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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The Reply
Varyvoda, T., Zolotarova, T., Moiz, A., Munteanu, D., Filion, K. B., & Eisenberg, M. J. (2026) · The American Journal of Medicine · doi:10.1016/j.amjmed.2026.01.051
Nicotine-Mediated Redox and Nitrosative Stress in Cardiorenal Health
Semenikhina, M., Jones, A., Pasham, V., Budisavljevic, M. N., Palygin, O., & Ilatovskaya, D. V. (2026) · Hypertension · doi:10.1161/hypertensionaha.126.26095
Biochemical verification of tobacco use in ICU patients using point-of-care urinary cotinine
Surace, S. J., Presneill, J., Ankravs, M. J., Panganiban, H. P., Moore, C., Barrese, A., Deane, A. M., & Plummer, M. P. (2026) · Critical Care and Resuscitation · doi:10.1016/j.ccrj.2026.100185
Effects of a Brief Smokeless Tobacco Cessation Counseling Among People with HIV Who Smoke Cigarettes in Nepal
Poudel, K. C., Silwal, R. C., Chalise, B. S., Shrestha, R., & Poudel‐Tandukar, K. (2026) · Substance Use & Misuse · doi:10.1080/10826084.2026.2671344
“…verification increases scientific rigor, self-report of tobacco use can be considered an acceptable standard in cessation trials and clinical practice, given the cost, feasibility of sample collection, and ability to draw clear conclusions from abstinence duration (Benowitz et al., 2020).”
Transcranial direct current stimulation (tDCS) as an additional treatment to cognitive behavior group therapy in adults with tobacco dependence - a double-blind, randomized, sham-controlled pilot trial
Goerigk, S. A., Burkhardt, G., Padberg, F., Zeren, A., Ludwig, H., Rabenstein, A., Kröger, C. B., Vragolic, S., Palm, U., Pogarell, O. M., et al. (2026) · Psychiatry Research · doi:10.1016/j.psychres.2026.117223
Effectiveness of a one-year smoking cessation intervention for people with severe mental illness: results of the KISMET cluster-randomized controlled trial
Küçükaksu, M. H., Hoekstra, T., Vermeulen, J. M., Jansen, L., Helmig, S., van Meijel, B., & Adriaanse, M. C. (2026) · Psychological Medicine · doi:10.1017/s0033291726104516
“Smoking cessation was determined through self-report (i.e. abstinent in the last 7 days) and verified by exhaled CO level lower than 10 parts per million (Benowitz et al., 2020).”
Race/Ethnicity-Based Discrimination and Cigarette Dependence and Abstinence among a Sample of Black and Hispanic/Latine Individuals with HIV Participating in a Randomized Clinical Trial for Smoking Cessation
Agterberg, S., Shuter, J., Stanton, C. A., Seng, E. K., & Weinberger, A. H. (2026) · Journal of Racial and Ethnic Health Disparities · doi:10.1007/s40615-026-03014-x
Association of Smoking Status and Urinary Cotinine Levels With Lipoprotein(a) in Korean Adults
Kim, B. J., Jang, A. Y., & Kang, J. (2026) · Journal of Lipid and Atherosclerosis · doi:10.12997/jla.2026.15.2.317
Digital-Assisted Community Pharmacy Cessation for Dual-Tobacco Users in Jordan: A Hybrid Cluster Randomized Controlled Trial
Abdel‐Qader, D. H., Mazrouei, N. A., Taybeh, E. O., Ibrahim, R. M., Albassam, A., Massad, E. M., Saleh, A., Jaradat, S., & Al-Omoush, S. (2026) · Pharmacy · doi:10.3390/pharmacy14030077
“Treatment varied according to the participant’s baseline tobacco-use phenotype [21]: (1) exclusive cigarette users (were primarily directed toward standard NRT or varenicline; (2) xclusive wa-terpipe/shisha users focused heavily on behavioral cue management and (3) dual users were recommended…”
Influential
Nurse-led smoking cessation with cytisinicline in primary care: An intervention study
García, R. M., Villoria, M. G. E., Fernández-Martínez, M. N., Madero, A. D., & Fernández-García, D. (2026) · International Journal of Nursing Studies Advances · doi:10.1016/j.ijnsa.2026.100578
“…of smoking abstinence at 1, 3, and 6 months (self-reported), and at 12 months (self-reported with biochemical verification using exhaled carbon monoxide measurement, with a cut-off point lower than 6 ppm (Benowitz et al., 2020), or urinary cotinine testing), which constituted the primary outcome.”
Beyond self-reports: Exploring the disconnect between subjective behavioural correlates, self-reported adherence, and objective behaviour using network analysis
Parragi, F. K., Vissers, G. C. W. P., Tanis, C. C., & Blanken, T. F. (2026) · Journal of Health Psychology · doi:10.1177/13591053261452202
Money Helps: Financial Incentives for Smoking Cessation Among People Experiencing Homelessness
Gu, D., Cuby, J., Gomez, O., Hawes, M. R., Hall, S., Stitzer, M. L., Kushel, M., & Vijayaraghavan, M. (2026) · Substance Use & Misuse · doi:10.1080/10826084.2026.2682312
Türkiye’de yeni uygulama: Aile sağlığı merkezinde sigara bırakma polikliniğinin ilk sonuçları
Altun, R., & Acar, T. (2026) · Turkish Journal of Tobacco Control · doi:10.64511/tjtc.2026.101
Tobacco smoke exposure and spine fracture risk in US adults: A cross-sectional analysis of the National Health and Nutrition Examination Survey 1999–2010, 2013–2014, 2017–2020
Zhang, R., Long, W., & Li, Y. (2026) · Tobacco Induced Diseases · doi:10.18332/tid/217959
“Tobacco smoke exposure was assessed by measuring serum cotinine, which serves as a proxy for both direct inhalation and passive inhalation of environmental tobacco smoke 11 .”
Comparative Effects of Cigarette and Hookah Smoking on Oral Microbiota Composition and Blood Indices in Young Adult Males
Alghofaili, F., Hussein, H. M., Najmuldeen, H. H. R., Tahsin, S. Y., Muhamad, A. H., Othman, A. J., Karim, K. F., Ali, A. O., & Karim, A. S. (2026) · FASEB BioAdvances · doi:10.1096/fba.2025-00296
Biomarker of exposure to nicotine-containing products - Saliva
Toolkit, P. (2026) · PhenX Toolkit · doi:10.82568/phenx_toolkit/091708
Biomarker of exposure to nicotine-containing products - Urine
Toolkit, P. (2026) · PhenX Toolkit · doi:10.82568/phenx_toolkit/091707
Biomarker of exposure to nicotine-containing products - Serum
Toolkit, P. (2026) · PhenX Toolkit · doi:10.82568/phenx_toolkit/091709
Expired Carbon Monoxide
Toolkit, P. (2026) · PhenX Toolkit · doi:10.82568/phenx_toolkit/720301
NNAL in Urine
Toolkit, P. (2026) · PhenX Toolkit · doi:10.82568/phenx_toolkit/720403
Social desirability and self-reported cigarette smoking among Lebanese adults
Ghostin, M., Gerges, C., Sacre, H., Malhab, S. B., Haddad, C., Hatem, R., Sakr, F., Eid, R., Chkayban, G., Karam, D., et al. (2026) · Discover Public Health · doi:10.1186/s12982-026-02204-6
“Moreover, using innovative or alternative data collection methods such as biomarker validation, indirect questioning, or digital behavior tracking would potentially reduce social desirability bias and help improve assessment accuracy [30].”
Respiratory symptoms and exercise responses among adult E‐cigarette users with and without obesity
Walsh, J. W., Beck, M., Hinton, A., Wagener, T. L., Lang, J. E., Wang, J. G., & Bhammar, D. M. (2026) · Physiological Reports · doi:10.14814/phy2.70993
“However, current smokers were excluded from participation, which was verified by exhaled carbon monoxide (Benowitz et al., 2020).”
A Meta-Analysis of Urinary Cotinine Cut-Off Concentrations in Children Under Five Years for Assessing Environmental Tobacco Smoke Exposure
Zain, S. M. S. M., Mohamad, N., Anual, Z. F., Shukor, I. H. A., & Azmi, W. N. F. W. (2026) · Tobacco Use Insights · doi:10.1177/1179173x261459432
“22,45 A wide range of urinary cotinine cut-off concentrations was identified across the included studies, reflecting substantial heterogeneity in exposure classification.”
Analytical Identification of Novel Furan Metabolites in Human Hepatocytes and Urine: Implications for Liver and Respiratory Disease Research
Vevang, K. R., Trinh, A., Schmitt, T. W., Zhao, Y., von Weymarn, L. B., Meier, E. M., Nomura, S. O., Robien, K., Wang, R., Yuan, J.-M., et al. (2026) · Chemical Research in Toxicology · doi:10.1021/acs.chemrestox.6c00222
Association between secondhand smoke exposure and hyperuricemia among never smokers: A cross-sectional analysis of NHANES data
Liang, Y., Zhou, T., Yang, A., Wang, D., Zhang, W., & Gong, W. (2026) · Tobacco Induced Diseases · doi:10.18332/tid/220846
“Among these, serum cotinine concentration serves as an objective and reliable biomarker for assessing exposure to tobacco smoke and associated health risks 14 .”
Insights into the validity of concurrent and retrospective maternal report of infant smoke exposure using biomarker-based validation
Micalizzi, L., Sokolovsky, A. W., Murphy, C. M., Knopik, V. S., & Risica, P. M. (2026) · Pediatric Research · doi:10.1038/s41390-026-05238-3
Evaluating cannabis–nicotine substitution and demand during nicotine cessation treatment in young adults: protocol for a prospective, remote 12-week nicotine cessation trial in the USA
Dowd, A. N., Baker, N. L., Koffarnus, M. N., Raiff, B. R., Tomko, R. L., Gray, K. M., & McClure, E. A. (2026) · BMJ Open · doi:10.1136/bmjopen-2025-110992
Influence of Magnesium Status on the Association of Tobacco Exposure With Depression in Old Patients With Heart Failure: A Cross‐Sectional Study of the NHANES Database
Liang, Y., Jiang, H., Zhong, Y., Qiu, S., Li, X., & Xie, P. (2026) · Cardiovascular Therapeutics · doi:10.1155/cdr/3372455 · Cited by 1
“…significant proximal metabolite of nicotine and is regarded as a trustworthy and sensitive indicator of tobacco smoke exposure within the past 72 h [33, 53], and therefore, cotinine has been recognized as a distinctive chemical reflecting an individual's degree of tobacco smoke exposure in recent…”
Influential
Pilot randomised controlled trial of an e-cigarette and tobacco use intervention for hospitalised youth
Masonbrink, A. R., Wooten, S., Yeh, H., Stancil, S. L., Miller, M. K., Wilson, K. M., Simon, T. D., Leventhal, A. M., & Catley, D. (2026) · Tobacco Control · doi:10.1136/tc-2025-060006
Trends in the accuracy of self-reported cigarette smoking in Canada
Guindon, G. E., Yu, S. D., & Anderson, L. N. (2026) · Nicotine & Tobacco Research · doi:10.1093/ntr/ntag172
Remote vs. In-Person Study Evaluation (RISE) Trial 1 of 3 to examine the impact of decentralized trial methods on accrual efficiency, retention, biospecimen capture, and treatment utilization: study protocol for a multi-center randomized controlled trial in the context of smoking cessation (RISE Above Smoking)
Hawk, L. W., Schnoll, R. A., Dahne, J., Carpenter, M. J., Cropsey, K. L., Wilding, G. E., Duerr, C., Allen, C. G., Nghiem, V. T., Shelton, R. C., et al. (2026) · Trials · doi:10.1186/s13063-026-09910-1
Age and sex modify the association between secondhand smoke exposure and self-reported asthma in school-aged children (6–11 years): a cross-sectional study from NHANES 2005–2020
Xiao, S., Hu, T., Du, C., Bai, L., Dong, K., Guo, W., & Jiang, X. (2026) · BMC Public Health · doi:10.1186/s12889-026-28663-9
“Cotinine, a nicotine metabolite, can signify if an individual is actively smoking or has been exposed to environmental tobacco smoke [14].”
Differentiating Factors Affecting the Initiation of Multiple Tobacco Product Use Among U.S. Adolescents and Young Adults: A Systematic Scoping Review
Frisbee, S., Misiewicz, R., Noonan, D., & Lipkus, I. (2026) · Journal of Child & Adolescent Substance Use · doi:10.1080/29973368.2026.2708751
“…be addressed by using more objec-tive measures, such as biochemical verification of nicotine exposure (e.g., cotinine or carbon monoxide testing) (Benowitz et al., 2020; SRNT Subcommittee on Biochemical Verification, 2002) or environmental assessments of secondhand smoke exposure (Office on…”
The associations between tobacco exposure and diarrhea within the National Health and Nutrition Examination Survey (NHANES)
Jiaheng, S. H. A. O., Huang, C., Chen, X., & Zhao, H. (2026) · Tobacco Induced Diseases · doi:10.18332/tid/224313
“Tobacco smoke is a highly complex aerosol containing over 4000 compounds 26 , and current assessments of tobacco exposure primarily rely on serum cotinine levels, a metabolite of nicotine 27 .”
Contingency Management for Smoking Cessation Among Adults Experiencing Homelessness
Gu, D., Chakravarty, D., Cuby, J., Hall, S., Stitzer, M. L., Kushel, M., Xia, F., & Vijayaraghavan, M. (2026) · JAMA Network Open · doi:10.1001/jamanetworkopen.2026.27917
Association between neutrophil-to-HDL cholesterol ratio and diabetic nephropathy in adults with diabetes mellitus
Zhou, Y., & Zhu, J. (2026) · Medicine · doi:10.1097/md.0000000000050146
“…included: BMI (kg/m 2 , continuous, computed from measured height/weight); smoking history (life-time consumption ≥ 100 cigarettes, binary) [17] ; alcohol use (≥12 drinks annually, binary) [18] ; hypertension (physician-diagnosed, antihypertensive medication use, or measured BP ≥ 130/80 mm…”
Effect of flavored on!® nicotine pouch products on smoking behaviors: A sequential, multiple assignment, randomized controlled trial
Karelitz, J. L., Rose, J. E., Kennedy, J. N., Freehauf, C., Willette, P. N., Cohen, G. A., Botts, D. R., Botts, T. L., Largo, E. G., Richter, N., et al. (2026) · Drug and Alcohol Dependence · doi:10.1016/j.drugalcdep.2026.113328
An Explainable and Uncertainty-Aware Machine Learning Framework for Automated Smoking Risk Assessment Using Clinical Health Indicators
Zahid, R. R., Alif, A. I., Sakib, S. A., Mim, M. A., Tanvir, M. A. H. A., & Hasib, A. (2026) · International Conference on Power, Electronics, Communications, Computing, and Intelligent Infrastructure (PECCII) · doi:10.1109/peccii70991.2026.11661991
“However, conventional methods rely on self-administered questionnaires and are prone to reporting bias, or on biochemical verification which is invasive and lacks scalability [6].”
Positive psychotherapy for smoking cessation enhanced with text messaging: a randomized controlled trial
Kahler, C. W., Cioe, P. A., Hoeppner, B. B., Strowger, M., Nalven, T., Spillane, N. S., Parks, A. C., Bock, B. C., & Brown, R. A. (2026) · Nicotine & Tobacco Research · doi:10.1093/ntr/ntag196
Redox Rewiring in Nicotine-Driven Gastric Carcinogenesis: Uncovering ROS-Dependent Oncogenic Circuits
Liu, X., Jiang, Q., Xie, B., Zhang, Z., Zhou, J., Zhou, T., & Wang, H. (2026) · Antioxidants and Redox Signaling · doi:10.1177/15230864261483986
Switching individuals in OUD treatment from cigarettes to the standardized research e-cigarette: a randomized waitlist-controlled cross-over trial
Streck, J. M., Regan, S., Chang, Y., Reyen, M., Sterling-Maisel, C., Cannistraro, J., Guerinot, J., Gouda, S., Nahvi, S., Wakeman, S. E., et al. (2026) · Nicotine & Tobacco Research · doi:10.1093/ntr/ntag205
Differences in ambulatory blood pressure and heart rate between smoking and abstinence periods among current smokers: A systematic review and meta-analysis
Akagi, Y., Arakawa, K., Sakima, A., Kabayama, M., Sugimoto, K., Akasaki, Y., Fukami, A., Sakata, S., Ryuno, H., Kadoya, H., et al. (2026) · Hypertension Research · doi:10.1038/s41440-026-02797-0

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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