Current research on cigarette toxicity: critical appraisal in view of clinical laboratory


  • Prajwal Gyawali School of Biomedical Sciences, School of Community Health, Charles Sturt University, New South Wales
  • Victor Maduabuchi Oguoma School of Psychological and Clinical Sciences, Charles Darwin University, Northern Territory



Biomarkers, Cigarette, Toxicity testing


Cigarette smoking has been implicated as a potential risk factor for development and progression of chronic obstructive pulmonary disease (COPD) and cardiovascular disease (CVD), including ischemic heart disease. Although, several methods are in existence to measuring cigarette toxicity, evidence regarding adoption of a gold standard technique is still imprecise. In this study, we reviewed articles describing methods of measuring cigarette toxicity in relation to clinical laboratory practice.  A critical analysis of the benefits and limitations of each method in relation to low-middle income countries is discussed.


Zevin S, Saunders S, Gourlay SG, Jacob P, Benowitz NL. Cardiovascular effects of carbon monoxide and cigarette smoking. J Am Coll Cardiol. 2001;38:1633-8.

Barnes P, Shapiro S, Pauwels R. Chronic obstructive pulmonary disease: molecular and cellularmechanisms. European Respiratory Journal. 2003;22:672-88.

Wald NJ, Hackshaw AK. Cigarette smoking: an epidemiological overview. Br Med Bull. 1996;52:3-11.

Gajalakshmi C, Jha P, Ranson K, Nguyen S, Mundial B. Global patterns of smoking and smoking-attributable mortality. Tobacco control in developing countries: Oxford University Press. 2000;9-39.

WHO. WHO Report on the global tobacco epidemic: Enforcing bans on tobacco advertising, promotion and sponsorship. Geneva: World Health Organisation. 2013.

Benowitz NL. Nicotine safety and toxicity: Oxford University Press. 1998.

Facchini FS, Hollenbeck CB, Jeppesen J, Chen YD, Reaven GM. Insulin resistance and cigarette smoking. Lancet. 1992;339:1128-30.

Scollo M, Winstanley M. The health effectes of active smoking. Tobacco in Australia: Facts and issues. Melbourne: Cancer Council Victoria. 2012.

Carnevali S, Petruzzelli S, Longoni B, Vanacore R, Barale R, Cipollini M, et al. Cigarette smoke extract induces oxidative stress and apoptosis in human lung fibroblasts. American Journal of Physiology-Lung Cellular and Molecular Physiology. 2003;284:L955-63.

Pryor WA, Stone K. Oxidants in cigarette smoke radicals, hydrogen peroxide, peroxynitrate, and peroxynitritea. Ann N Y Acad Sci. 1993;686:12-27.

Rahman I, MacNee W. Lung glutathione and oxidative stress: implications in cigarette smoke-induced airway disease. American Journal of Physiology-Lung Cellular and Molecular Physiology. 1999;277:L1067-L88.

Montuschi P, Collins JV, Ciabattoni G, Lazzeri N, Corradi M, Kharitonov SA, et al. Exhaled 8-isoprostane as an in vivo biomarker of lung oxidative stress in patients with COPD and healthy smokers. Am J Respir Crit Care Med. 2000;162:1175-7.

Hulea S, Olinescu R, Nita S, Crocnan D, Kummerow F. Cigarette smoking causes biochemical changes in blood that are suggestive of oxidative stress: a case-control study. Journal of environmental pathology, toxicology and oncology: official organ of the International Society for Environmental Toxicology and Cancer. 1994;14:173-80.

Tappia PS, Troughton KL, Langley-Evans SC, Grimble RF. Cigarette smoking influences cytokine production and antioxidant defences. Clinical science (London, England : 1979). 1995;88:485-9.

Arnson Y, Shoenfeld Y, Amital H. Effects of tobacco smoke on immunity, inflammation and autoimmunity. Journal of autoimmunity. 2010;34:J258-65.

Yanbaeva DG, Dentener MA, Creutzberg EC, Wesseling G, Wouters EF. Systemic effects of smoking. Chest. 2007;131:1557-66.

Patrick DL, Cheadle A, Thompson DC, Diehr P, Koepsell T, Kinne S. The validity of self-reported smoking: a review and meta-analysis. Am J Public Health. 1994;84:1086-93.

Coultas DB, Howard CA, Peake GT, Skipper BJ, Samet JM. Discrepancies between self-reported and validated cigarette smoking in a community survey of New Mexico Hispanics. Am Rev Respir Dis. 1988;137:810-4.

El-Khoury JM, Wang S. Recent advances in MS methods for nicotine and metabolite analysis in human matrices: clinical perspectives. Bioanalysis. 2014;6:2171-83.

Florescu A, Ferrence R, Einarson T, Selby P, Soldin O, Koren G. Methods for quantification of exposure to cigarette smoking and environmental tobacco smoke: focus on developmental toxicology. Ther Drug Monit. 2009;31:14.

Akins JR, Bernert JT, Jr., Covey TR, Gunter EW, Hannon WH, Miller BB, et al. Development and validation of sensitive method for determination of serum cotinine in smokers and nonsmokers by liquid chromatography/atmospheric pressure ionization tandem mass spectrometry. Clin Chem. 1997;43:2281+.

Petersen GO, Leite CE, Chatkin JM, Thiesen FV. Cotinine as a biomarker of tobacco exposure: Development of a HPLC method and comparison of matrices. J Sep Sci. 2010;33:516-21.

Okayasu I, Ohnishi H, Sarandi I, Shojima J, Komatsu J, Oritsu M, et al. Significant Increase of Prostaglandin E-Major Urinary Metabolite in Male Smokers: A Screening Study of Age and Gender Differences Using a Simple Radioimmunoassay. J Clin Lab Anal. 2014;28:32-41.

Olivieri M, Poli A, Zuccaro P, Ferrari M, Lampronti G, De Marco R, et al. Tobacco smoke exposure and serum cotinine in a random sample of adults living in Verona, Italy. Arch Environ Health. 2002;57:355-9.

Antunes MV, da Silva CFR, Finger MA, Moore C, Linden R. Correlation Analysis Between Cotinine Hair Concentrations From Active Smokers and Nicotine Intake and Dependence. Therapeutic drug monitoring. 2015;37:405-7.

Barker SJ, Curry J, Redford D, Morgan S. Measurement of Carboxyhemoglobin and Methemoglobin by Pulse OximetryA Human Volunteer Study. The Journal of the American Society of Anesthesiologists. 2006;105:892-7.

Jarman KH. Method and apparatus for improved photoplethysmographic monitoring of oxyhemoglobin, deoxyhemoglobin, carboxyhemoglobin and methemoglobin. Google Patents; 1998.

Middleton ET, Morice AH. Breath carbon monoxide as an indication of smoking habit. Chest. 2000;117:758-63.

Vogt TM, Selvin S, Widdowson G, Hulley SB. Expired air carbon monoxide and serum thiocyanate as objective measures of cigarette exposure. Am J Public Health. 1977;67:545-9.

Stookey G, Katz B, Olson B, Drook C, Cohen S. Evaluation of biochemical validation measures in determination of smoking status. J Dent Res. 1987;66:1597-601.

Glasgow RE, Mullooly JP, Vogt TM, Stevens VJ, Lichtenstein E, Hollis JF, et al. Biochemical validation of smoking status: pros, cons, and data from four low-intensity intervention trials. Addict Behav. 1993;18:511-27.

Hoffmann D, Hoffmann I. The changing cigarette: chemical studies and bioassays. Smoking and tobacco control monograph. 2001;13:159-92.

Zhang Q, Li L, Smith M, Guo Y, Whitlock G, Bian Z, et al. Exhaled carbon monoxide and its associations with smoking, indoor household air pollution and chronic respiratory diseases among 512 000 Chinese adults. Int J Epidemiol. 2013;42:1464-75.

Buha A, Vaseashta A, Bulat Z, Matović V. Carboxyhemoglobin in blood of smokers and non-smokers determined by gas chromatography with thermal conductivity detector. NATO Science for Peace and Security Series B: Physics and Biophysics. 2013;163-71.

Imbriani M, Melotti A, Ghittori S. Methemoglobin and carboxyhemoglobin levels in smokers and non-smokers. G Ital Med Lav. 1987;9:11-4.

Theophilus EH, Coggins CRE, Chen P, Schmidt E, Borgerding MF. Magnitudes of biomarker reductions in response to controlled reductions in cigarettes smoked per day: A one-week clinical confinement study. Regul Toxicol Pharmacol. 2015;71:225-34.

Zhou J, Yan X, Guo F, Sun N, Qian Z, Ding D. Effects of cigarette smoking and smoking cessation on plasma constituents and enzyme activities related to oxidative stress. Biomedical and environmental sciences: BES. 2000;13:44-55.

Morrow JD, Frei B, Longmire AW, Gaziano JM, Lynch SM, Shyr Y, et al. Increase in circulating products of lipid peroxidation (F2-isoprostanes) in smokers—smoking as a cause of oxidative damage. N Engl J Med. 1995;332:1198-203.

Mendall M, Patel P, Asante M, Ballam L, Morris J, Strachan D, et al. Relation of serum cytokine concentrations to cardiovascular risk factors and coronary heart disease. Heart. 1997;78:273-7.

Ambrose JA, Barua RS. The pathophysiology of cigarette smoking and cardiovascular disease: An update. J Am Coll Cardiol. 2004;43:1731-7.

Tracy RP, Psaty BM, Macy E, Bovill EG, Cushman M, Cornell ES, et al. Lifetime Smoking Exposure Affects the Association of C-Reactive Protein with Cardiovascular Disease Risk Factors and Subclinical Disease in Healthy Elderly Subjects. Arterioscler Thromb Vasc Biol. 1997;17:2167-76.

Bermudez EA, Rifai N, Buring JE, Manson JE, Ridker PM. Relation between markers of systemic vascular inflammation and smoking in women. Am J Cardiol. 2002;89:1117-9.

Mazzone A, Cusa C, Mazzucchelli I, Vezzoli M, Ottini E, Ghio S, et al. Cigarette smoking and hypertension influence nitric oxide release and plasma levels of adhesion molecules. Clin Chem Lab Med. 2001;39:822-6.

Rodrigues FMM, Ramos D, Xavier RF, Ito JT, De Souza AP, Fernandes RA, et al. Nasal and systemic inflammatory profile after short term smoking cessation. Respir Med. 2014;108:999-1006.

Celermajer D, Sorensen K, Georgakopoulos D, Bull C, Thomas O, Robinson J, et al. Cigarette smoking is associated with dose-related and potentially reversible impairment of endothelium-dependent dilation in healthy young adults. Circulation. 1993;88:2149-55.

Barua RS, Ambrose JA, Eales-Reynolds L-J, DeVoe MC, Zervas JG, Saha DC. Dysfunctional endothelial nitric oxide biosynthesis in healthy smokers with impaired endothelium-dependent vasodilatation. Circulation. 2001;104:1905-10.

Barua RS, Ambrose JA, Srivastava S, DeVoe MC, Eales-Reynolds L-J. Reactive oxygen species are involved in smoking-induced dysfunction of nitric oxide biosynthesis and upregulation of endothelial nitric oxide synthase an in vitro demonstration in human coronary artery endothelial cells. Circulation. 2003;107:2342-7.

Kojda G, Harrison D. Interactions between NO and reactive oxygen species: pathophysiological importance in atherosclerosis, hypertension, diabetes and heart failure. Cardiovasc Res. 1999;43:652-71.

Napoli C, de Nigris F, Williams-Ignarro S, Pignalosa O, Sica V, Ignarro LJ. Nitric oxide and atherosclerosis: an update. Nitric Oxide. 2006;15:265-79.

Yu KJ, Zhang MJ, Li Y, Wang RT. Increased whole blood viscosity associated with arterial stiffness in patients with non-alcoholic fatty liver disease. Journal of Gastroenterology and Hepatology (Australia). 2014;29:540-4.

de Simone G, Devereux RB, Chinali M, Best LG, Lee ET, Welty TK, et al. Association of blood pressure with blood viscosity in American Indians. Hypertension. 2005;45:625-30.

Zhang L, Pu K, Zhang SY, Ren WQ. Blood rheological properties are strongly related to the metabolic syndrome in middle-aged Chinese. Int J Cardiol. 2006;112:229-33.

Ernst E, Matria A, Schmölzl C, Magyarosy I. Dose-effect relationship between smoking and blood rheology. Br J Haematol. 1987;65:485-7.

Ernst E, Matrai A. Abstention from chronic cigarette smoking normalizes blood rheology. Atherosclerosis. 1987;64:75-7.

Feher MD, Rampling MW, Brown J, Robinson R, Richmond W, Cholerton S, et al. Acute Changes in Atherogenic and Thrombogenic Factors with Cessation of Smoking. J R Soc Med. 1990;83:146-8.

Bogar L. Hemorheology and hypertension: Not “chicken or egg” but two chickens from similar eggs. Clin Hemorheol Microcirc. 2002;26:81.

Belch J, McArdle B, Burns P, Lowe G, Forbes C. The effects of acute smoking on platelet behaviour, fibrinolysis and haemorheology in habitual smokers. Thromb Haemost. 1984;51:6-8.

Mikhailidis D, Barradas M, Nystrom M, Jeremy J. Cigarette smoking increases white blood cell aggregation in whole blood. J R Soc Med. 1993;86:680.

Benowitz NL. The use of biologic fluid samples in assessing tobacco smoke consumption. . In: Grabowski J, Bell CS, editors. Measurement in the analysis and treatment of smoking behavior. Washington, DC: U.S. Government Printing Office. : National Institute on Drug Abuse. 1983;6-26.

Peach H, Ellard GA, Jenner PJ, Morris RW. A simple, inexpensive urine test of smoking. Thorax. 1985;40:351-7.

Ubbink JB, Lagendijk J, Vermaak WH. Simple high-performance liquid chromatographic method to verify the direct barbituric acid assay for urinary cotinine. Journal of Chromatography B: Biomedical Sciences and Applications. 1993;620:254-9.

Davis RA, Stiles MF, Reynolds JH. Dietary nicotine: a source of urinary cotinine. Food Chem Toxicol. 1991;29:821-7.

Benowitz NL, Kuyt F, Jacob P. Circadian blood nicotine concentrations during cigarette smoking. Clin Pharmacol Ther. 1982;32:758-64.

Davis RA, Curvall M. Determination of nicotine and its metabolites in biological fluids in vivo studies. In: Gorrod JW, Jacob P, editors. Analytical determination of nicotine and related compounds and their metabolites. Amsterdam: Elsevier. 1999;583-644.

Benowitz NL, Jacob Iii P, Ahijevych K, Jarvis MJ, Hall S, LeHouezec J, et al. Biochemical verification of tobacco use and cessation. Nicotine Tob Res. 2002;4:149-59.

Benowitz NL, Kuyt F, Jacob P, Jones RT, Osman AL. Cotinine disposition and effects. Clin Pharmacol Ther. 1983;34:604-11.

Perezstable EJ, Benowitz NL, Marin G. Is Serum Cotinine a Better Measure of Cigarette-Smoking Than Self-Report? Prev Med. 1995;24:171-9.

Feyerabend C, Russell M. A rapid gas‐liquid chromatographic method for the determination of cotinine and nicotine in biological fluids. J Pharm Pharmacol. 1990;42:450-2.

Acosta MC, Buchhalter AR, Breland AB, Hamilton DC, Eissenberg T. Urine cotinine as an index of smoking status in smokers during 96-hr abstinence: comparison between gas chromatography/mass spectrometry and immunoassay test strips. Nicotine Tob Res. 2004;6:615-20.

Cummings SR, Richard RJ. Optimum cutoff points for biochemical validation of smoking status. Am J Public Health. 1988;78:574-5.

Wagenknecht LE, Burke GL, Perkins LL, Haley NJ, Friedman GD. Misclassification of smoking status in the CARDIA study: a comparison of self-report with serum cotinine levels. Am J Public Health. 1992;82:33-6.

Etter J-F, Due TV, Perneger TV. Saliva cotinine levels in smokers and nonsmokers. Am J Epidemiol. 2000;151:251-8.

Knuutinen A, Kokkonen N, Risteli J, Vähäkangas K, Kallioinen M, Salo T, et al. Smoking affects collagen synthesis and extracellular matrix turnover in human skin. Br J Dermatol. 2002;146:588-94.

Overbeek SA, Braber S, Koelink PJ, Henricks PAJ, Mortaz E, LoTam Loi AT, et al. Cigarette Smoke-Induced Collagen Destruction; Key to Chronic Neutrophilic Airway Inflammation? PLoS ONE. 2013;8.

Estanol MV, Crisp CC, Oakley SH, Kleeman SD, Fellner AN, Pauls RN. Systemic markers of collagen metabolism and vitamin C in smokers and non-smokers with pelvic organ prolapse. European Journal of Obstetrics & Gynecology and Reproductive Biology. 2015;184:58-64.

Morita A. Tobacco smoke causes premature skin aging. J Dermatol Sci. 2007;48:169-75.

Marinucci L, Bodo M, Balloni S, Locci P, Baroni T. Sub-Toxic Nicotine Concentrations Affect Extracellular Matrix and Growth Factor Signaling Gene Expressions in Human Osteoblasts. J Cell Physiol. 2014;229:2038-48.

Vikman P, Xu C-B, Edvinsson L. Lipid-soluble cigarette smoking particles induce expression of inflammatory and extracellular-matrix-related genes in rat cerebral arteries. Vascular health and risk management. 2009;5:333.

Wang H, Ren Y, McLuckey MN, Manicke NE, Park J, Zheng L, et al. Direct quantitative analysis of nicotine alkaloids from biofluid samples using paper spray mass spectrometry. Analytical chemistry. 2013;85:11540-4.

Florescu A, Ferrence R, Einarson T, Selby P, Soldin O, Koren G. Methods for quantification of exposure to cigarette smoking and environmental tobacco smoke: focus on developmental toxicology. Ther Drug Monit. 2009;31:14-30.

Stepanov I, Hecht SS, Lindgren B, Jacob P, 3rd, Wilson M, Benowitz NL. Relationship of human toenail nicotine, cotinine, and 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol to levels of these biomarkers in plasma and urine. Cancer Epidemiol Biomarkers Prev. 2007;16:1382-6.

Stepanov I, Feuer R, Jensen J, Hatsukami D, Hecht SS. Mass spectrometric quantitation of nicotine, cotinine, and 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol in human toenails. Cancer Epidemiol Biomarkers Prev. 2006;15:2378-83.

Al-Delaimy WK, Willett WC. Measurement of tobacco smoke exposure: comparison of toenail nicotine biomarkers and self-reports. Cancer Epidemiol Biomarkers Prev. 2008;17:1255-61.

Dong MW. The Essence of Modern HPLC: Advantages, Limitations, Fundamentals, and Opportunities. LCGC North Am. 2013;31.

Koster RA, Alffenaar JW, Greijdanus B, VanDernagel JE, Uges DR. Fast and highly selective LC-MS/MS screening for THC and 16 other abused drugs and metabolites in human hair to monitor patients for drug abuse. Ther Drug Monit. 2014;36:234-43.

Piller M, Gilch G, Scherer G, Scherer M. Simple, fast and sensitive LC-MS/MS analysis for the simultaneous quantification of nicotine and 10 of its major metabolites. Journal of chromatography B, Analytical technologies in the biomedical and life sciences. 2014;951-952:7-15.

Haustein KO, Krause J, Haustein H, Rasmussen T, Cort N. Effects of cigarette smoking or nicotine replacement on cardiovascular risk factors and parameters of haemorheology. J Intern Med. 2002;252:130-9.

Galea G, Davidson RJ. Haematological and haemorheological changes associated with cigarette smoking. J Clin Pathol. 1985;38:978-84.

Pezzuto A, Pietrangeli V. Respiratory Function Tests and CEA Level Monitoring of Patients Undergoing Smoking Cessation Treatment. Journal of Smoking Cessation. 2011;6:138-43.




How to Cite

Gyawali, P., & Oguoma, V. M. (2017). Current research on cigarette toxicity: critical appraisal in view of clinical laboratory. International Journal of Research in Medical Sciences, 4(6), 1785–1793.



Review Articles