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Assessing secondhand smoke using biological markers
  1. Erika Avila-Tang1,
  2. Wael K Al-Delaimy2,
  3. David L Ashley3,
  4. Neal Benowitz4,
  5. John T Bernert3,
  6. Sungroul Kim5,
  7. Jonathan M Samet6,
  8. Stephen S Hecht7
  1. 1Department of Epidemiology, Institute for Global Tobacco Control, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
  2. 2Department of Family and Preventive Medicine, University of California, San Diego, La Jolla, California, USA
  3. 3National Center for Environmental Health, Centers for Disease Control and Prevention, Georgia, Atlanta, USA
  4. 4Division of Clinical Pharmacology, Departments of Medicine and Bioengineering & Therapeutic Sciences, University of California San Francisco, San Francisco, California, USA
  5. 5Department of Environmental Health Sciences, SoonChunHyang University, Asan, Republic of Korea
  6. 6Department of Preventive Medicine, University of Southern California, Los Angeles, California, USA
  7. 7Cancer Center, University of Minnesota, Minneapolis, Minnesota, USA
  1. Correspondence to Dr Erika Avila-Tang, Institute for Global Tobacco Control, Johns Hopkins Bloomberg School of Public Health, 2213 McElderry Street, 4th Floor, Baltimore, MD 21205, USA; etang{at}


Secondhand smoke exposure (SHSe) is a known cause of many adverse health effects in adults and children. Increasingly, SHSe assessment is an element of tobacco control research and implementation worldwide. In spite of decades of development of approaches to assess SHSe, there are still unresolved methodological issues; therefore, a multidisciplinary expert meeting was held to catalogue the approaches to assess SHSe and with the goal of providing a set of uniform methods for future use by investigators and thereby facilitate comparisons of findings across studies. The meeting, held at Johns Hopkins, in Baltimore, Maryland, USA, was supported by the Flight Attendant Medical Research Institute (FAMRI). A series of articles were developed to summarise what is known about self-reported, environmental and biological SHSe measurements. Non-smokers inhale toxicants in SHS, which are mainly products of combustion of organic materials and are not specific to tobacco smoke exposure. Biomarkers specific to SHSe are nicotine and its metabolites (eg, cotinine), and metabolites of 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone (NNK). Cotinine is the preferred blood, saliva and urine biomarker for SHSe. Cotinine and nicotine can also be measured in hair and toenails. NNAL (4-[methylnitrosamino]-1-[3-pyridyl]-1-butanol), a metabolite of NNK, can be determined in the urine of SHS-exposed non-smokers. The selection of a particular biomarker of SHSe and the analytic biological medium depends on the scientific or public health question of interest, study design and setting, subjects, and funding. This manuscript summarises the scientific evidence on the use of biomarkers to measure SHSe, analytical methods, biological matrices and their interpretation.

  • Secondhand smoke exposure
  • questionnaires
  • biological markers
  • environmental exposure
  • validation
  • surveillance and monitoring
  • prevalence
  • human rights
  • secondhand smoke
  • smoking caused disease
  • environmental tobacco smoke
  • harm reduction
  • product analysis
  • carcinogens
  • global health
  • litigation
  • carcinogens

This is an open-access article distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits use, distribution, and reproduction in any medium, provided the original work is properly cited, the use is non commercial and is otherwise in compliance with the license. See: and

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  • Funding This work was supported by the Flight Attendant Medical Research Institute's grant for the Centers of Excellence at Johns Hopkins; the University of California, San Francisco Bland Lane; and the American Academy of Pediatrics Julius B Richmond. The funding organisation had no role in the preparation of the manuscripts.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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