Cited by 621Smoking Behavior and CessationSubstance Abuse Treatment and OutcomesPrenatal Substance Exposure Effects

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Biochemical Verification of Tobacco Use and Abstinence: 2019 Update

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Benowitz, Neal L, Bernert, John T, Foulds, Jonathan, Hecht, Stephen S, Jacob, Peyton, Jarvis, Martin J, Joseph, Anne, Oncken, Cheryl, Piper, Megan E·2020·Nicotine & Tobacco Research

DOI 10.1093/ntr/ntz132PMC PMC7882145

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Abstract

BACKGROUND: The changing prevalence and patterns of tobacco use, the advent of novel nicotine delivery devices, and the development of new biomarkers prompted an update of the 2002 Society for Research on Nicotine and Tobacco (SRNT) report on whether and how to apply biomarker verification for tobacco use and abstinence. METHODS: The SRNT Treatment Research Network convened a group of investigators with expertise in tobacco biomarkers to update the recommendations of the 2002 SNRT Biochemical Verification Report. RESULTS: Biochemical verification of tobacco use and abstinence increases scientific rigor and is recommended in clinical trials of smoking cessation, when feasible. Sources, appropriate biospecimens, cutpoints, time of detection windows and analytic methods for carbon monoxide, cotinine (including over the counter tests), total nicotine equivalents, minor tobacco alkaloids, and 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol are reviewed, as well as biochemical approaches to distinguishing cigarette smoking from use of electronic nicotine delivery devices (ENDS). CONCLUSIONS: Recommendations are provided for whether and how to use biochemical verification of tobacco use and abstinence. Guidelines are provided on which biomarkers to use, which biospecimens to use, optimal cutpoints, time windows to detection, and methodology for biochemical verifications. Use of combinations of biomarkers is recommended for assessment of ENDS use. IMPLICATIONS: Biochemical verification increases scientific rigor, but there are drawbacks that need to be assessed to determine whether the benefits of biochemical verification outweigh the costs, including the cost of the assays, the feasibility of sample collection, the ability to draw clear conclusions based on the duration of abstinence, and the variability of the assay within the study population. This paper provides updated recommendations from the 2002 SRNT report on whether and how to use biochemical markers in determining tobacco use and abstinence.

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Method
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“49 This will be carried out by using the same carbon Open access monoxide monitor and additionally by analysing a urine sample for cotinine exposure using a multilevel lateral flow immunoassays urine test strip with a nominal 200 ng/mL cut-off.”
Method
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Behavioral and Genetic Factors Associated with Successful Long-Term Cessation in Persons with HIV Who Smoke Cigarettes
Shuter, J., Hosgood, H. D., Kim, R. S., Ye, K. Q., Montagna, C., Shan, J., Weinberger, A. H., & Ward, K. D. (2021) · The Journal of Smoking Cessation · doi:10.1155/2021/1894160 · Cited by 1
“, 5-6 ppm) for nonsmoker status, but these recommendations did not exist at the time that the present study was conducted [10].”
Background
Measuring cotinine to monitor tobacco use and smoking cessation
Stubbs, K. R. (2021) · Current Psychiatry · doi:10.12788/cp.0115 · Cited by 1
Extending contingency management for smoking cessation to patients with or at risk for cardiovascular disease: A preliminary trial of a home-based intervention.
Coleman, S. R. M., Higgins, S. T., Smyth, J. M., Rodriguez, B. L., Loganathan, M., & Gaalema, D. E. (2023) · Experimental and Clinical Psychopharmacology · doi:10.1037/pha0000677 · Cited by 1
The sweet spot study—Developing e-liquid product standards for nicotine form and concentration to improve public health: Protocol for a randomized, double-blinded, crossover study
Cho, Y. J., Brinkman, M. C., Hinton, A. M., Nshimiyimana, J. D., Mehta, T. R., Adeniji, A., Norton, K. J., Hellani, A. E., & Wagener, T. L. (2023) · PLoS ONE · doi:10.1371/journal.pone.0291522 · Cited by 2
The Role of Seed Users in Nurturing an Online Health Community for Smoking Cessation Among People With HIV/AIDS
Wang, X., Zhao, K., Amato, M. S., Stanton, C. A., Shuter, J., & Graham, A. L. (2023) · Annals of Behavioral Medicine · doi:10.1093/abm/kaad063 · Cited by 1
Biomarkers in Substance Use Disorder
Lane, S. D., Yoon, J. H., Heads, A. M. B., de Dios, C., Yammine, L., Hong, J. H., Webber, H. E., Weaver, M. F., Schmitz, J. M., & Walss‐Bass, C. (2023) · Springer eBooks · doi:10.1007/978-3-031-43356-6_18 · Cited by 1
Comparing the Effectiveness of the Blended Delivery Mode With the Face-to-Face Delivery Mode of Smoking Cessation Treatment: Noninferiority Randomized Controlled Trial
Siemer, L., Pieterse, M. E., Allouch, S. B., Postel, M. G., & Brusse-Keizer, M. G. J. (2023) · Journal of Medical Internet Research · doi:10.2196/47040 · Cited by 2
“Cotinine-validated and CO-validated abstinence measurements were used to measure biochemically validated point prevalence abstinence rates [36-38].”
Tobacco policies and changes in the tendency of smoking cessation in cigarette users in Chile: a longitudinal cross-sectional study
Domínguez-Cancino, K. A., Martínez, P., & Nazif‐Muñoz, J. I. (2024) · BMJ Open · doi:10.1136/bmjopen-2024-085248 · Cited by 1
“16 Some authors have suggested that smoke-free public spaces could lead to changes in smoking habits through social diffusion or displacement.”
Background
Nicotine Use Disorder
Khan, A., Tampi, R. R., & Tampi, D. J. (2024) · Springer eBooks · doi:10.1007/978-3-031-55711-8_16 · Cited by 1
Analysis of patient health questionnaire-9 (PHQ-9) based depression prevalence according to a discordance between quantitative urinary cotinine levels and self-report of second-hand smoke exposure among adults: A cross-sectional study
Lee, H., Lee, Y. J., Cho, J., & Park, D. (2024) · Heliyon · doi:10.1016/j.heliyon.2024.e32125 · Cited by 1
“Serum cotinine is a widely used biomarker for smoking status verification [43], and urinary 4-(Methylni-trosamino)-1-(3-pyridyl)-1-butanol (NNAL) is more sensitive than UC for detecting SHS exposure over a much longer period [43].”
„Rauchfrei im Mai 2024“ – Konzept und Deskription der Teilnehmenden
Hanewinkel, R., Barthels, F., & Isensee, B. (2024) · Pneumologie · doi:10.1055/a-2405-2840 · Cited by 1
Effects of in vivo NRT sampling on smoking abstinence and NRT adherence: A randomized clinical trial
Cropsey, K. L., Wagner, W. P., Bontemps, A. P., Hawes, E. S., Pridgen, B. E., Lahti, A. C., Hendricks, P. S., Azuero, A., & Carpenter, M. J. (2024) · Drug and Alcohol Dependence · doi:10.1016/j.drugalcdep.2024.112458 · Cited by 1
Identifying Patterns of Tobacco Use and Associated Cardiovascular Disease Risk Through Machine Learning Analysis of Urine Biomarkers
Siegel, N. S., Zhao, J., Benjamin, E. J., Bhatnagar, A., Hall, J. L., & Stokes, A. C. (2025) · JACC Advances · doi:10.1016/j.jacadv.2025.101630 · Cited by 1
Sex dependent genetic architecture of biochemically verified tobacco use
Chenoweth, M. J., Lerman, C. E., Knight, J., & Tyndale, R. F. (2025) · Psychiatry Research · doi:10.1016/j.psychres.2025.116465 · Cited by 1
“However, self-reported measures do not account for differences in smoking (e.g. depth of inhalation) (Burling et al., 1985) and are affected by social desirability and recall bias (Benowitz, 2020).”
Combined Smoking Cessation and Alcohol Abstinence Treatment for People Experiencing Homelessness: A Randomized Trial
Onigbogi, O. O., Pratt, R. J., Luo, X., Everson‐Rose, S. A., Cooney, N. L., Specker, S. M., Thomas, J., & Okuyemi, K. S. (2025) · Nicotine & Tobacco Research · doi:10.1093/ntr/ntaf085 · Cited by 1
“As a secondary outcome analysis, we examined repeated measures of the CO-verified and self-reported point-prevalence smoking abstinence outcomes at weeks 5, 12, and 26, using a generalized linear mixed model with covariates of treatment arm, discrete time, and their interaction.”
Clearing the air: Empowering high-risk adults with digital tools for smoking cessation and lung cancer screening adoption
Cooley, M. E., Kim, S. S., Xiong, N., Heiling, H., Mazzola, E., Nayak, M. M., DeMarco, R. F., Kitts, A. B., Underhill-Blazey, M. L., Healey, M. J., et al. (2025) · Lung Cancer · doi:10.1016/j.lungcan.2025.108647 · Cited by 1
Which Method of Assessing Depression and Anxiety Best Predicts Smoking Cessation: Screening Instruments or Self-Reported Conditions?
Watson, N. L., Heffner, J. L., Mull, K. E., McClure, J. B., & Bricker, J. B. (2020) · Nicotine & Tobacco Research · doi:10.1093/ntr/ntaa099 · Cited by 1
Differences in Cognitive Task Performance, Reinforcement Enhancement, and Nicotine Dependence Between Menthol and Nonmenthol Cigarette Smokers
Jao, N. C., Levin, E. D., Simon, M. A., & Hitsman, B. L. (2021) · Nicotine & Tobacco Research · doi:10.1093/ntr/ntab120 · Cited by 1
Varenicline Treatment for Waterpipe Smoking Cessation
Chami, H. A., Zaouk, N., Makki, M. H., Tamim, H., Shaya, M., & Talih, F. R. (2022) · Nicotine & Tobacco Research · doi:10.1093/ntr/ntac162 · Cited by 1
Salivary cotinine level and treatment response in muscle invasive bladder cancer: A pilot study
Gotschall, J. W., Major, C. K., Jacobs, L. A., Blauch, A. N., Pucci, D. A., Palmer, S. C., & Mamtani, R. (2022) · BJUI Compass · doi:10.1002/bco2.204 · Cited by 1
“The primary exposure was active smoking or no active smoking, defined using salivary cotinine concentration level (<10 and >10 ng/ml, respectively).(5) The association”
Method
Change in cardiovascular health among adults with current or past major depressive disorder enrolled in intensive smoking cessation treatment
Carroll, A. J., Huffman, M. D., Wileyto, E. P., Khan, S. S., Fox, E. N., Smith, J. D., Bauer, A., Leone, F. T., Schnoll, R. A., & Hitsman, B. L. (2023) · Journal of Affective Disorders · doi:10.1016/j.jad.2023.04.089 · Cited by 1
Nicotine patches with e-cigarettes for smoking cessation: Twitter discussion from a respirology journal club – Authors' reply
Walker, N. K., Parag, V., Verbiest, M. E. A., Laking, G. R., Laugesen, M., & Bullen, C. (2020) · The Lancet Respiratory Medicine · doi:10.1016/s2213-2600(20)30073-4 · Cited by 1
Review of: "Improving on estimates of the potential relative harm to health from using modern ENDS (vaping) compared to tobacco smoking"
Herzig, Z., Bates, C., & Hájek, P. (2022) · doi:10.32388/jpjuxw · Cited by 1
Efficacy and Safety of Electronic Cigarettes as a Smoking Cessation Intervention: A Systematic Review and Network Meta-AnalysisPreprint
Quigley, J. M., Walsh, C., Lee, C., Long, J., Kennelly, H., McCarthy, A., & Kavanagh, P. (2020) · SSRN Electronic Journal · doi:10.2139/ssrn.3739810 · Cited by 1
Análise prognóstica de um programa de tabagismo entre pacientes com comorbidade psiquiátrica
Lima, D. R. (2022) · Digital Library of Theses and Dissertations (Universidade de São Paulo) · doi:10.11606/t.5.2022.tde-22122022-095558 · Cited by 1
Maternal smoking in early pregnancy disrupts placental function through syncytiotrophoblast and macrophage dysregulationPreprint
Valdes, D. S., Nimo, J., Nonn, O., Ulrich, J., Forstner, D., Haider, S., Ernhoefer-Reßler, M., Pignitter, M., Müller, D. N., Dechend, R., et al. (2025) · bioRxiv (Cold Spring Harbor Laboratory) · doi:10.1101/2025.07.10.664172 · Cited by 1
Association of e-cigarette use and smoking cessation among Canadian young adult smokers: secondary analysis of data from a randomised controlled trial
Saxena, A., Baskerville, N. B., & Garcia, J. M. (2020) · The Journal of Smoking Cessation · doi:10.1017/jsc.2020.2
Blended smoking cessation treatment: user experience, adherence, effectiveness
Siemer, L. (2020) · doi:10.3990/1.9789036550703
The risk of colorectal neoplasm in ex- and never-smokers according to urinary cotinine level
Roh, S. J., Kim, B., Oh, J. Y., Han, K. S., Kim, B. C., Hong, C. W., & Sohn, D. K. (2021) · Medicine · doi:10.1097/md.0000000000025842
“Plasma thiocyanate has the disadvantage of poor specificity for detecting light smoking,([6]) and exhaled CO is not measured in smokeless tobacco or electronic cigarette exhalent.([7]) Therefore, urinary cotinine level is known as an objective and quantitative indicator related to smoking.”
BackgroundMethodInfluential
Health-Related Associates of Negative Affect among Latinx and Black Adults with Psychiatric Disorders
Gittleman, J. M., Shpigel, D. M., Agterberg, S., Mercedes, E., & Weinberger, A. H. (2021) · Journal of Underrepresented & Minority Progress · doi:10.32674/jump.v5i1.3282
La Spagna e l'Europa
Maiques, J. V. B. I. (2004) · Ambiente società territorio: Geografia nelle scuole
Expired Air Carbon Monoxide Testing Is Effective for Preoperative Screening of Cigarette Use in Orthopaedic Patients: A Prospective Pilot Study of 70 Veterans
(2021) · American Journal of Orthopedic Research and Reviews · doi:10.28933/ajorr-2021-07-1505
Reaching Intermittent Tobacco Users With Technology: New Evidence
Busch, A. M., Conroy, D. E., & Pagoto, S. (2021) · American Journal of Public Health · doi:10.2105/ajph.2021.306449
EVALUATION OF SALIVARY COTININE LEVEL IN SECOND-HAND SMOKERS - A CASE CONTROL STUDY
Chatra, L., Vijila, K. V., Shenoy, P., Veena, K. M., Rachana, P., & Prathima, S. (2022) · Indian Journal Of Applied Research · doi:10.36106/ijar/3905753
Diagnostik und Dokumentation
Batra, A., Petersen, K. U., Hering, T., Kröger, C. B., Lindinger, P., & Kotz, D. (2022) · Springer eBooks · doi:10.1007/978-3-662-63679-4_3
Optimizing digital smoking cessation interventions
Elling, J. M. (2022) · doi:10.26481/dis.20221207je
Cognitive-behavioral therapy for tobacco use disorder in smokers with depression: A critical review
González‐Roz, A., Weidberg, S. E., & MacKillop, J. M. (2023) · Elsevier eBooks · doi:10.1016/b978-0-323-85726-0.00031-4
An Open-label Pilot Study of NicoBloc as a Novel Smoking Cessation Intervention
Chichester, K. R., Sisson, M. L., Chana, S. M., Wolford‐Clevenger, C., Hugley, M. J., Hawes, E. S., Palenski, P. E., Nguyen, A., Dahne, J., Hendricks, P. S., et al. (2023) · Journal of Addiction Medicine · doi:10.1097/adm.0000000000001157
Study protocol for approach bias retraining for nicotine addiction among dual combustible and electronic cigarette users
Clausen, B. K., Rinck, M., Nizio, P., Matoska, C. T., Zappi, C., Smits, J. A. J., Gallagher, M. W., Zvolensky, M. J., & Garey, L. (2023) · Contemporary Clinical Trials · doi:10.1016/j.cct.2023.107145
A Financial Incentives Program to Promote Smoking Cessation Among Recently Hospitalized Individuals: Feasibility and Acceptability Study
Shusterman, S., Villarreal‐Calderon, R., Gunawan, A., Foreman, A. G., O’Donnell, C., Wakeman, C., Javeed, H., Keteyian, J., Howard, J., Bulekova, K., et al. (2023) · JMIR Formative Research · doi:10.2196/44979
“Of note, an update was published in late 2020 suggesting that an appropriate cutpoint may be 4 to 10 ppm for research and clinical purposes depending on local smoke-free legislation, smoking prevalence, and air pollution levels [25].”
Background
A telephone-based smoking cessation intervention for individuals with COVID-19: A randomized controlled feasibility study
Grech, J. L. (2023) · Tobacco Prevention & Cessation · doi:10.18332/tpc/165826
“As recommended by Benowitz et al.30, biochemical verification of tobacco abstinence was carried out by using a carbon monoxide (CO) monitor (cut-off 6 ppm) and by testing saliva for cotinine exposure using a multilevel lateral flow 6Tob.”
Method
Seeing Through the Blind: Belief About Treatment Randomization and Smoking Cessation Outcome Among People With Current or Past Major Depressive Disorder Who Smoke in a Placebo-Controlled Trial of Varenicline
Schnoll, R. A., Wileyto, E. P., Bauer, A., Fox, E. N., Blumenthal, D., Quinn, M. H., Leone, F. T., Huffman, M. D., Khan, S. S., Gollan, J. K., et al. (2023) · Nicotine & Tobacco Research · doi:10.1093/ntr/ntad218
Effectiveness of Contingency Management in Tobacco Smokers with Depressive Symptoms: A Systematic Review
Marchal-Mateos, M. I., López-Núñez, C., & Fernández‐Artamendi, S. (2024) · Substance Use & Misuse · doi:10.1080/10826084.2024.2302169 · Cited by 1
“The target behavior (mainly abstinence) has to be assessed objectively and, more specifically in the case of smoking, by analyzing urinary cotinine or carbon monoxide (CO) levels through exhaled air (Benowitz et al., 2020; Perkins et al., 2013; Sigmon and Patrick, 2012).”
Background
THE EFFECT OF NURSES' CHALLENGES TO STOPPING SMOKING ON NICOTINE ADDICTIONS
Aktürk, Ü., Yağmur, S., Türkmen, R. M., & Aktürk, S. (2024) · International Journal of Health Services Research and Policy · doi:10.33457/ijhsrp.1415543
Acceptability of heart rate-based remote monitoring of smoking status
Mitnick, M., Goodwin, S. R., Bubna, M., White, J. S., & Raiff, B. R. (2024) · Addictive Behaviors Reports · doi:10.1016/j.abrep.2024.100561
“Objective biological verification methods provide an unbiased way to measure smoking and typically include measuring exhaled breath carbon monoxide levels or blood, saliva, or urine-based nicotine metabolites such as cotinine or tobacco alkaloids (Benowitz et al., 2020; Thrul et al., 2023).”
Method
Urinary anatalline and nicotelline cut-points to distinguish between exclusive and dual use of tobacco products
Edwards, K. C., Helen, G. S., Jacob, P., Ozga, J. E., & Stanton, C. A. (2024) · Biomarkers · doi:10.1080/1354750x.2024.2389047
“…active versus passive cigarette smoke exposure (Mourino et al. 2021) and compliance with cigarette smoking abstinence in various research settings (Benowitz et al. 2020), there are limitations to the use of cotinine as a biomarker. since cotinine is a metabolite of nicotine and that nicotine is…”
Self-citation
Impact of quitline services on tobacco cessation: an application of modern epidemiologic methods
Sedani, A. E., Frank-Pearce, S. G., Chen, S., Peck, J. D., Campbell, J. E., Chou, A. F., & Beebe, L. A. (2024) · American Journal of Epidemiology · doi:10.1093/aje/kwae292
Tobacco, nicotine, and cannabis use and exposure in an Australian Indigenous population during pregnancy: A protocol to measure parental and foetal exposure and outcomes
Ratsch, A., Burmeister, E. A., Bird, V., Bonner, A. J., Miller, U. G., Speedy, A. M., Douglas, G., Ober, S., Woolcock, A., Murdoch), S. B. (., et al. (2024) · PLoS ONE · doi:10.1371/journal.pone.0300406
Long-Term Effectiveness of a Quitline for Smoking Cessation: Results of a Randomized Controlled Trial
Delle, S., Kraus, L., Maspero, S., Pogarell, O. M., Hoch, E., & Lochbühler, K. (2024) · European Addiction Research · doi:10.1159/000541682

Authors: Benowitz, N. L., Bernert, J. T., Foulds, J., Hecht, S. S., Jacob, P., Jarvis, M. J., Joseph, A., Oncken, C., & Piper, M. E.
Affiliations: University of California, San Francisco (US)
Centers for Disease Control and Prevention (US)
Pennsylvania State University (US)
University of Minnesota (US)
University College London (GB)
University of Connecticut (US)
University of Wisconsin–Madison (US)
Corresponding author: Benowitz, Neal L
ORCID: Benowitz, Neal L
Foulds, Jonathan
Hecht, Stephen S
Jacob, Peyton
Jarvis, Martin J
Joseph, Anne
Oncken, Cheryl
Piper, Megan E
Venue: Nicotine & Tobacco Research
Publisher: Oxford University Press (OUP)
Published: 2019-10-01
Volume: 22
Issue: 7
Pages: 1086-1097
ISSN: 1462-2203 (ISSN-L)
1469-994X
DOI: 10.1093/ntr/ntz132
PMC: PMC7882145
OpenAlex: W2978389675
Cited by: 619
References: 121
Citations by year: 2026: 99 · 2025: 84 · 2024: 107 · 2023: 103 · 2022: 87 · 2021: 79 · 2020: 54 · 2019: 4
FWCI: 6.58
Type: journal article
Language: en
Open access: green
www.ncbi.nlm.nih.gov
Licence: academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model (vor)
Locations: Nicotine & Tobacco Research (publishedVersion)
PubMed (publishedVersion)
PubMed Central (acceptedVersion)
eScholarship (California Digital Library) (submittedVersion)
Funders: National Institutes of Health (CC999999)
Topics: Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Smoking Behavior and Cessation
Health Sciences › Medicine › Epidemiology › Substance Abuse Treatment and Outcomes
Health Sciences › Medicine › Pediatrics, Perinatology and Child Health › Prenatal Substance Exposure Effects
Keywords: tobacco use, smoking abstinence, biomarkers, cotinine, carbon monoxide, electronic cigarettes, NNAL, biological specimen, detection window
MeSH terms: Cigarette Smoking, Carbon Monoxide, Cotinine, Humans, Nicotine, United States, Biomarkers, Smoking Cessation, Tobacco Products

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Biochemical Verification of Tobacco Use and Abstinence: 2019 Update

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