Nicotine and its proximate metabolite cotinine are eliminated in part by renal clearance. These compounds are filtered, secreted, and reabsorbed, and the resultant renal clearances are quite variable among individuals and are highly influenced by urine pH. In this study of 139 pairs of twins, we have estimated the genetic and environmental contributions to total renal clearance and net secretory/reabsorptive clearance of nicotine and cotinine. At uncontrolled urine pH both nicotine and cotinine undergo net reabsorption. Additive genetic factors were not important contributors to the variation in total renal clearance of nicotine but played a relatively more substantial role in accounting for the variation in total renal clearance of cotinine (43% of variance). Variations in glomerular filtration rate and the net secretory/reabsorptive clearance of nicotine and cotinine were largely influenced by nonadditive genetic influences (41.5-61% of variance). Earlier research has shown that renal secretory clearance of drugs can be highly heritable, presumably related to genetic variation in transporters. Our study suggests that the renal clearance of drugs that undergo extensive renal reabsorption can be substantially influenced by nonadditive genetic and/or shared environmental factors.