Am J Perinatol 2022; 39(15): 1634-1642
DOI: 10.1055/s-0041-1736287
Short Communication

Handwashing Results in Incomplete Nicotine Removal from Fingers of Individuals who Smoke: A Randomized Controlled Experiment

1   Department of Family and Community Medicine, The University of Texas Health Science Center at Houston (UTHealth), McGovern Medical School, Houston, Texas
Angela L. Stotts
2   Department of Family and Community Medicine, Department of Psychiatry and Behavioral Sciences, The University of Texas Health Science Center at Houston (UTHealth), McGovern Medical School, Houston, Texas
Robert Suchting
3   Department of Psychiatry and Behavioral Sciences, UTHealth, McGovern Medical School, Houston, Texas
Amir M. Khan
4   Department of Pediatrics, The University of Texas Health Science Center at Houston (UTHealth), McGovern Medical School, Houston, Texas
Michelle R. Klawans
5   Department of Family and Community Medicine, The University of Texas Health Science Center at Houston (UTHealth), McGovern Medical School, Houston, Texas
Charles Green
6   Department of Pediatrics, Center for Clinical Research and Evidence-Based Medicine, The University of Texas Health Science Center at Houston (UTHealth), McGovern Medical School, Houston, Texas
Eunha Hoh
7   Division of Environmental Health, School of Public Health, San Diego State University, San Diego, California
Melbourne F. Hovell
8   Center for Behavioral Epidemiology and Community Health, Graduate School of Public Health, Division of Health Promotion and Behavioral Science, San Diego State University, San Diego, California
Georg E. Matt
9   Department of Psychology, San Diego State University, San Diego, California
Penelope J. E. Quintana
10   Division of Environmental Health, School of Public Health, San Diego State University, San Diego, California
› Author Affiliations


Objective Tobacco residue, also known as third-hand smoke (THS), contains toxicants and lingers in dust and on surfaces and clothes. THS also remains on hands of individuals who smoke, with potential transfer to infants during visitation while infants are hospitalized in neonatal intensive care units (NICUs), raising concerns (e.g., hindered respiratory development) for vulnerable infants. Previously unexplored, this study tested handwashing (HW) and sanitization efficacy for finger-nicotine removal in a sample of adults who smoked and were visiting infants in an NICU.

Study Design A cross-sectional sample was recruited to complete an interview, carbon monoxide breath samples, and three nicotine wipes of separate fingers (thumb, index, and middle). Eligible participants (n = 14) reported current smoking (verified with breath samples) and were randomly assigned to 30 seconds of HW (n = 7) or alcohol-based sanitization (n = 7), with the order of finger wipes both counterbalanced and randomly assigned. After randomization, the first finger was wiped for nicotine. Participants then washed or sanitized their hands and finger two was wiped 5 minutes later. An interview assessing tobacco/nicotine use and exposure was then administered, followed by a second breath sample and the final finger wipe (40–60 minutes after washing/sanitizing).

Results Generalized linear mixed models found that HW was more effective than sanitizer for nicotine removal but failed to completely remove nicotine.

Conclusions Without proper protections (e.g., wearing gloves and gowns), NICU visitors who smoke may inadvertently expose infants to THS. Research on cleaning protocols are needed to protect vulnerable medical populations from THS and associated risks.

Key Points

  • NICU infants may be exposed to THS via visitors.

  • THS is not eliminated by HW or sanitizing.

  • THS removal protections for NICU infants are needed.


This work was supported by the Eunice Kennedy Shriver National Institute of Child Health & Human Development (1R03HD088847; PI: T.F.N.) at the U.S. National Institutes of Health and Department of Health and Human Services. This work was supported in part by the National Heart, Lung, and Blood Institute (R01 HL107404, PI: A.L.S.) at the U.S. National Institutes of Health and Department of Health and Human Services.

Publication History

Received: 09 June 2021

Accepted: 01 September 2021

Article published online:
11 October 2021

© 2021. Thieme. All rights reserved.

Thieme Medical Publishers, Inc.
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  • References

  • 1 Matt GE, Quintana PJ, Destaillats H. et al. Thirdhand tobacco smoke: emerging evidence and arguments for a multidisciplinary research agenda. Environ Health Perspect 2011; 119 (09) 1218-1226
  • 2 Quintana PJE, Hoh E, Dodder NG. et al. Nicotine levels in silicone wristband samplers worn by children exposed to secondhand smoke and electronic cigarette vapor are highly correlated with child's urinary cotinine. J Expo Sci Environ Epidemiol 2019; 29 (06) 733-741
  • 3 Northrup TF, Stotts AL, Suchting R. et al. Medical staff contributions to thirdhand smoke contamination in a neonatal intensive care unit. Tob Induc Dis 2019; 17: 37
  • 4 Mahabee-Gittens EM, Merianos AL, Matt GE. Preliminary evidence that high levels of nicotine on children's hands may contribute to overall tobacco smoke exposure. Tob Control 2018; 27 (02) 217-219
  • 5 Northrup TF, Khan AM, Jacob III P. et al. Thirdhand smoke contamination in hospital settings: assessing exposure risk for vulnerable paediatric patients. Tob Control 2016; 25 (06) 619-623
  • 6 Bekö G, Morrison G, Weschler CJ. et al. Measurements of dermal uptake of nicotine directly from air and clothing. Indoor Air 2017; 27 (02) 427-433
  • 7 Northrup TF, Jacob III P, Benowitz NL. et al. Thirdhand smoke: state of the science and a call for policy expansion. Public Health Rep 2016; 131 (02) 233-238
  • 8 Drehmer JE, Walters BH, Nabi-Burza E, Winickoff JP. Guidance for the clinical management of thirdhand smoke exposure in the child health care setting. J Clin Outcomes Manag 2017; 24 (12) 551-559
  • 9 Hang B, Wang P, Zhao Y. et al. Adverse health effects of thirdhand smoke: from cell to animal models. Int J Mol Sci 2017; 18 (05) 932-939
  • 10 Díez-Izquierdo A, Cassanello-Peñarroya P, Lidón-Moyano C, Matilla-Santander N, Balaguer A, Martínez-Sánchez JM. Update on thirdhand smoke: a comprehensive systematic review. Environ Res 2018; 167: 341-371
  • 11 Figueiró LR, Linden R, Ziulkoski AL, Dantas DCM. Cellular effects of thirdhand tobacco smoke from smokers' homes. Toxicol Mech Methods 2018; 28 (04) 243-251
  • 12 Martins-Green M, Adhami N, Frankos M. et al. Cigarette smoke toxins deposited on surfaces: implications for human health. PLoS One 2014; 9 (01) e86391
  • 13 Bahl V, Shim HJ, Jacob III P, Dias K, Schick SF, Talbot P. Thirdhand smoke: Chemical dynamics, cytotoxicity, and genotoxicity in outdoor and indoor environments. Toxicol In Vitro 2016; 32: 220-231
  • 14 Prins JM, Wang Y. Quantitative proteomic analysis revealed N′-nitrosonornicotine-induced down-regulation of nonmuscle myosin II and reduced cell migration in cultured human skin fibroblast cells. J Proteome Res 2013; 12 (03) 1282-1288
  • 15 Rehan VK, Sakurai R, Torday JS. Thirdhand smoke: a new dimension to the effects of cigarette smoke on the developing lung. Am J Physiol Lung Cell Mol Physiol 2011; 301 (01) L1-L8
  • 16 Jung JW, Ju YS, Kang HR. Association between parental smoking behavior and children's respiratory morbidity: 5-year study in an urban city of South Korea. Pediatr Pulmonol 2012; 47 (04) 338-345
  • 17 Northrup TF, Stotts AL, Suchting R. et al. Thirdhand smoke contamination and infant nicotine exposure in a neonatal intensive care unit: an observational study. Nicotine Tob Res 2021; 23 (02) 373-382
  • 18 Vohr B. Long-term outcomes of moderately preterm, late preterm, and early term infants. Clin Perinatol 2013; 40 (04) 739-751
  • 19 Crump C, Winkleby MA, Sundquist J, Sundquist K. Prevalence of survival without major comorbidities among adults born prematurely. JAMA 2019; 322 (16) 1580-1588
  • 20 Koumbourlis AC, Motoyama EK, Mutich RL, Mallory GB, Walczak SA, Fertal K. Longitudinal follow-up of lung function from childhood to adolescence in prematurely born patients with neonatal chronic lung disease. Pediatr Pulmonol 1996; 21 (01) 28-34
  • 21 Martin JA, Hamilton BE, Sutton PD, Ventura SJ, Menacker F, Munson ML. Births: final data for 2003. Natl Vital Stat Rep 2005; 54 (02) 1-116
  • 22 Villamor-Martínez E, Pierro M, Cavallaro G, Mosca F, Villamor E. Mother's own milk and bronchopulmonary dysplasia: a systematic review and meta-analysis. Front Pediatr 2019; 7: 224
  • 23 Underwood MA, Danielsen B, Gilbert WM. Cost, causes and rates of rehospitalization of preterm infants. J Perinatol 2007; 27 (10) 614-619
  • 24 Lamarche-Vadel A, Blondel B, Truffer P. et al; EPIPAGE Study Group. Re-hospitalization in infants younger than 29 weeks' gestation in the EPIPAGE cohort. Acta Paediatr 2004; 93 (10) 1340-1345
  • 25 Morris BH, Gard CC, Kennedy K. NICHD Neonatal Research Network. Rehospitalization of extremely low birth weight (ELBW) infants: are there racial/ethnic disparities?. J Perinatol 2005; 25 (10) 656-663
  • 26 Bekö G, Morrison G, Weschler CJ. et al. Dermal uptake of nicotine from air and clothing: experimental verification. Indoor Air 2018; 28 (02) 247-257
  • 27 Northrup TF, Stotts AL, Suchting R. et al. Thirdhand smoke associations with the gut microbiomes of infants admitted to a neonatal intensive care unit: An observational study. Environ Res 2021; 197: 111180
  • 28 Mahabee-Gittens EM, Merianos AL, Hoh E, Quintana PJ, Matt GE. Nicotine on children's hands: limited protection of smoking bans and initial clinical findings. Tob Use Insights 2019; 12: X18823493
  • 29 Mahabee-Gittens EM, Merianos AL, Jandarov RA, Quintana PJE, Hoh E, Matt GE. Differential associations of hand nicotine and urinary cotinine with children's exposure to tobacco smoke and clinical outcomes. Environ Res 2021; 202: 111722
  • 30 Curwin BD, Hein MJ, Sanderson WT, Nishioka MG, Buhler W. Nicotine exposure and decontamination on tobacco harvesters' hands. Ann Occup Hyg 2005; 49 (05) 407-413
  • 31 Matt GE, Quintana PJ, Hovell MF. et al. Households contaminated by environmental tobacco smoke: sources of infant exposures. Tob Control 2004; 13 (01) 29-37
  • 32 Fleming T, Ashley J. Polycyclic aromatic hydrocarbon (PAH) residues on tobacco smokers' hands: potential vector for exposure to non-smokers. In: McConnell LL, Dachs J, Hapeman CJ. eds. Occurrence, Fate and Impact of Atmospheric Pollutants on Environmental and Human Health (ACS Symposium Series). Washington, DC: ACS Publications; 2013: 83-93
  • 33 Stotts AL, Green C, Northrup TF. et al. Feasibility and efficacy of an intervention to reduce secondhand smoke exposure among infants discharged from a neonatal intensive care unit. J Perinatol 2013; 33 (10) 811-816
  • 34 Stotts AL, Northrup TF, Schmitz JM. et al. Baby's Breath II protocol development and design: a secondhand smoke exposure prevention program targeting infants discharged from a neonatal intensive care unit. Contemp Clin Trials 2013; 35 (01) 97-105
  • 35 Chatkin J, Fritscher L, de Abreu C. et al. Exhaled carbon monoxide as a marker for evaluating smoking abstinence in a Brazilian population sample. Prim Care Respir J 2007; 16 (01) 36-40
  • 36 Middleton ET, Morice AH. Breath carbon monoxide as an indication of smoking habit. Chest 2000; 117 (03) 758-763
  • 37 Matt GE, Quintana PJ, Zakarian JM. et al. When smokers move out and non-smokers move in: residential thirdhand smoke pollution and exposure. Tob Control 2011; 20 (01) e1-e1
  • 38 Matt GE, Quintana PJ, Fortmann AL. et al. Thirdhand smoke and exposure in California hotels: non-smoking rooms fail to protect non-smoking hotel guests from tobacco smoke exposure. Tob Control 2014; 23 (03) 264-272
  • 39 Quintana PJ, Matt GE, Chatfield D, Zakarian JM, Fortmann AL, Hoh E. Wipe sampling for nicotine as a marker of thirdhand tobacco smoke contamination on surfaces in homes, cars, and hotels. Nicotine Tob Res 2013; 15 (09) 1555-1563
  • 40 Matt GE, Quintana PJE, Hoh E. et al. A Casino goes smoke free: a longitudinal study of secondhand and thirdhand smoke pollution and exposure. Tob Control 2018; 27 (06) 643-649
  • 41 Gelman A, Carlin JB, Stern HS, Dunson DB, Vehtari A, Rubin DB. Bayesian Data Analysis. 3rd ed.. Boca Raton, FL: Chapman and Hall/CRC; 2013
  • 42 McElreath R. Statistical rethinking: A Bayesian course with examples in R and Stan. Boca Raton, FL: Chapman and Hall/CRC; 2018
  • 43 Suchting R, Yoon JH, Miguel GGS. et al. Preliminary examination of the orexin system on relapse-related factors in cocaine use disorder. Brain Res 2020; 1731: 146359
  • 44 Lee MD, Wagenmakers E-J. Bayesian Cognitive Modeling: A Practical Course. Cambridge, United Kingdom: Cambridge university press; 2014
  • 45 Jeffreys H. The Theory of Probability. 3rd ed.. Oxford, United Kingdom: Oxford University Press; 1998
  • 46 The R project for statistical computing. Accessed October 29, 2018 at:
  • 47 Stan Development Team. RStan, the R interface to Stan. Accessed December 11, 2019 at:
  • 48 Bürkner PC. Advanced Bayesian multilevel modeling with the R package brms. R J 2018; 10 (01) 395-411
  • 49 Matt GE, Fortmann AL, Quintana PJ. et al. Towards smoke-free rental cars: an evaluation of voluntary smoking restrictions in California. Tob Control 2013; 22 (03) 201-207
  • 50 Matt GE, Quintana PJE, Hoh E. et al. Persistent tobacco smoke residue in multiunit housing: legacy of permissive indoor smoking policies and challenges in the implementation of smoking bans. Prev Med Rep 2020; 18: 101088
  • 51 Matt GE, Quintana PJE, Zakarian JM. et al. When smokers quit: exposure to nicotine and carcinogens persists from thirdhand smoke pollution. Tob Control 2016; 26 (05) 548-556
  • 52 Erasmus V, Daha TJ, Brug H. et al. Systematic review of studies on compliance with hand hygiene guidelines in hospital care. Infect Control Hosp Epidemiol 2010; 31 (03) 283-294
  • 53 Talbot TR, Johnson JG, Fergus C. et al. Sustained improvement in hand hygiene adherence: utilizing shared accountability and financial incentives. Infect Control Hosp Epidemiol 2013; 34 (11) 1129-1136
  • 54 Shwayder T, Akland T. Neonatal skin barrier: structure, function, and disorders. Dermatol Ther 2005; 18 (02) 87-103
  • 55 Alarabi A, Ali H, Karim Z. et al. Investigation of the mechanistic impact of prenatal exposure to thirdhand smoke on platelet activation. FASEB J 2021; 35 (S1) DOI: 10.1096/fasebj.2021.35.S1.04465.
  • 56 Jiang W, Wu H, Yu X. et al. Third-hand smoke exposure is associated with abnormal serum melatonin level via hypomethylation of CYP1A2 promoter: Evidence from human and animal studies. Environ Pollut 2021; 277: 116669
  • 57 Matt GE, Quintana PJE, Hoh E. et al. Tobacco smoke is a likely source of lead and cadmium in settled house dust. J Trace Elem Med Biol 2021; 63: 126656
  • 58 Neves Cruz J, Santana de Oliveira M, Gomes Silva S. et al. Insight into the Interaction Mechanism of Nicotine, NNK, and NNN with Cytochrome P450 2A13 Based on Molecular Dynamics Simulation. J Chem Inf Model 2020; 60 (02) 766-776
  • 59 Snijders AM, Zhou M, Whitehead TP. et al. In utero and early-life exposure to thirdhand smoke causes profound changes to the immune system. Clin Sci (Lond) 2021; 135 (08) 1053-1063
  • 60 Torres S, Samino S, Ràfols P, Martins-Green M, Correig X, Ramírez N. Unravelling the metabolic alterations of liver damage induced by thirdhand smoke. Environ Int 2021; 146: 106242