160 - New Extremely High Urine Cotinine Levels in Adolescents Who Vape Nicotine — Massachusetts, January 2023-January 2025

Publication Number: 1150.160

Dinah Sher Gongora, Boston Children's Hospital, Boston, MA, United States; Emily Nields, Boston Children's Hospital, Exeter, NH, United States; Sharon Levy, Boston Children's Hospital, Boston, MA, United States; Elissa R. Weitzman, Boston Children's Hospital, and Harvard Medical School, Brookline, MA, United States

Background: FDA-Unauthorized e-cigarettes remain illegal yet widely available, with ongoing product updates. We report a sudden increase in urinary cotinine levels among adolescents presenting for substance use disorder (SUD) treatment beginning in October 2024.

Objective: To quantify cotinine concentrations in urine samples collected from youth enrolled in a SUD treatment program between January 1, 2023, and January 31, 2025.

Design/Methods: Urine cotinine was quantified via HPLC-MS/MS with HILIC separation. Adolescents with "extremely high" (>4000 ng/mL) vs "typical" positive (>4- < 4000 ng/mL) levels were compared using medical record data. A Bayesian change-point model (MCMC, random effects; standardized time and cotinine) identified trajectory shifts. Marginal means pre/post change point were estimated using a linear mixed-effects model. The study was IRB-exempt.

Results: Among 157 adolescents (mean age 16.5 years), 1913 urine samples were collected over an average 7-month follow-up. Most participants were male (73.2%), White (63.1%), and non-Hispanic (75.2%); 96.8% used e-cigarettes, and 12% used other nicotine products. Twenty-six (16%) had ≥1 sample >4000 ng/ml. Cotinine levels rose sharply in October 2024 (β₂ = 4.58, 95% HPD [3.63, 5.47]) after a stable period (β₁ = 0.04, 95% HPD [-0.04, 0.12]). Marginal monthly maximum cotinine increased from 1061.8 ng/mL (95% CI: 865.3-1258.2) to 2959.2 ng/mL (95% CI: 2689.7-3228.6).

Conclusion(s): Average and maximum urine cotinine concentrations abruptly increased after October 2024, suggesting a new or altered exposure among youth who use nicotine, which might be observed if products with higher nicotine concentrations or new additives that make nicotine more bioavailable or engender more frequent or intense use became available.  For example, cooling flavors are popular and associated with nicotine dependence (2).  Synthetic cooling additives are common, make e-cigarettes more appealing (3), and are not detected as flavor (4). Nicotine content in disposable e-cigarettes rose dramatically from 2019-2024 (5). Addition of coolants that increase nicotine absorption could explain our finding and would be consistent with historical tobacco industry practice of innovating products to deliver more nicotine. We call for immediate elimination of illegal nicotine product importation, removal of existing illegal and unregulated nicotine products, and transparent and informative labeling.

Observed Cotinine Concentration Over Time with Model-Derived Change Point - Jan 2023-Jan 2025