency/article/002510.htm. Last updated January 30, 2013. Accessed December 2, 2013.

Medical Health Tests. Can you beat a cotinine urine test by drinking a lot of water? Available online at http://www.medicalhealthtests.com/askquestion/166/can-you-beat-a-cotinine-urine-test-by-drinking-a-l.html. Published April 1, 2010. Accessed December 2, 2013.

Jen Wieczner. 10 Things E-Cigarettes Won’t Tell You. The Wall Street Journal. Available online at http://online.wsj.com/news/articles/SB10001424052702304448204579184052293918312. Published November 10, 2013. Accessed December 2, 2013.

(June 2011) American Lung Association. General Smoking Facts. Available online at http://www.lung.org/stop-smoking/about-smoking/facts-figures/general-smoking-facts.html. Accessed December 2013.

(July 2012) National Institute on Drug Abuse. Tobacco/Nicotine Addiction. Available online at http://www.drugabuse.gov/drugs-abuse/tobacco-addiction-nicotine. Accessed December 2013.

Ralph Magnotti, PhD, DABCC. Lab Tests Online adjunct board member.

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