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Preliminary Data: Exposure of Persons Aged greater than 4 Years to Tobacco Smoke -- United States, 1988-1991

The recent report of the U.S. Environmental Protection Agency on the respiratory health effects of passive smoking (1) and the known adverse effects of active smoking emphasize the need to quantify the exposure of the U.S. population to tobacco smoke. Measurements of cotinine (a nicotine metabolite) in serum, urine, and saliva have been used effectively to quantify exposure to tobacco smoke (2-10). As part of the Third National Health and Nutrition Examination Survey (NHANES III), CDC's National Center for Environmental Health and National Center for Health Statistics is measuring serum levels of cotinine to assess exposure to tobacco smoke by persons in the United States aged greater than or equal to 4 years. This report presents preliminary findings on the first 800 persons in this survey of tobacco-smoke exposure.

NHANES III is being conducted from 1988 through 1994 in 81 counties throughout the United States and consists of two national probability samples: one from October 1988 through October 1991 and the second from October 1991 through October 1994. For the two national samples in NHANES III, CDC is measuring serum cotinine levels for approximately 23,000 persons. NHANES III also includes questionnaire data on individual smoking and smokeless tobacco habits, smoking habits of persons in the household, and exposure to tobacco smoke at work.

CDC developed an isotope dilution-liquid chromatography-tandem mass spectrometry method (CDC, unpublished data) to measure serum cotinine at levels as low as 0.030 nanograms per milliliter (ng/mL). No known substances interfere with the analysis of cotinine using the tandem mass spectrometry procedure (i.e., the specificity of the analytic procedure for serum cotinine is extremely high). This analytic method allows quantitative measurement of both low levels of tobacco-smoke exposure from environmental tobacco smoke (ETS) and higher levels of exposure from active smoking.

Serum samples have been analyzed for cotinine for 800 persons aged 4-91 years in the NHANES III survey. All (100%) of the 800 persons tested had measurable levels of cotinine in their serum. The frequency distribution of these serum cotinine levels appears bimodal, with one group of persons having cotinine levels greater than 10-15 ng/mL and a second group with levels below 10-15 ng/mL. For the 800 persons tested, serum cotinine levels ranged from 0.030 to 650 ng/mL, a span of more than four orders of magnitude.

Reported by: Div of Health Examination Statistics, National Center for Health Statistics; Div of Environmental Health Laboratory Sciences, National Center for Environmental Health, CDC.

Editorial Note

Editorial Note: Cotinine in serum results from exposure to nicotine. The most common sources of nicotine exposure are active smoking and exposure to ETS. Appropriate interpretation of serum cotinine levels must also consider other nicotine sources including nicotine gum, nicotine dermal patches, chewing tobacco, and snuff.

The presence of cotinine in the serum of all 800 persons indicates at least some exposure to nicotine in each of the survey participants. Other investigators (7-9) have found that levels of serum cotinine greater than approximately 10-15 ng/mL characterize smokers, and serum cotinine levels less than this amount characterize nonsmokers. Serum cotinine levels below 10-15 ng/mL have been attributed to exposure to ETS (7-10). Further interpretation of these NHANES III serum cotinine levels must await analysis of the smoking questionnaire data in the survey.

The new analytic method for measuring serum cotinine and its application in NHANES III affords a rare opportunity to obtain objective estimates of exposure to tobacco smoke in a representative sample of the U.S. population aged greater than or equal to 4 years. In addition, substantial samples of persons in different racial/ethnic and age groups and persons of differing socioeconomic status in NHANES III will provide important data on exposure in these population groups.

Comparison of serum cotinine results of the first national sample in NHANES III with the second national sample in NHANES III and subsequent NHANES surveys will help in assessing the effectiveness of public health efforts to reduce exposure to tobacco smoke in the United States. CDC is continuing to analyze NHANES III serum samples for cotinine and will publish results of these analyses when the first national probability sample is completed.


  1. US Environmental Protection Agency. Respiratory health effects of passive smoking: lung cancer and other disorders. Washington, DC: US Environmental Protection Agency, Office of Health and Environmental Assessment, Office of Atmospheric and Indoor Air Programs, May 1990; publication no. EPA/600/6- 90/006F.

  2. Watts RR, Langone JJ, Knight GJ, Lewtas J. Cotinine analytical workshop report: consideration of analytical methods for determining cotinine in human body fluids as a measure of passive exposure to tobacco smoke. Environ Health Perspect 1990;84:173-82.

  3. Wall MA, Johnson J, Peyton J, Neal LB. Cotinine in the serum, saliva and urine of nonsmokers, passive smokers and active smokers. Am J Public Health 1988;78:699-701.

  4. Jarvis MJ, Russell MAH, Benowitz NL, Feyerabend C. Elimination of cotinine from body fluids: implications for noninvasive measurement of tobacco smoke exposure. Am J Public Health 1988;78:696-8.

  5. Haley NJ, Axelrad CM, Tilton KA. Validation of self-reported smoking behavior: biochemical analyses of cotinine and thiocyanate. Am J Public Health 1983;73:1204-7.

  6. Jarvis MJ, Tunstall-Pedoe H, Feyerabend C, Vesey C, Saloojee Y. Biochemical markers of smoke absorption and self reported exposure to passive smoking. J Epidemiol Community Health 1984;38:335-9.

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

  8. Woodward M, Tunstall-Pedoe H. An iterative technique for identifying smoking deceivers with application to the Scottish Heart Health Study. Prev Med 1992;21:88-97.

  9. Jarvis MJ, Tunstall-Pedoe H, Feyerabend C, Vesey C, Saloojee Y. Comparison of tests used to distinguish smokers from nonsmokers. Am J Public Health 1987;77:1435-8.

  10. Woodward M, Tunstall-Pedoe H, Smith WCS, Tavendale R. Smoking characteristics and inhalation biochemistry in the Scottish population. J Clin Epidemiol 1991;44:1405-10.

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