Nicotine and Metabolites, Saliva

CPT CODE:

USEFUL FOR:

Monitoring tobacco use
Monitoring nicotine replacement therapy to verify it is adequate

SPECIMEN REQUIRED:

Patient should spit into a container (eg, a small, plastic cup) until 3 mL of saliva has been collected. Transfer collection into a small, screw-capped container, and send specimen refrigerated. Note:      Label container with patient's name and collection date.

TRANSPORT TEMPERATURE:

Refrig\Ambient OK\Frozen OK

CLINICAL INFORMATION:

Tobacco use is the leading cause of death in the United States.  Nicotine, coadministered in tobacco products such as cigarettes, pipe, cigar, or chew, is an addicting substance that causes individuals to continue use of tobacco despite concerted efforts to quit. Nicotine stimulates dopamine release and elevates dopamine concentrationin the nucleus accumbens, a mechanism that is thought to be the basisfor addiction for drugs of abuse.(1)
Nicotine is rapidly metabolized in the liver to cotinine, exhibiting anelimination half-life of 2 hours. Cotinine exhibits an apparent eliminationhalf-life of 15 hours. Saliva nicotine and cotinine concentrations arein equilibrium with serum concentrations and reflect serum status.
Patients using tobacco strive to achieve nicotine concentrationin saliva in the range of 30 ng/mL to 50 ng/mL. Cotinine is present insaliva in proportion to dose and hepatic metabolism (which is geneticallydetermined); cotinine concentrations observed in most tobacco usersare in the range of 200 ng/mL to 800 ng/mL. Heavy tobacco userswho abstain from tobacco for 2 weeks exhibit saliva nicotine <2.0ng/mLand cotinine <2.0 ng/mL. Passive exposure to tobacco smoke cancause accumulation of nicotine metabolites in nontobacco users.Saliva cotinine concentrations up to 8.0 ng/mL may be due to passiveexposure.(3)
Tobacco users engaged in programs to abstain from tobacco require support in the form of counseling, pharmacotherapy, and continuousencouragement. Occasionally, health care professionals may elect to monitor abstinence by biochemical measurement of nicotine and metabolites in saliva to verify abstinence. If results of biological testing indicate the patient is actively using a tobacco product during therapy, additional counseling or intervention may be appropriate. To discriminate if a patient on replacement therapy is actively using a tobacco product, see #82510 "Nicotine and Metabolites, Urine" analysis; the presence of anabasine, a tobacco alkaloid not present in nicotine replacement, indicates recent tobacco use.
Quantification of saliva 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 sameconcentrations early in treatment to assure adequate nicotinereplacement so the patient may avoid the strong craving they mayexperience early in the

CLINICAL INTERPRETATION:

Saliva nicotine concentration in the range of 30 ng/mL to 50 ng/mLWith cotinine in the range of 200 ng/mL to 800 ng/mL indicates thesubject is either actively using a tobacco product or on nicotinereplacement therapy.
To discriminate if a patient on nicotine replacement therapy is activelyusing a tobacco product, see #82510 "Nicotine and Metabolites, Urine"analysis; the presence of anabasine in urine, a tobacco alkaloid notpresent in nicotine replacement products, indicates recent tobacco use.
Typical findings are as follows:
While using a tobacco or nicotine product:Peak nicotine concentration:  30 ng/mL to 50 ng/mLPeak cotinine concentration:  200 ng/mL to 800 ng/mL**Higher values may be seen in subjects with highcytochrome P(450) 2D6 activity.
Tobacco user after 2 weeks complete abstinence:Nicotine concentration:  <2.0 ng/mLCotinine concentration:  <2.0 ng/mL
Non-tobacco user with passive exposure:Nicotine concentration:  <2.0 ng/mLCotinine concentration:  <8.0 ng/mL
Non-tobacco user with no passive exposure:Nicotine concentration:  <2.0 ng/mLCotinine concentration:  <2.0 ng/mL

REFERENCE VALUES:

NICOTINE

      <2.0 ng/mL

COTININE

      <2.0 ng/mL