OBJECTIVE To examine the relationship between prenatal secondhand smoke (SHS) exposure, preterm birth and immediate neonatal outcomes by measuring maternal hair nicotine. DESIGN Cross-sectional, observational design. SETTING A metropolitan Kentucky birthing center. PARTICIPANTS Two hundred and ten (210) mother-baby couplets. METHODS Nicotine in maternal hair was used as the biomarker for prenatal SHS exposure collected within 48 hours of birth. Smoking status was confirmed by urine cotinine analysis. RESULTS Smoking status (nonsmoking, passive smoking, and smoking) strongly correlated with low, medium, and high hair nicotine tertiles (ρ=.74; p<.001). Women exposed to prenatal SHS were more at risk for preterm birth (odds ratio [OR]=2.3; 95% Confidence Interval [CI] [.96, 5.96]), and their infants were more likely to have immediate newborn complications (OR=2.4; 95% CI [1.09, 5.33]) than nonexposed women. Infants of passive smoking mothers were at increased risk for respiratory distress syndrome (RDS) (OR=4.9; 95% CI [1.45, 10.5]) and admission to a Neonatal Intensive Care Unit (NICU) (OR=6.5; CI [1.29, 9.7]) when compared to infants of smoking mothers (OR=3.9; 95% CI [1.61, 14.9]; OR=3.5; 95% CI [2.09, 20.4], respectively). Passive smokers and/or women with hair nicotine levels greater than .35 ng/ml were more likely to deliver earlier (1 week), give birth to infants weighing less (decrease of 200-300 g), and deliver shorter infants (decrease of 1.1-1.7 cm). CONCLUSIONS Prenatal SHS exposure places women at greater risk for preterm birth, and their newborns are more likely to have RDS, NICU admissions, and immediate newborn complications.