Background: Heterocyclic aromatic amines (HAA) are a group of hazardous substances produced during combustion of tobacco or high-temperature cooking of meats. 2-Amino-9H-pyrido [2,3b]indole (AaC) is a major carcinogenic HAA in tobacco smoke.Methods: Urinary AaC, used as a marker of AaC exposure, was analyzed on spot urine samples from adult participants of the 2013-2014 cycle of the National Health and Nutrition Examination Survey (N ¼ 1,792). AaC was measured using isotope-dilution liquid chromatography-tandem mass spectrometry. Exclusive combusted tobacco smokers were differentiated from nonusers of tobacco products through both self-report and serum cotinine data.Results: Among exclusive smokers, sample-weighted median urinary AaC was 40 times higher than nonusers. Sampleweighted regression models showed that urinary AaC increased significantly with serum cotinine among both exclusive tobacco users and nonusers with secondhand smoke exposure. Among nonusers, eating beef cooked at high temperature was associated with a significant increase in urinary AaC, whereas consuming vegetables was associated with decreased AaC. In addition, smoking one-half pack of cigarettes per day was associated with a significant increase of 23.6 pg AaC/mL calculated at geometric mean of AaC, controlling for potential confounders. In comparison, increase in AaC attributable to consuming the 99th percentile of beef cooked at high temperature was 0.99 pg AaC/mL.Conclusions: Both exclusive smokers and nonusers of tobacco in the general U.S. population are exposed to AaC from tobacco smoke, with additional, lesser contributions from certain dietary components.Impact: AaC is an important biomarker that is associated with tobacco smoke exposure.Research on Cancer (IARC) categorized a number of HAAs as possible (Group 2B) and probable (Group 2A) human carcinogens (18).Among more than 25 HAAs so far identified ( 19), 2-amino-9Hpyrido[2,3-b]indole (AaC, Group 2B carcinogen) is one of most abundant carcinogenic HAAs in tobacco smoke (10). AaC levels in tobacco smoke can reach as high as 260 ng per cigarette (7,10,20,21). This approaches the levels of other well-known carcinogens in tobacco smoke, such as N'-nitrosonornicotine, 4-(methylnitrosamino)-1-(3pyridyl)-1-butanone, and benzo[a]pyrene (5,22,23).Another carcinogenic HAA detected in tobacco smoke is 2-amino-3-methyl-9H-pyrido[2,3-b]indole (MeAaC, Group 2B carcinogen; Supplementary Fig. S1). MeAaC is a methyl homolog of AaC. MeAaC levels in tobacco smoke are about 10-fold lower than AaC levels (7, 8, 10). These two HAAs are carcinogenic in animal models (5,(24)(25)(26)(27)(28), and IARC classifies AaC and MeAaC as suspected human carcinogens (29). In addition, the FDA lists AaC and MeAaC as harmful and potentially harmful constituents in tobacco products and tobacco smoke (30). Besides tobacco smoke, AaC and MeAaC can form in foods prepared at high temperatures (approximately 200 C-300 C), such as barbecued, fried, or broiled meats, poultry, and fish (8,(31)(32)(33)(34).Metabolic activatio...